DVT Deep Vein Thrombosis Nursing Diagnosis Interventions NCELX Review and Care Plans
Nursing Study Guide for Deep Vein Thrombosis
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, dizziness, 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.
Nursing Care Plans for Deep Vein Thrombosis
- 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.
|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.|
- 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.
|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.|
Other Nursing Diagnoses for DVT:
- Deficient Knowledge
- Risk for Bleeding
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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