Deep Vein Thrombosis Nclex Review
What is it? Its the formation of a clot within a deep vein.
- Its a type of venous thromboembolism , which is a blood clot that starts in the vein. The other type of VTE is a pulmonary embolism, which is where a deep vein thrombosis breaks off within the vein and goes to the lungs.
- A pulmonary embolism is a risk from the development of a DVT.
What veins are most susceptible for a DVT?
Veins located in the pelvis, lower leg , and thighs. This includes:
- Peroneal and posterior tibial in the calves
- Popliteal and superficial femoral
DVTs tend to occur in the lower extremities , but can occur in the upper extremities as well. However, DVTs in the lower extremities tend to have a higher chance of breaking off and turning into a PE .
What factors play a role in the development of a DVT? To answer that question, we must review Virchows Triad.
Virchows Triad gives us three main factors that can lead to blood clot formation within a vein. Remember there are THREE factors .
Anyone can develop a deep vein thrombosis, especially if these risk factors are present.
Remember: SHE
Stasis of Venous Circulation:
What are some conditions that cause stasis of blood flow?
- Usage of Estrogen
- Heparin Induced Thrombocytopenia
- Postpartum Period
What are some conditions that cause damage the endothelial lining?
- Indwelling devices
- Medications that are damaging to the vein
- Trauma or injury to the vessel
How does a clot form and what substances are involved?
Nursing Diagnosis For Pulmonary Embolism
This nursing care plan include a diagnosis, and many interventions for the following conditions: Pulmonary Embolism, PE
What are nursing care plans? How do you develop a nursing care plan?
What nursing care plan book do you recommend helping you develop a nursing care plan?
This care plan is listed to give an example of how a Nurse may plan to treat a patient with those conditions.
Important Disclosure: Please keep in mind that these care plans are listed for Example/Educational purposes only, and some of these treatments may change over time. Do not treat a patient based on this care plan.
Care Plans are often developed in different formats. The formatting isnt always important, and care plan formatting may vary among different nursing schools or medical jobs. Some hospitals may have the information displayed in digital format, or use pre-made templates. The most important part of the care plan is the content, as that is the foundation on which you will base your care.
How Common Is Deep Vein Thrombosis
Each year, approximately 1 to 3 in every 1,000 adults develop a DVT or pulmonary embolism in the United States, and up to 300,000 people die each year as a result of DVT/PE. Its the third most common vascular disease, behind heart attacks and strokes. Acute DVT/PE can occur at any age, but are less common in children and adolescents and more common in those over the age of 60. More than half of all DVTs happen as a result of being in the hospital from a medical illness or following surgery. The reason why DVTs are more common after a hospital stay is because youre lying in bed most of the time instead of moving around like you normally would.
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Diagnosis And Treatment Of Venous Thromboembolism
There are other conditions with signs and symptoms similar to those of DVT and PE. For example, muscle injury, cellulitis , and inflammation of veins that are just under the skin can mimic the signs and symptoms of DVT. It is important to know that heart attack and pneumonia can have signs and symptoms similar to those of PE. Therefore, special tests that can look for clots in the veins or in the lungs are needed to diagnose DVT or PE.
Imbalanced Nutrition Nursing Care Plan
Nurses should monitor any changes in weight among people with deep vein thrombosis for malnutrition because it may cause shock or coma when left unchecked. If the patients weight changes by more than ten percent from baseline, nurses should intervene and offer a balanced diet to encourage the intake of food.
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Deep Vein Thrombosis Nursing Care Plans
Thrombophlebitis is the inflammation of the vein wall resulting in the formation of a thrombosis that may interfere the normal blood flow through the vessel.
Typically, venous thrombophlebitis occurs in the lower extremities. It may also occur in superficial veins such as cephalic, basilic, and greater saphenous veins, which usually is not life threatening and does not necessitate hospitalization, or it may happen in a deep vein, which can be life-threatening because clots may travel to the bloodstream and cause a pulmonary embolism.
Three contributing factors can lead to the development of deep vein thrombosis which includes venous stasis, hypercoagulability, and a vessel wall injury.
Venous stasis occurs when blood flow is decreased, as in immobility, medication therapies and in heart failure. Hypercoagulability occurs most commonly in clients with deficient fluid volume, pregnancy, oral contraceptive use, smoking, and some blood dyscrasias. Venous wall damage may occur secondary to venipuncture, certain medications, trauma, and surgery. The objective of treatment of DVT involves preventing the clot from dislodgement and reducing the risk of post-thrombotic syndrome.
How Is A Dvt Prevented
Finallythe good stuff! What are you going to do about it? As the nurse, you are going to do plenty! Below are the key components of DVT nursing interventions:
- Early ambulation. One of the best things you can do to prevent DVT is get those patients up and walking. Patients often dont want to walk because theyre in pain so try to ensure their pain is manageable prior to ambulation. Also, youll be surprised how quickly patients lose strength while on bedrest, so they may be quite weak. Use walkers, gait belts, and any other assistive devices you need to get those patients moving safely!
- If the patient cant walk at this time, they can still mobilize in bed or in the chairhaving them step on the gas by alternating dorsiflexion with plantarflexion helps improve venous return.
- Sequential compression devices . Youll often hear these referred to as scuds which is what we say instead of S-C-Ds most of the time. They gently squeeze each leg in turn, promoting venous return when patients are in bed or immobile for any period of time.
- Antiembolic stockings . One thing to know about these stockings is they are pretty snug fitting, so theyre hard-as-heck to get on. Also, if they roll down, they can become so tight at the location of the roll that they have a tourniquet effect. Also, make sure there are no creases or folds in the fabric that could lead to skin breakdown.
- Administer anticoagulants as prescribed
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Ineffective Peripheral Tissue Perfusion
The pregnant woman is at increased risk for venous thrombosis because of the venous stasis from compression of the blood vessels by the heavy uterus or by pressure behind the knees when the legs are placed in stirrup leg supports episiotomy repair. If the client has varicose veins or remains on bed rest, her hypercoagulability state increases her risk of thrombus formation.
Nursing Diagnosis
- Swelling of the affected extremity
- Redness/erythema
Desired Outcomes
- The client will demonstrate improved perfusion as evidenced by palpable and equal peripheral pulses, good capillary refill, reduced edema, and erythema.
- The client will engage in behaviors or actions to enhance peripheral tissue perfusion.
- The client will display increased tolerance to activity.
Nursing Assessment and Rationales
1. Assess the clients vital signs closely.It is important to closely monitor the clients vital signs for slight elevations in temperature, possibly to 101 , and report this finding. Because the client diagnosed with DVT is at risk of developing a pulmonary embolism, be alert and immediately report any sudden onset of breathing difficulties.
7. Examine extremities for obviously prominent veins. Palpate gently for local tissue tension, stretched skin, and knots or bumps along the course of the vein.Distention of superficial veins can occur in DVT because of backflow through communicating veins. Thrombophlebitis in superficial veins may be visible or palpable.
How Is Dvt Diagnosed
Your healthcare provider will do a physical exam and review your medical history. Youll also need to have imaging tests.
Tests to diagnose a DVT
Duplex venous ultrasound. This is the most common test for diagnosing a DVT because it is non-invasive and widely available. This test uses ultrasound waves to show blood flow and blood clots in your veins. A vascular ultrasound technologist applies pressure while scanning your arm or leg. If the pressure doesnt make your vein compress, it could mean theres a blood clot. If the results of the duplex ultrasound arent clear, your provider can use another imaging test
Venography. In this invasive test, your provider numbs the skin of your neck or groin and uses a catheter to inject a special dye into your veins to see if any blood clots are partially or completely blocking blood flow inside your veins. Venography is rarely used nowadays, but sometimes it is necessary
Magnetic Resonance Imaging or Magnetic Resonance Venography . MRI shows pictures of organs and structures inside your body. MRV shows pictures of the veins in specific locations in your body. In many cases, MRI and MRV can offer more information than a duplex ultrasound or CT scan.
Computed tomography scan is a type of X-ray that shows structures inside your body. Your provider may use a CT scan to find a DVT in your abdomen, pelvis or brain, as well as blood clots in your lung .
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Venous Thromboembolism And Pregnancy
Pregnant? Recently had a baby? You are at increased risk for developing a blood clot. But the good news is, blood clots may be preventable and treated if discovered early.
Expecting or recently had a baby? Dont let a blood clot spoil your joy.
While everyone is at risk for developing a blood clot , pregnancy increases that risk fivefold. Learn other interesting facts about blood clots.
How Is A Dvt Diagnosed
- D-Dimer blood test: This test measures the byproducts that occur when clots degrade. If its elevated, this could be positive for the presence of a clot. Note that other conditions can cause an elevated D-Dimer, so your physician team will look at the entire patient presentation before diagnosing the DVT.
- Ultrasound: This is a pretty common way to diagnose DVT and how we typically do it where I work You may see it ordered as a venous duplex ultrasoundwhen you see that, youll know what it means.
- Venography: In this test, contrast dye is injected into the vein and it is viewed on X-raythe clot shows up at the location where the flow of dye is impaired.
- CT or MRI: These tests may be used to diagnose a clot, but Ive never seen it. We typically use less intensive tests first, but these may be used in some situations.
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Risk Nursing Diagnoses For Pulmonary Embolism
1. Risk for decreased cardiac output: risk factors may include dysrhythmias, cardiogenic shock, heart failure
2. Risk for ineffective cerebral/ renal/ cardiac tissue perfusion: risk factors may include cardiogenic shock, heart failure, pulmonary artery occlusion
Reference
Comer, S. and Sagel, B. . CRITICAL CARE NURSING CARE PLANS. Skidmore-Roth Publications.
Gulanick, M. and Myers, J. . NURSING CARE PLANS: Diagnoses, Interventions, and Outcomes . Elsevier/Mosby.
Herdman, T., Kamitsuru, S. & Lopes, C. . NURSING DIAGNOSES: Definitions and Classifications 2021-2023 . Thieme.
Swearingen, P. . ALL-IN-ONE CARE PLANNING RESOURCE . Elsevier/Mosby.
What Is A Deep Vein Thrombosis
A deep vein thrombosis is a blood clot that forms in the deep veins of the body, most often in the legs, but they can occur in the upper extremities as well. These blood clots can become dislodged leading to a pulmonary embolism. Notice that the thrombus caused the embolism. A thrombus is the blood clot as it exists in the vessel once it dislodges and starts to travel throughout the blood stream, it is then called an embolus. Think of an embolus as a thrombus on the move! Actually, an embolus can be ANYTHING that is traveling through the blood stream , but for this discussion were talking about blood clots. These emboli travel along in the blood stream until they get to a vessel too small for them to continue and thats where the embolism occursleading to all sorts of problems for your patient. But, with the right DVT nursing interventions, you can help protect your patients
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Ineffective Tissue Perfusion Nursing Care Plan
Nurses can help reduce ineffective tissue perfusion by encouraging patients with deep vein thrombosis to keep their extremities warmer than usual and avoid sitting or standing for prolonged periods of time. This is common among the nursing interventions for DVT.
Nurses should also monitor and notify the doctor if a patients feet are cold to the touch more than usual, or if they have any signs of redness in their legs like swelling or tenderness. The condition could be an indication that blood is not circulating properly through the body.
How Can I Reduce My Risk
After you have a DVT, youll need to reduce your risk of future DVT/PE clots by:
- Taking your medications exactly as your healthcare provider tells you to.
- Keeping your follow-up appointments with your doctor and the laboratory. These tell your provider how well your treatment is working.
- Making lifestyle changes, such as eating healthier foods, being more active and avoiding tobacco products.
If youve never had a DVT, but have an increased risk of developing one, be sure to:
- Exercise your calf muscles if you need to sit still for a long time. Stand up and walk at least every half hour if youre on a long flight. Or get out of the car every hour if youre on a long road trip.
- Get out of bed and move around as soon as you can after youre sick or have surgery. The sooner you move around, the less chance you have of developing a DVT.
- Take medications or use compression stockings after surgery to reduce your risk of a clot.
- Follow up with your provider as directed and follow their recommendations to reduce your risk of a clot.
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Effect Of Clinical Nursing Pathway Intervention Based On Evidence
Jin Ji
Abstract
1. Introduction
2. Methods
2.1. Clinical Information
A total of 170 patients hospitalized in the hospital from January 2021 to October 2021 were selected, and the bed time was more than 2 weeks. They were randomly divided into the observation group and control group, with 85 cases in each group. Underlying diseases include stroke, coronary heart disease, coronary heart disease, diabetes, hypertension, fractures, and no venous thromboembolism. Patients and their families voluntarily joined and signed the consent form, requiring them to cooperate with nursing work. In the observation group , the age ranged from 57 to 83 years, with an average of years. In the control group , the age ranged from 55 to 79 years, with an average of years. The general data of the two groups were statistically processed, and the difference was not statistically significant .
2.2. Nursing Intervention Measures
The control group was treated with routine prevention and intervention methods, including the use of anticoagulants, raising the lower limbs and massage, wearing elastic socks, and routine health education.
2.3. Observation Indicators
After evidence-based nursing intervention, the clinical manifestations, symptoms, signs, and laboratory examination results of long-term bedridden patients were analyzed. The results of venous thrombosis, lower limb pain, swelling, D-dimer level, hemodynamic parameters, and nursing satisfaction were compared between the two groups.
3. Results
Major Signs And Symptoms Of Deep Vein Thrombosis
Contents
- One of the major symptoms of DVT is pain in the area that is affected it may feel as a sore area or a cramped part of the body.
- The affected area becomes a bit warmer as compared to the rest of the body parts.
- Erythema or redness of skin in the affected part.
- The DVT patients may show no symptoms at all in the early stage of the problem, some patients even ignore the light symptoms till the situation gets worse and complications arise due to mismanagement of the health condition. The symptoms that are related to pulmonary embolism include shortness of breath, coughing up blood, dizziness and severe chest pain.
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Complications Of Deep Vein Thrombosis
Mobility Impairment Risk Care Plan
Nurses should encourage people who have deep vein thrombosis to sit up in bed as often as possible throughout the day to prevent immobility and any complications from developing.
Along with this, the nursing care plan for deep vein thrombosis should include other interventions to reduce immobility such as walking and elevation of the legs while in bed. Such activities ensure that patients with deep vein thrombosis are not only able to do something but also that they can get out of bed when needed.
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