Understanding Risk for Deep Vein Thrombosis: A Comprehensive Nursing Diagnosis Guide

Deep vein thrombosis (DVT) is a serious medical condition characterized by the formation of a blood clot, or thrombus, within a deep vein. This typically occurs in the legs, specifically in the thigh or calf. The development of a DVT can lead to partial or complete blockage of blood flow through the affected vein. Critically, a DVT can become life-threatening if the clot breaks loose and travels through the bloodstream to the heart and lungs, potentially causing a pulmonary embolism.

In the context of patient care, nurses play a vital role in managing and preventing DVT, particularly in hospital settings. Depending on the severity of the DVT, hospitalization might be necessary for treatments like IV anticoagulants, requiring meticulous monitoring to ensure therapeutic effectiveness. Nurses are at the forefront of identifying patients at risk for DVT and implementing crucial preventative measures, as well as managing and monitoring those diagnosed with DVT to prevent recurrence and complications.

The Nursing Process and DVT

Nursing care for patients with DVT begins with a thorough nursing assessment. This initial step involves gathering comprehensive data, including physical, psychosocial, emotional, and diagnostic information. This section will delve into the collection of both subjective and objective data pertinent to deep vein thrombosis.

Comprehensive Health History Review

1. Identifying General Symptoms: A primary step in assessment is to identify and document the patient’s presenting symptoms. Key indicators of DVT include:

• Unilateral Leg Swelling: Noticeable swelling in one leg that is significantly greater than the other is a hallmark symptom.
• Leg Pain or Tenderness: Patients may experience pain or tenderness in the leg, often described as a cramping or aching sensation.
• Localized Warmth: Increased warmth to the touch over the affected area of the leg can indicate inflammation and clot formation.
• Skin Discoloration: Changes in skin color, such as redness or bluish discoloration, may be observed.

It’s also crucial to assess for symptoms that might suggest a DVT has progressed to a pulmonary embolism (PE). These symptoms include:

• Dyspnea: Difficulty breathing or shortness of breath is a critical symptom of PE.
• Cough: Coughing, sometimes producing blood, can occur with a PE.
• Chest Pain: Patients may experience chest pain, often described as sharp and worsening with deep breaths.
• Syncope: Fainting or loss of consciousness can be a sign of significant cardiopulmonary compromise due to PE.
• Palpitations: An awareness of rapid or irregular heartbeats.

2. Risk Factor Identification: A thorough assessment must include identifying factors that elevate a patient’s risk for DVT. Established risk factors include:

• Advanced Age: The risk of DVT increases with age.
• Ethnicity: African American ethnicity is associated with a higher risk.
• Smoking History: Smoking significantly increases the risk of blood clot formation.
• Obesity: Excess weight is a major risk factor for DVT.
• Recent Surgical Procedures: Especially orthopedic, neurovascular, or major abdominal surgeries.
• Immobility: Prolonged periods of inactivity, such as extended bed rest or paralysis.
• Prior DVT History: A previous episode of DVT significantly increases recurrence risk.
• Active Cancer: Certain cancers and cancer treatments elevate DVT risk.
• Pregnancy: Pregnancy and the postpartum period are associated with increased risk.
• Prolonged Travel: Long car or plane trips involving extended periods of sitting.
• Intravenous Drug Use: IV drug use can damage veins and increase clotting risk.
• Hypercoagulable Disorders: Inherited or acquired conditions that predispose to blood clotting.

3. Medication Review: Certain medications can increase the risk of DVT. It’s important to review the patient’s medication list for:

• Oral Contraceptives: Estrogen-containing contraceptives can increase clotting risk.
• Hormone Replacement Therapy (HRT): HRT, particularly estrogen-based therapies, carries a DVT risk.
• Glucocorticoids: Steroid medications can increase clotting tendency.
• Tamoxifen and Raloxifene: Selective estrogen receptor modulators used in breast cancer treatment and prevention.
• Testosterone Therapy: Testosterone replacement therapy can increase red blood cell production and blood viscosity, potentially raising DVT risk.
• Antidepressants: Some antidepressants, particularly SSRIs and tricyclics, have been linked to a slightly increased risk.

4. Medical Condition History: Chronic medical conditions can significantly elevate DVT risk. Inquire about:

• Cardiovascular Disease: Heart failure and other heart conditions.
• Chronic Lung Disease: Conditions like COPD.
• Inflammatory Bowel Disease (IBD): Crohn’s disease and ulcerative colitis.
• Systemic Lupus Erythematosus (SLE): And other autoimmune disorders.
• Myeloproliferative Neoplasms: Disorders of the bone marrow.
• Nephrotic Syndrome: A kidney disorder leading to protein loss.

5. Central Catheter Assessment: The presence of central venous access devices needs to be noted. Peripherally inserted central catheters (PICCs) have been shown to approximately double the risk of DVT compared to traditional central venous catheters (CVCs).

Physical Examination

1. Homan’s Sign Assessment: Historically, Homan’s sign (calf pain upon dorsiflexion of the foot with the knee extended) was used as an indicator of DVT. However, it is now considered unreliable due to poor sensitivity and specificity. While still sometimes assessed, its absence does not rule out DVT, and its presence is not definitive.

2. Risk Stratification with Wells’ Criteria: Clinical decision rules like the Wells’ Criteria are crucial tools for objectively assessing a patient’s pretest probability of DVT and pulmonary embolism (PE). The Wells’ score helps categorize patients into low, moderate, or high risk, guiding subsequent diagnostic testing and treatment strategies.

3. Integumentary Assessment: Careful inspection and palpation of the skin over the suspected DVT site is essential. Expected findings may include:

• Palpable Venous Cord: A tender, indurated, subcutaneous venous segment that feels like a cord upon palpation.
• Lower Extremity Discoloration: The affected leg may exhibit a reddish-purple (erythema) or bluish (cyanotic) discoloration.
• Edema: Swelling in the affected limb.
• Petechiae: Small, pinpoint red or purple spots on the skin, indicating capillary bleeding.
• Blanching: In rare cases, blanching (paleness) of the skin may be observed.

4. Respiratory Status Evaluation: Given the serious complication of pulmonary embolism, assessing respiratory status is paramount. Signs and symptoms of PE include:

• Pleuritic Chest Pain: Chest pain that worsens with coughing or deep inspiration.
• Tachypnea: Rapid breathing.
• Tachycardia: Rapid heart rate.
• Palpitations: Awareness of heart racing or irregular beats.
• Dyspnea: Shortness of breath.
• Dizziness or Syncope: Lightheadedness or fainting.
• Hemoptysis: Coughing up blood.

Diagnostic Procedures

1. Blood Tests: Several blood tests are utilized to aid in DVT diagnosis:

• D-dimer Assay: D-dimer is a protein fragment produced when blood clots break down. Elevated D-dimer levels suggest recent or ongoing clot formation, but it is not specific for DVT and can be elevated in other conditions. A negative D-dimer result is highly sensitive for ruling out DVT, particularly in low-risk patients.
• Coagulation Profile: Tests such as prothrombin time (PT) and activated partial thromboplastin time (aPTT) assess the blood’s clotting ability. While not diagnostic for DVT, they are crucial for managing anticoagulation therapy.

2. Venous Imaging: Imaging studies are essential for confirming the presence and location of a DVT.

• Duplex Venous Ultrasonography: This is the most widely used initial diagnostic test for DVT. It is non-invasive, readily available, and uses ultrasound waves to visualize veins and assess blood flow, directly detecting clots.
• Venography: Involves injecting contrast dye into the veins of the leg followed by X-rays. Venography is highly accurate but more invasive and less commonly used than ultrasound due to its invasiveness and potential for complications from contrast dye.
• Magnetic Resonance Venography (MRV): MRV provides detailed images of veins using magnetic resonance imaging. It is very sensitive and specific for DVT, particularly in the pelvis and thigh, but is more expensive and less accessible than ultrasound. MRV is valuable for patients with contraindications to contrast dye used in venography.

Nursing Interventions for DVT

Nursing interventions are crucial for managing DVT, preventing complications, and promoting patient recovery. The primary goals of DVT treatment are:

1. Preventing clot propagation and enlargement.
2. Preventing pulmonary embolism by stopping clot embolization.
3. Reducing the risk of recurrent DVT and long-term complications like post-thrombotic syndrome.

1. Anticoagulation Therapy Initiation: Anticoagulation is the cornerstone of DVT treatment. It prevents further clot formation and reduces the risk of PE.

2. Cautious Medication Administration and Bleeding Precautions: Anticoagulants and thrombolytics (clot-dissolving medications) increase bleeding risk. Nurses must diligently monitor coagulation profiles (PT/INR, aPTT) and implement bleeding precautions:

• Soft Bristle Toothbrush: To prevent gum bleeding.
• Minimize Invasive Procedures: Avoid unnecessary IV insertions, injections, etc.
• Avoid Forceful Nose Blowing/Sneezing: Teach gentle techniques.
• Fall Prevention: Implement measures to prevent falls and injuries.
• Electric Razors: Use electric razors for shaving to prevent cuts.
• Pressure Application Post-IV Removal: Apply prolonged pressure to venipuncture sites.

3. Monitoring aPTT with Unfractionated Heparin (UFH): Intravenous UFH requires close monitoring. Nurses typically monitor aPTT every 6 hours and adjust the infusion rate based on established protocols to maintain therapeutic anticoagulation.

4. Low Molecular Weight Heparin (LMWH) Administration: LMWH options like enoxaparin, apixaban, and rivaroxaban are commonly used for DVT treatment and prophylaxis. They offer more predictable anticoagulation and can often be administered subcutaneously, sometimes on an outpatient basis.

5. Warfarin Therapy and INR Monitoring: For long-term anticoagulation, warfarin may be prescribed. It requires careful monitoring of the international normalized ratio (INR). Warfarin is typically overlapped with another anticoagulant (like LMWH) until a therapeutic INR of 2-3 is achieved.

6. Vena Cava Filter Consideration: An inferior vena cava (IVC) filter may be placed in patients at high risk of PE who have contraindications to anticoagulation or who develop recurrent PE despite anticoagulation. The IVC filter traps large emboli, preventing them from reaching the lungs, but it does not prevent new clot formation.

7. Compression Stocking Application: Graduated compression stockings and intermittent pneumatic compression devices are used to reduce venous stasis, promote venous return, and decrease edema, thus lowering the risk of post-thrombotic syndrome and recurrent DVT.

8. Ambulation and Position Changes: Prolonged immobility increases DVT risk. Encourage frequent ambulation and position changes. Even for patients with limited mobility, encourage leg exercises like ankle pumps, rotations, and knee lifts in bed.

9. DVT Prophylaxis Promotion: Pharmacological and mechanical prophylaxis is essential for at-risk patients. Factor Xa inhibitors (rivaroxaban, apixaban, etc.) are increasingly used for DVT prevention, often without routine lab monitoring.

10. Medication Adherence and Testing Emphasis: Patient education on the importance of strict adherence to anticoagulant therapy and scheduled lab monitoring (especially for warfarin) is critical. Anticoagulation duration is typically at least three months, and longer for recurrent DVT.

11. Surgical Options Discussion: In cases of extensive DVT causing severe venous obstruction and limb ischemia, surgical interventions such as thrombectomy (clot removal), angioplasty, and stenting may be considered.

12. Reversal Agent Preparedness: Protamine sulfate is the antidote for heparin, and vitamin K is the antidote for warfarin. These reversal agents must be readily available to manage severe bleeding complications. For factor Xa inhibitors, specific reversal agents are available, but discontinuation and supportive care may suffice in many bleeding situations due to their shorter half-lives.

13. Lifestyle Modification Counseling: Educate patients on lifestyle changes to reduce DVT recurrence risk:

• Smoking Cessation: Smoking is a major modifiable risk factor.
• Blood Pressure Management: Control hypertension.
• Weight Management: Achieve and maintain a healthy weight.
• Regular Exercise: Promote daily physical activity.
• Loose Clothing: Avoid restrictive clothing that can impede circulation.
• Hydration: Increase daily water intake to maintain blood viscosity.
• Natural Blood Thinners (with Physician Guidance): Discuss potential use of foods or supplements like vitamin E, ginger, cayenne pepper, garlic, turmeric, and cinnamon, but emphasize that these are not substitutes for prescribed anticoagulants and should only be used with medical advice.

14. Dietary Education for Warfarin Users: Patients on warfarin need to be educated about dietary vitamin K intake. Consistent intake of vitamin K-rich foods (e.g., leafy green vegetables) is important to maintain stable INR levels. Drastic changes in vitamin K intake should be avoided.

15. Guidance on Seeking Immediate Medical Attention: Educate patients on recognizing signs of bleeding (e.g., nosebleeds, blood in urine or stool, excessive bruising) and when to seek immediate medical care. Uncontrolled bleeding requires emergency department evaluation.

Nursing Care Plans for Deep Vein Thrombosis

Nursing care plans provide a structured approach to patient care, prioritizing nursing diagnoses, assessments, and interventions to achieve short- and long-term patient goals. Here are examples of nursing care plans for common nursing diagnoses associated with DVT:

Decreased Cardiac Output

Decreased cardiac output related to DVT primarily arises from pulmonary embolism, where a clot obstructs pulmonary blood flow, increasing cardiac workload and reducing oxygenation.

Nursing Diagnosis: Decreased Cardiac Output

Related To:

• Pulmonary embolism secondary to DVT
• Obstruction of pulmonary blood flow
• Altered cardiac muscle contractility
• Increased right ventricular afterload

As Evidenced By:

• Tachycardia
• Cardiac dysrhythmias
• Sudden onset of chest pain
• Decreased oxygen saturation (SpO2)
• Acute dyspnea
• Tachypnea
• Altered level of consciousness
• Dizziness or lightheadedness
• Restlessness, anxiety
• Syncope
• Prolonged capillary refill time

Expected Outcomes:

• Patient will maintain blood pressure and heart rate within acceptable limits for their baseline.
• Patient will report absence or relief of chest pain and shortness of breath.
• Patient will maintain adequate oxygen saturation (SpO2 > 92%).

Assessments:

1. Recognize Acute PE Symptoms: Immediately recognize and respond to reports of chest pain, sudden dyspnea, tachypnea, and hypoxemia, as these indicate potential PE requiring immediate intervention.
2. Monitor Cardiovascular Function: Assess for signs of reduced cardiac output, such as hypotension, tachycardia, jugular venous distension, peripheral edema, and abnormal heart sounds, which may indicate right ventricular strain from PE.
3. Obtain ECG: Obtain a 12-lead ECG to assess for cardiac ischemia or strain patterns. Sinus tachycardia is a common finding in PE. Other ECG changes can include right bundle branch block, ST-segment elevation or depression, and T-wave inversions.

Interventions:

1. Initiate Immediate Anticoagulation: If PE is suspected, promptly initiate anticoagulation with IV unfractionated heparin, low molecular weight heparin, or fondaparinux as per physician orders and protocols.
2. Consider Thrombolytic Therapy: For hemodynamically unstable patients with massive PE, thrombolytic therapy to dissolve the clot and restore pulmonary blood flow may be indicated.
3. Prepare for Surgical or Catheter Embolectomy: In patients with massive PE who are hemodynamically unstable or have contraindications to thrombolysis, surgical embolectomy or catheter-directed clot removal may be necessary.
4. Manage Hypotension and Shock: Anticipate and treat potential shock. Carefully administer intravenous fluids to avoid right ventricular overload, and administer vasopressors as needed to maintain blood pressure and tissue perfusion.

Deficient Knowledge

Patients with DVT require comprehensive education to understand their condition, treatment, and prevention strategies.

Nursing Diagnosis: Deficient Knowledge

Related To:

• Unfamiliarity with DVT diagnosis, treatment, and prevention
• Inadequate understanding of risk factors
• Lack of prior exposure to information

As Evidenced By:

• Expresses questions and concerns about DVT diagnosis and management
• Demonstrates errors in medication administration (if applicable)
• Poor adherence to follow-up lab appointments (if applicable)
• Recurrent DVT episodes, potentially indicating lack of understanding of prevention

Expected Outcomes:

• Patient will verbalize accurate understanding of DVT diagnosis, treatment plan, and prognosis.
• Patient will articulate the importance of medication adherence and scheduled follow-up lab tests (if applicable).
• Patient will identify their individual DVT risk factors and describe at least three strategies to prevent DVT recurrence.

Assessments:

1. Assess Knowledge of Risk Factors: Evaluate the patient’s baseline knowledge about DVT risk factors. Many patients may be unaware of their specific risks or how to mitigate them.
2. Evaluate Medication Regimen Understanding: Assess the patient’s understanding of their prescribed medications, including dosage, frequency, route, purpose, and potential side effects. This is crucial for high-risk medications like anticoagulants.
3. Assess Understanding of Follow-up Care: Determine the patient’s comprehension of necessary follow-up care, such as INR monitoring for warfarin, and the importance of adherence to these appointments.

Interventions:

1. Educate on Pulmonary Embolism Signs and Symptoms: Thoroughly instruct the patient on the signs and symptoms of pulmonary embolism (sudden chest pain, dyspnea, tachycardia, tachypnea, anxiety). Emphasize that PE is a medical emergency requiring immediate attention.
2. Discuss Individual Risk Factors and Mitigation: Review the patient’s specific DVT risk factors. Provide tailored advice on risk reduction strategies, such as smoking cessation, weight management, regular exercise, and avoiding prolonged immobility.
3. Provide Comprehensive Medication Education: Provide detailed education about all prescribed medications, including name, purpose, dosage, administration instructions, potential side effects, drug interactions, and duration of therapy. Use teach-back methods to confirm understanding.
4. Teach DVT Recurrence Prevention Strategies: Instruct on practical measures to prevent recurrent DVT. Advise against prolonged sitting with legs crossed, encourage regular ambulation during long periods of sitting (travel, work), recommend leg exercises during immobility, and emphasize the importance of hydration.

Impaired Gas Exchange

Impaired gas exchange in DVT is primarily a consequence of pulmonary embolism, where blood flow obstruction to the lungs compromises oxygenation and carbon dioxide removal.

Nursing Diagnosis: Impaired Gas Exchange

Related To:

• Ventilation-perfusion mismatch in the lungs due to PE
• Reduced pulmonary blood flow
• Alveolar-capillary diffusion impairment

As Evidenced By:

• Dyspnea, particularly worsened by exertion
• Sudden onset of chest pain
• Cough, possibly with hemoptysis
• Tachypnea
• Dizziness, lightheadedness
• Syncope
• Changes in level of consciousness (confusion, restlessness)
• Cyanosis or pallor
• Tachycardia
• Palpitations
• Anxiety, restlessness

Expected Outcomes:

• Patient will achieve and maintain oxygen saturation (SpO2) within normal limits (e.g., >92%) for their baseline.
• Patient will demonstrate normal breathing pattern, rate, and depth.
• Patient will report relief of dyspnea, chest pain, and dizziness.
• Patient will maintain baseline level of consciousness and orientation.

Assessments:

1. Recognize PE Symptoms: Promptly identify and assess for signs and symptoms of pulmonary embolism, as PE is the most critical complication of DVT impacting gas exchange.
2. Auscultate Lung Sounds: Assess lung sounds for abnormalities such as crackles, wheezes, or diminished breath sounds, which can indicate pulmonary congestion or airway obstruction associated with PE.
3. Monitor Mental Status: Assess for changes in mental status, such as confusion, restlessness, or decreased level of consciousness, as these may indicate hypoxemia and reduced cerebral oxygen delivery due to PE.
4. Utilize Pulmonary Embolism Rule-Out Criteria (PERC): In low-risk patients suspected of PE, consider using the PERC rule to assess the need for further diagnostic testing. PERC criteria include factors like age ≥50 years, heart rate ≥100 bpm, SpO2 <95%, hemoptysis, prior DVT/PE, unilateral leg edema, hormone use, and recent surgery/trauma. Absence of PERC criteria may rule out PE in low-risk individuals.

Interventions:

1. Obtain Ventilation/Perfusion (V/Q) Scan or CT Pulmonary Angiography: Prepare the patient for diagnostic imaging such as V/Q scan or CT pulmonary angiography to confirm or exclude PE if suspected.
2. Administer Supplemental Oxygen: Apply supplemental oxygen (nasal cannula, face mask, or non-rebreather mask) to maintain SpO2 above 90% or as ordered, to improve oxygenation.
3. Implement Non-Pharmacological Measures: Position patient for optimal lung expansion (semi-Fowler’s or high-Fowler’s). Encourage deep breathing and coughing exercises if appropriate. Apply compression stockings to prevent further thromboembolism.
4. Prepare for Respiratory Support: Anticipate potential need for advanced respiratory support. Severe hypoxemia or respiratory failure may necessitate intubation and mechanical ventilation.

Ineffective Peripheral Tissue Perfusion

Ineffective peripheral tissue perfusion in DVT arises from venous obstruction by the thrombus, impairing blood flow and potentially causing distal ischemia and discomfort.

Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion

Related To:

• Venous stasis due to DVT
• Mechanical obstruction of venous blood flow
• Potential inflammatory processes affecting vessel walls
• Hypercoagulability contributing to clot formation

As Evidenced By:

• Edema in the affected extremity
• Pain or tenderness in the affected limb
• Increased warmth to touch in the area of the clot
• Skin discoloration (redness, cyanosis)
• Palpable tenderness along the affected vein

Expected Outcomes:

• Patient will remain free from pulmonary embolism (absence of dyspnea, chest pain, or related symptoms).
• Patient will demonstrate improved peripheral tissue perfusion in the affected extremity, evidenced by reduced edema, decreased pain, palpable peripheral pulses, and adequate capillary refill.

Assessments:

1. Assess for DVT Signs and Symptoms: Regularly assess the affected limb for signs and symptoms of DVT, including edema, pain, tenderness, skin color and temperature changes, capillary refill time, and peripheral pulse quality.
2. Identify Risk Factors: Assess for predisposing risk factors for DVT, such as recent surgery, immobility, trauma, obesity, pregnancy, dehydration, and hypercoagulable conditions, to identify patients at higher risk and guide preventative measures.
3. Measure Leg Circumference: Measure and compare the circumference of both legs at consistent points (e.g., below tibial tuberosity and above patella). A difference of >3 cm may suggest DVT, prompting further investigation.

Interventions:

1. Administer Anticoagulants as Prescribed: Administer prescribed anticoagulants (heparin, LMWH, warfarin, DOACs) promptly and monitor for therapeutic effects and side effects. Ensure appropriate lab monitoring (aPTT, PT/INR) as indicated.
2. Apply Compression Stockings: Apply graduated compression stockings to the affected limb to promote venous return, reduce edema, and decrease venous stasis. Ensure proper fit and application.
3. Ensure Adequate Hydration: Promote adequate hydration to reduce blood viscosity and improve circulation. Encourage oral fluid intake, or administer IV fluids as needed, unless contraindicated by other medical conditions.
4. Prepare for Doppler Ultrasound: If DVT is suspected or to monitor known DVT, prepare the patient for Doppler ultrasound of the affected limb to assess venous blood flow and confirm the presence and extent of thrombus.

Risk for Bleeding

Patients receiving anticoagulation therapy for DVT are inherently at increased risk for bleeding complications.

Nursing Diagnosis: Risk for Bleeding

Related To:

• Anticoagulant medication therapy (heparin, LMWH, warfarin, DOACs)
• Underlying conditions that may increase bleeding risk (e.g., thrombocytopenia, bleeding disorders)
• Invasive procedures

As Evidenced By:

Risk diagnoses are not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.

Expected Outcomes:

• Patient will maintain coagulation parameters within therapeutic ranges for prescribed anticoagulants (e.g., therapeutic aPTT or INR).
• Patient will verbalize understanding of safety precautions to minimize bleeding risk.
• Patient will remain free from signs and symptoms of bleeding complications.

Assessments:

1. Monitor for Bleeding Signs and Symptoms: Regularly assess for signs and symptoms of bleeding, including hypotension, tachycardia, dizziness, pallor, bruising, petechiae, hematomas, bleeding gums, nosebleeds, hematuria, melena, hemoptysis, and changes in mental status.
2. Monitor Coagulation Labs: Closely monitor relevant laboratory values, including platelet count, PT, PTT, and INR, to assess the patient’s coagulation status and guide anticoagulant dosage adjustments.
3. Assess Heparin-Induced Thrombocytopenia (HIT) Risk: For patients on heparin, monitor platelet counts regularly to assess for heparin-induced thrombocytopenia (HIT), a serious complication characterized by a paradoxical decrease in platelets and increased thrombotic risk.

Interventions:

1. Provide Bleeding Risk Education: Educate the patient and family about bleeding risks associated with anticoagulation therapy. Instruct on safety measures to reduce bleeding risk, such as using a soft toothbrush, electric razor, avoiding forceful coughing or nose blowing, and avoiding activities with high injury risk.
2. Take Immediate Action for Bleeding: If bleeding occurs, promptly assess the source and severity. For patients on IV heparin, immediately stop the infusion, notify the physician, draw blood for PTT and other coagulation studies, and anticipate potential heparin reversal with protamine sulfate.
3. Educate on Bleeding Precautions at Home: For patients discharged on oral anticoagulants, reinforce bleeding precautions for home. Emphasize the importance of safety to prevent injuries, and instruct them to seek immediate medical attention for any signs of significant bleeding, especially head injuries.
4. Ensure Availability of Antidotes: Ensure that antidotes for prescribed anticoagulants (protamine sulfate for heparin, vitamin K for warfarin, and specific reversal agents for DOACs if applicable) are readily available in case of severe bleeding requiring reversal of anticoagulation.