Overview of Deep Vein Thrombosis | Nursing Diagnosis for Deep Vein
A deep vein thrombosis (DVT) is a blood clot in a deep vein. A clot inside a blood vessel is called a thrombosis. DVTs predominantly occur in the legs and may have no symptoms. The non-specific signs of DVT include pain, swelling, redness, warmness, and engorged superficial veins in the leg.
A DVT may go away naturally, but the most serious complication is when a thrombosis dislodges (embolizes) and travels to the lungs to become a life-threatening pulmonary embolism (PE). DVT and PE are the two manifestations of the disease venous thromboembolism (VTE). A late complication of DVT is the post-thrombotic syndrome, which can manifest itself as edema, pain or discomfort and skin problems. About 1 in a 1000 adults develop a DVT annually.
According to Virchow's triad, described initially in 1856 by the German pathologist Rudolph Virchow, venous thrombosis occurs due to three factors:
- Decreased flow rate of the blood (venous stasis),
- Damage or activation of the blood vessel wall, and
- An increased tendency of the blood to clot (hypercoagulability).
DVT formation typically begins in the calves, inside vein valves, where the blood is relatively oxygen deprived. Several medical conditions increase the risk for DVT, such as cancer, trauma, and antiphospholipid syndrome. Other risk factors include older age (the strongest), surgery, immobilization (as with bed-rest, orthopedic casts, or during long-haul flights), oral contraceptives and inborn tendencies to form clots known as thrombophilia (for example, in carriers of factor V Leiden). Women have an increased risk during pregnancy (due to altered blood protein levels) and in the postnatal period, partially due to substances released by the placenta. However, some of those who develop DVT have no recognized risk factors. (Wikipedia.org)
Prognosis of Deep Vein Thrombosis | Nursing Diagnosis for Deep Vein Thrombosis
The clot may develop without any outward signs for some time. It may also be due to another disease process or medication which affects clotting abilities. A small piece of the clot may break free to become an embolus and travel elsewhere in the body. This embolus may lodge in a vessel in the lung (a pulmonary embolism), causing acute respiratory symptoms, possibly even death.
Signs and Symptoms of Deep Vein Thrombosis| Nursing Diagnosis for Deep Vein Thrombosis
- Some patients will be asymptomatic
- Unilateral leg (or arm) pain or tenderness (calf, thigh, groin, upper or lower arm) depending on location of thrombosis
- Unilateral swelling of leg (or arm) due to vascular occlusion
- Positive Homan’s sign (pain on dorsiflexion of foot) seen in minority of patients with DVT
- Warmth over the site
Interpreting Test Result of Deep Vein Thrombosis| Nursing Diagnosis for Deep Vein Thrombosis
- Doppler flow studies.
- Venous duplex ultrasound.
- Impedence plethysmography looks at venous outflow; better at diagnosis in thigh than in calf.
- Venography uses contrast dye to visualize the thrombus; not commonly done due to need for dye and other available tests.
- MRI direct thrombus imaging useful for inferior vena cava and pelvic vein locations.
- PT, PTT, INR, and CBC with platelet count as baseline.
- D-dimer to test for hypercoagulable state.
Nursing Diagnosis for Deep Vein Thrombosis: Treatment of Deep Vein Thrombosis
Treatment of Deep Vein Thrombosis | Nursing Diagnosis for Deep Vein Thrombosis
- Most patients undergo medical management and rest. Preventive measures are instituted for future occurrences. Patients with repeat occurrences may have an umbrella filter implanted.
- Bedrest with elevation of extremity.
- Warm, moist soaks of the area.
- Monitor prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR).
- Weight-dosed heparin IV.
- Low molecular weight heparin.
- Warfarin.
- Thrombolytic therapy to dissolve clot with drugs such as recombinant tissue plasminogen activator (t-PA).
- Umbrella filter is inserted into the inferior vena cava for patients with recurring DVT.
- Thrombectomy is the surgical removal of the thrombus.
Nursing Diagnosis for Deep Vein Thrombosis and Nursing Interventions
Most Common Nursing Diagnosis for Deep Vein Thrombosis
- Impaired physical mobility
- Risk for acute pain
Nursing Interventions for Deep Vein Thrombosis
- Monitor vital signs for changes.
- Monitor for signs of pulmonary embolism, shortness of breath, chest pain, tachycardia (rapid heart rate), tachypnea (rapid respirations), and diaphoresis (sweating).
- Avoid massaging the area to lessen the possibility of dislodging the clot.
- Intermittent warm, moist soaks. Assess skin between changes.
- Follow weight-dosed heparin protocol.
- Monitor lab results: PT, PTT, INR, and CBC with platelets.
- Low molecular weight heparin (enoxaparin, dalteparin).
- Warfarin orally.
- Monitor for signs of bleeding or bruising.
- Instruct patient to:
- Report signs of bleeding or bruising to physician, nurse practitioner, or physician assistant.
- Avoid injury.
- Use of electric razor and soft toothbrush; avoid flossing between teeth.
- Diet restrictions, and to check with health care provider or pharmacist about interactions of any medications, if on warfarin as outpatient.
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This is a sample of Medical Surgical Nursing: nursing diagnosis for Deep Vein Thrombosis (DVT).