Deep Vein Thrombosis (DVT) Overview

DVT Overview

• Deep Vein Thrombosis involves blood clot formation in the deep veins.
• DVT typically occurs in the legs, but can rarely affect the arms and neck.
• A major complication of DVT is pulmonary embolization.

Pathophysiology of DVT

• Virchow's triad describes three conditions leading to DVT.
• Venous stasis is a condition of Virchow's triad
• Hypercoagulability of blood is a condition of Virchow's triad
• Injury to venous wall (vascular damage) is a condition of Virchow's triad

Clinical Manifestations

• Patients may be asymptomatic with DVT.
• Edema, warmth, and redness may indicate DVT.
• Calf pain or thigh tenderness and aching pain can be clinical signs.
• Increased temperature and WBC count may occur.

Risk Factors

• Inherited clotting disorders like Factor V Leiden deficiency increase risk.
• Prolonged bedrest or sitting can lead to venous stasis and heightened risk.
• Smoking damages blood vessels, augmenting DVT risk.
• Oral contraceptives can cause hypercoagulability, increasing risk.
• Injury or surgery can damage vessels and raise risk.
• Pregnancy is a risk factor for DVT.

Lifestyle Modifications

• Weight loss can aid in DVT prevention.
• Exercise is beneficial in DVT prevention.
• Smoking cessation is important in DVT prevention.
• Appropriate fluid intake is useful in DVT prevention.

DVT Prevention

• Tissue perfusion promotion and venous stasis prevention are key to DVT prevention.
• Venous thromboembolism (VTE) prophylaxis is a core measure.
• Wearing compression stockings aids prevention.
• Avoid clothing that constricts the legs for prevention.
• Avoid prolonged sitting or standing.
• Encouraging exercises and physical activity can help prevent DVT.
• Passive Range of Motion (ROM) exercises can help prevent DVT.
• Maintaining desired weight for height can aid prevention.

At-Risk Patients

• Immobility increases DVT risk.
• Post-operative patients are at higher risk.
• Surgical patients older than 40 are at increased risk.
• Heart diseases requiring major abdominal, pelvic, or orthopedic surgery also increase risk.

Prevention with Anticoagulants

• Administering prescribed anticoagulants helps prevent DVT.
• Subcutaneous heparin is used as a preventive measure.
• Lovenox (enoxaparin) is used in DVT prevention.
• Xarelto (rivaroxaban) is used in DVT prevention.

Medical Management

• Diagnostic tests include Venous duplex scan which is the best choice, venogram, and D-Dimer.
• Increase fluid intake and dietary fiber
• A diet monitoring food high in vitamin K (dark green, yellow vegetables) can help counteract the effects of coumadin.
• Activity promotes venous blood flow, helps maintain muscle tone and joint mobility, and increases a sense of well-being.
• Anticoagulation (see medication sheet on BB)

Anticoagulants

• Heparin can be given subcutaneously or as an IV infusion.
• Enoxaparin Sodium (Lovenox) is given subcutaneously as prophylaxis.
• Warfarin (Coumadin) is given orally.

Surgical Management

• Thrombectomy involves the removal of thrombosis and is used if anticoagulant therapy is contraindicated; this is rarely performed.
• An IVC filter (Greenfield filter) is placed through the femoral or jugular vein into the inferior vena cava below the kidneys and traps large emboli to prevent pulmonary embolism.

Assessment Indicators

• Subjective indicators include pain in the calf at rest or with exercise, tenderness in the leg to palpation, and a history of DVT.
• Objective indicators include unilateral ankle edema, rapid swelling of the entire limb, redness, warmth, increased skin temperature, and low-grade fever.

Nursing Diagnosis and Actions: Ineffective Tissue Perfusion

• Apply compression stockings.
• Check pulses, monitor calf circumference, and watch for edema.
• Administer anticoagulant therapy.
• Teach patients to avoid standing still and prolonged sitting.
• Monitor for signs of pulmonary edema.

Additional Nursing Interventions

• Promote comfort with warm packs to the legs to encourage vasodilation.
• Administer analgesics.
• Avoid NSAIDs and ASA in patients receiving anticoagulants; Tylenol may be used instead.

Nursing Diagnosis and Actions: Ineffective Health Maintenance

• Oral anticoagulants should be taken at the same time every day and should not be stopped unless a doctor discontinues the order.
• Monitor labs, usually 1-2 weeks after discharge.
• Monitor intake of dark greens due to vitamin K content.
• Restrict alcohol intake, as it can increase anticoagulant effects.

Core Measure Statistics

• DVT occurs in 10% to 40% of hospitalized patients who do not receive prophylaxis.
• Patients with risk factors like malignancy, immobility, pelvic surgery, joint replacement, previous DVT, or a hypercoagulable state have a higher incidence of DVTs.
• Pulmonary embolism is a potentially fatal complication of DVT, contributing to up to 10% of in-hospital deaths.
• Pharmacologic prophylaxis can reduce a hospitalized patient's risk of developing DVT by 40% to 60%.

Compression Devices for Prophylaxis

• Compression devices are recommended as the sole method of prophylaxis only for patients who have a contraindication to pharmacologic prophylaxis, such as a high bleeding risk.

Chronic Venous Insufficiency (CVI)

• Blood flow through the veins is inadequate, causing blood to pool in the legs.
• Malfunction of venous walls and/or valves in systemic circulation particularly in the legs
• Causes include: varicose veins (incompetent valves), blood clots (obstruction of the veins) and obesity, fluid retention, inactivity

CVI Assessment Findings

• Thin, shiny skin
• Weeping dermatitis
• Leg aching
• Brown skin pigmentation

Post-Thrombotic Syndrome and CVI Treatment

• Post-thrombotic syndrome is CVI as a complication of DVT.
• Symptoms include pain, swelling, and skin ulcers.

Common Nursing Interventions for CVI

• Leg elevation helps promote blood flow back to the heart.
• Prescribed compression stockings should be worn.
• Encourage ambulation and avoid standing for long periods of time.
• Avoid crossing legs.
• Do not wear constrictive clothing.

Treatments

• Compression stockings improve poor circulation by squeezing the muscle and blood vessels, causing contractions to help the blood move more efficiently through the leg and back to the heart.
• Medications: diuretics, anticoagulants, medications to increase blood flow
• Surgery - vein bypass