DVT Nursing Care Plans Diagnosis and Interventions
DVT NCLEX Review and Nursing Care Plans
Deep vein thrombosis (DVT) is a medical condition which involves the formation of a blood clot called thrombus in a deep vein/s in the body.
The legs are the most common sites of DVT. While DVT can manifest as acute pain and/or swelling, some patients do not experience any symptoms in the beginning.
This is the reason why DVT screening is important for high risk patient groups, such as those who have had a recent surgery, accident or trauma, or bedbound.
DVT can cause serious complications, and one of them is when part of the thrombus breaks out and travels via the bloodstream.
Now called an embolus, the blood clot may block a part of the lungs, causing pulmonary embolism.
Signs and Symptoms of Deep Vein Thrombosis
- Pain in the affected area (usually leg pain which starts in the calf and can be described as sore or cramping)
- Warmth on the affected area
- Redness or erythema
DVT patients can be asymptomatic or have very mild symptoms that they may ignore until they become worse or develop complications.
Signs of pulmonary embolism include shortness of breath, coughing up blood, chest pain, and lightheadedness or dizziness.
Causes and Risk Factors of Deep Vein Thrombosis
Anything that causes the blood to clot or circulate abnormally may cause blood clot formation, leading to DVT. These include accident or trauma that injures a deep vein, surgery, limited movement, and some medications such as those used in hormone replacement therapy (HRT).
The risk factors that may increase the chance of developing DVT include:
- Age above 60
- Genetic blood-clotting disorder
- Paralysis or bedbound patients
- Sedentary lifestyle
- Prolonged bedrest
- Trauma and injury
- HRT medications or birth control pills
Complications of Deep Vein Thrombosis
- Pulmonary Embolism. DVT can lead to pulmonary embolism when the blood clot, or part of it, travel to the lungs via the bloodstream. It is a life-threatening situation with the following warning signs and symptoms: chest pain triggered by coughing or taking a deep breath, shortness of breath, tachycardia, dizziness, and coughing up blood or hemoptysis.
- Postphlebetic Syndrome. Also known as post thrombotic syndrome, this condition involves the reduction of blood flow in the affected area. Signs and symptoms include skin discoloration or cyanosis, leg pain, leg edema, and skin sores.
Diagnosis of Deep Vein Thrombosis
- Physical examination and history taking – to check for any swelling, pain and other signs and symptoms of DVT; to check for any risk factors related to DVT
- Blood test – to check for D-dimer levels, which is elevated in people with severe DVT
- Imaging – ultrasound, CT or MRI to visualize any blood clot; venography to look for blood clots by means of injecting a dye in a large vein and using an X-ray machine
Treatment for Deep Vein Thrombosis
- Anticoagulants. The first line of treatment for DVT involves the use of blood thinners called anticoagulants. They decrease the ability of the blood to clot, preventing the clot to become bigger and reducing the risk of developing more clots. However, they are not able to break up the existing clot. These can either be oral tablets (such as warfarin and dabigatran) or subcutaneous injections (such as dalteparin, enoxaparin, or fondaparinux). Routine blood tests to check coagulation and platelet levels are necessary for a patient on anticoagulation therapy.
- Thrombolytics. These clot buster medications are able to break up the clot easily for cases of severe DVT or DVT with pulmonary embolism. These include alteplase, reteplase, actylase, and anistreplase. These are given either directly into the clot via a catheter, or through an intravenous line. Thrombolytics are used in caution due to the risk of serious bleeding.
- Filter insertion. If the patient is not eligible for anticoagulant therapy, the physician may insert a filter in the abdominal vena cava to prevent the clot from the leg to break loose and travel to the lungs, thus lowering the risk for pulmonary embolism.
- Compression stockings. These are helpful to reduce the swelling of the legs, as well as to lower the risk of blood pooling and eventual clotting. The compression stockings should be worn for at least 2 years.
DVT Nursing Diagnosis
DVT Nursing Care Plan 1
Nursing Diagnosis: Ineffective Tissue Perfusion (Peripheral) related to venous stasis of the left leg as evidenced by calf pain upon palpation, unilateral left leg edema, increased leg warmth and tenderness
Desired Outcome: The patient will maintain optimal tissue perfusion in the left leg (affected extremity) as evidenced by having strong and palpable pulses, and reduced calf pain, warmth, and tenderness.
|DVT Nursing Interventions||Rationales|
|Assess the patient’s vital signs at least every 4 hours, or more frequently if there is a change in them.||To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment for DVT.|
|Measure the circumference of the left leg (affected extremity) 10 cm below the tibial tuberosity with a tape measure. Then, measure the circumference of the same leg but 10 –15 cm above the patella.||DVT is to be suspected if the difference is greater than 3 cm between the extremities.|
|Administer the prescribed anticoagulants.||To prevent blood clot formation using anticoagulants such as heparin or warfarin.|
|Administer analgesics as prescribed.||To provide pain relief especially in the calf area.|
|Elevate the legs and apply compression stocking. Provide heat on the affected extremity. Encourage to mobilize and perform exercise.||To decrease the swelling and reduce the risk of clot formation. To provide comfort and help decrease the inflammation. To reduce the risk of clot formation.|
|Ensure adequate hydration.||Increased blood viscosity is a contributory factor to clotting and venous stasis. Adequate hydration helps reduce blood viscosity.|
DVT Nursing Care Plan 2
Nursing Diagnosis: Acute Pain related to inflammatory response in the affected vein, as evidenced by pain score of 10 out of 10, burning and sharp pain when palpating the calf of the affected leg, guarding sign on the affected leg, blood pressure level of 180/90, respiratory rate of 29 bpm, and restlessness
Desired Outcome: The patient will demonstrate relief of pain as evidenced by a pain score of 0 out of 10, stable vital signs, and absence of restlessness.
|DVT Nursing Interventions||Rationale|
|Administer prescribed analgesics.||To provide pain relief and patient comfort by decreasing muscular tension.|
|Assess the patient’s vital signs and characteristics of pain at least 30 minutes after administration of medication.||To monitor effectiveness of medical treatment for the relief of acute pain. The time of monitoring of vital signs may depend on the peak time of the drug administered.|
|Elevate the affected leg/ extremity.||To promote venous return and help re-establish optimal blood circulation.|
|Apply a heat pad on the affected area for 2 hours and remove it for 2 hours.||To facilitate vasodilation, improving blood circulation in the affected area and eventually relieving pain.|
DVT Nursing Care Plan 3
Nursing Diagnosis: Deficient Knowledge related to new diagnosis of deep vein thrombosis (DVT) as evidenced by patient’s verbalization of “I want to know more about my diagnosis and care”
- At the end of the health teaching session, the patient will be able to demonstrate sufficient knowledge of deep vein thrombosis and its management.
- The patient will be able to verbalize understanding of DVT and express willingness to participate in the management of the medical condition.
|DVT Nursing Interventions||Rationale|
|Assess the patient’s readiness to learn, misconceptions, and blocks to learning (e.g., acute pain that distracts the patient)||To address the patient’s cognition and mental status towards the new diagnosis of deep vein thrombosis and to help the patient overcome blocks to learning.|
|Explain what deep vein thrombosis is, and how it can develop into complications such as pulmonary embolism if left untreated. Avoid using medical jargon and explain in layman’s terms.||To provide information on deep vein thrombosis and its pathophysiology in the simplest way possible.|
|Educate the patient about anticoagulation therapy. Inform him/her the target therapeutic range. Instruct the patient regarding routine coagulation testing/monitoring.||To give the patient enough information on anticoagulation therapy and its role in the management of deep vein thrombosis. Routine coagulation blood tests are needed to check if the anticoagulant is taken within the therapeutic range, or whether the dose needs to be amended.|
|Inform the patient of the signs of worsening DVT which may lead to pulmonary embolism:|
-Tachypnea or rapid breathing
-Dyspnea or shortness of breath
-Sudden chest pain
-Restlessness or irritability
|A blood clot may break off from the original clot in the extremities. This blood clot may travel to the lung, causing pulmonary embolism which is a dangerous complication of deep vein thrombosis.|
|Teach the patient on how to identify signs of excessive anticoagulation.||Anticoagulation therapy is usually done over weeks or even long-term. The patient needs to know the signs of too much anticoagulant therapy to alert him/her to inform the doctor.|
|Inform the patient the details about the prescribed medications (e.g., drug class, use, benefits, side effects, and risks) involved in anticoagulation therapy, and explain how to properly self-administer each of them. Ask the patient to repeat or demonstrate the self-administration details to you.||To inform the patient of each prescribed drug and to ensure that the patient fully understands the purpose, possible side effects, adverse events, and self-administration details.|
|Advise the patient not to rub or massage the affected area, which is usually the calf or leg/s.||Massaging or rubbing the affected area may cause a blood clot to break off from the original clot, and travel to other parts of the body as an embolus via blood circulation.|
|Inform the patient about compression stockings if indicated. Demonstrate how to correctly apply compression or anti-embolic stockings and allow the patient to demonstrate it to you. Also, advise the patient to avoid constricting/ tight socks or garters.||Correct application of compression stockings prevents clot formation on the legs. However, stockings that are incorrectly applied may act as a tourniquet and facilitate the formation of clot/s on the legs.|
|Educate the patient about the need to mobilize regularly and avoid staying seated, lying down, or any other position for long periods of time. During travels such as a long flight, tell the patient to move around at least every hour. Encourage regular exercise at least 30 minutes in most days of the week. Also, advise the patient not to sit with their legs crossed.||Increased mobility helps reduce the risk for venous stasis, thereby lowering the risk for clot formation and deep vein thrombosis.|
|Advise patient to quit smoking if he or she is a smoker.||The nicotine in cigarettes is a potent vasoconstrictor that can affect clot formation and blood circulation.|
DVT Nursing Care Plan 4
Nursing Diagnosis: Risk for Bleeding related to anticoagulant therapy for deep vein thrombosis
Desired Outcome: To prevent any bleeding episode while the patient is on anticoagulant therapy.
|DVT Nursing Interventions||Rationale|
|Assess the patient’s vital signs and perform a focused physical assessment, looking for any signs of bleeding.||Anticoagulants put the patient at risk for bleeding. Early signs of bleeding include gum bleeding, epistaxis, and unexplained bruises. Low blood pressure, low temperature, and dizziness may result from excessive bleeding.|
|Obtain blood samples and monitor platelet counts as well as coagulation levels (INR, PT, and PTT).||To ensure that the anticoagulant dosing is in line with the target therapeutic range, thus reducing the risk of bleeding.|
|Administer the anticoagulant as prescribed.||There are different anticoagulants in different forms. The most common ones are IV heparin, subcutaneous low-molecular weight heparin (LMWH), and oral warfarin.|
|Monitor the patient’s risk for heparin-induced platelet aggregation (HIPA) by checking any sudden drops in platelet counts. If HIPA is suspected, it is important to stop any heparin-containing medications and suggest a consultation with a hematologist.||Heparin-induced platelet aggregation (HIPA) is the main cause of heparin-induced thrombocytopenia (HIT), which is evidenced by the sudden reduction in platelet counts as seen in daily blood trends. A hematologist can give expert advice on the treatment of HIPA in patients with DVT.|
|Recommend to switch from IV anticoagulant to subcutaneous or oral anticoagulant to the doctor when the therapeutic range has been reached.||To facilitate safe transition of anticoagulation therapy from clinical management to patient self-management before discharge.|
|If bleeding is found while patient is on IV heparin, perform the following actions immediately:|
-Stop the infusion at once
-Inform the physician
-Re-evaluate the patient’s PTT level
-Re-check the dosage of heparin on the basis of PTT result
|Further treatment of DVT is guided by current laboratory data and changes in the patient’s condition, particularly the presence of bleeding. The normal range for PTT level is between 1.5 to 2.|
DVT Nursing Care Plan 5
Desired Outcome: The patient will have improved oxygenation and will not show any signs of respiratory distress.
|DVT Nursing Interventions||Rationale|
|Assess the patient’s vital signs and characteristics of respirations at least every 4 hours.||To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment. Pulmonary obstruction is suspected when there is tachypnea or increased respiratory rate and dyspnea or shortness of breath.|
|Monitor the patient’s level of consciousness and mentation.||Decreased level of consciousness as evidenced by irritability, confusion, and/or restlessness may indicate hypoxemia or the further decrease in the oxygen level of the blood.|
|Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.||To increase the oxygen level and achieve an SpO2 value within the target range.|
|Administer thrombolytics and other supportive medications as prescribed.||Thrombolytics can be administered to facilitate the breakdown of the blood clot (clot lysis), in order to restore blood flow to the affected areas of the lung, such as the alveoli.Bronchodilators increase the delivery of oxygen by means of improving the dilation of small airways. Anxiolytics can help reduce anxiety and allow the patient to improve his or her work of breathing in order to maximize gas exchange in the alveolar level.|
|Encourage small but frequent meals. To avoid abdominal distention and diaphragm elevation which can lead to a decrease in lung capacity.|
|Elevate the head of the bed to 20 – 30 degrees. Assist the patient to assume semi-Fowler’s position.||Head elevation and semi-Fowler’s position help improve the expansion of the lungs, enabling the patient to breathe more effectively.|
|Encourage the patient to increase his/her oral fluid intake if not contraindicated. If unable to drink more, ask the physician if intravenous therapy can be prescribed.||Increased fluid volume can help reduce the hyper viscosity of the blood and assist in adequate tissue perfusion.|
|If bronchoscopy is indicated by the physician, educate the patient about the procedure, obtain consent, and prepare the patient for it.||Bronchoscopy is performed to effectively visualize the lungs and to facilitate the removal of blood clot/s in order to clear the patient’s airways.|
|If surgery is indicated by the physician, educate the patient about the procedure, verify consent once the doctor has obtained it, and prepare the patient for the surgery.||Some patients experience deep vein thrombosis and develop blood clots despite adequate anticoagulant therapy, while others are not eligible for anticoagulation at all. Surgical interventions, such as vena caval ligation, may be indicated in these cases.|
|Assess patient’s level of fatigue and ability to perform self-care. Encourage rest periods and assist in doing activities of daily living (ADLs) while on a state of impaired gas exchange.||Impaired gas exchange in patients with DVT can result to mild to severe fatigue. Patients need to know that the nursing staff are there to support them in performing ADLs while they are unwell in order to promote recovery and reduce the risk for falls or injury.|
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