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Deep Vein Thrombosis

Deep Vein Thrombosis.Marie, 30 weeks pregnant, started to feel tenderness at her right leg. She habitually elevates her legs to relieve her edema, yet now the edema started to get worse. A week passes by and her leg is now painfully swollen but cool to the touch. She went for a consultation and was diagnosed with deep vein thrombosis.

Description


Deep vein thrombosis is a part of a condition called venous thromboembolism.
  • Deep vein thrombosis occurs when a blood clot (thrombus) forms in one or more of the deep veins in the body, usually in the legs.
  • Deep vein thrombosis can cause leg pain or swelling, but may occur without any symptoms.
  • Deep vein thrombosis is a serious condition because blood clots in the veins can break loose, travel through the bloodstream, and obstruct the lungs, blocking blood flow.

Pathophysiology

Although the exact cause of deep vein thrombosis remains unclear, there are mechanisms believed to play a significant role in its development.
  • Reduced blood flow. Venous stasis occurs when blood flow is reduced, when veins are dilated, and when skeletal muscle contraction is reduced.
  • Damage. Damage to the intimal lining of blood vessels creates a site for clot formation.
  • Phlebitis. Formation of a thrombus frequently accompanies phlebitis, which is an inflammation of the vein walls.
  • Platelet aggregates. Venous thrombi are aggregates of platelets attached to the vein wall that have a tail-like appendage containing fibrin, white blood cells, and many red blood cells.
  • Tail. The “tail” can grow or can propagate in the direction of the blood flow as successive layers of the thrombus form.
  • Fragmentation. Fragmentation of the thrombus can occur spontaneously as it dissolves naturally, or it can occur with an elevated venous pressure.
  • Recanalization. After an acute episode of DVT,  recanalization or reestablishment of the lumen of the vessel typically occurs.

Statistics and Incidences

The incidences of deep vein thrombosis that occurs together with pulmonary embolism are:
  • The incidence of DVT is 10% to 20% in general medical patients, 20% to 50% in patients who have had stroke, and up to 80% in critically ill patients.
  • It is estimated that as many as 30% of patients hospitalized with DVT develop long-term post-thrombotic complications.

Causes

The exact cause of deep vein thrombosis remains unknown, but there are factors that may aggravate it further.
  • Direct trauma. Direct trauma to the vessels, as with fracture or dislocation, diseases of the veins, and chemical irritation of the veins from IV medications and solutions, can damage the veins.
  • Blood coagulability. Increased blood coagulability occurs most commonly in patients for whom anticoagulant medications have been abruptly withdrawn.
  • Oral contraceptives. Oral contraceptives use also lead to hypercoagulability.
  • Pregnancy. Normal pregnancy is accompanied by an increase in clotting factors that may not return to baseline until longer than 8 weeks postpartum, increasing the risk of thrombosis.
  • Repetitive motions. Repetitive motions may cause irritation to the vessel wall, causing inflammation and subsequent thrombosis.

Clinical Manifestations

A major problem associated with recognizing DVT  is that the signs and symptoms are nonspecific.
  • Edema. With obstruction of the deep veins comes edema and swelling of the extremity because the outflow of venous blood is inhibited
  • Phlegmasia cerulea dolens. Also called massive iliofemoral venous thrombosis, the entire extremity becomes massively swollen, tense, painful , and cool to the touch.
  • Tenderness. Tenderness, which usually occurs later, is produced by inflammation of the vein wall and can be detected by gently palpating the affected extremity.
  • Pulmonary embolus. In some cases, signs and symptoms of a pulmonary embolus are the first indication of DVT.

Prevention

Deep vein thrombosis can be prevented, especially if patients who are considered high risk are identified and preventive measures are instituted without delay.
  • Graduated compression stockings. Compression stockings prevent dislodgement of the thrombus.
  • Pneumatic compression device. Intermittent pneumatic compression devices increase blood velocity beyond that produced by the stockings.
  • Leg exercises. Encourage early mobilization and leg exercises to keep the blood circulating adequately.

Complications

The following complications should be monitored and managed:
  • Bleeding. The principal complication of anticoagulant therapy is spontaneous bleeding, and it can be detected by microscopic examination of urine.
  • Thrombocytopenia. A complication of heparin therapy may be heparin-induced thrombocytopenia, which is defined as a sudden decrease in platelet count by at least 30% of baseline levels.
  • Drug interactions.  Because oral anticoagulants interact with many other medications and herbal and nutritional supplements, close monitoring of the patient’s medication schedule is necessary.

Assessment and Diagnostic Findings

Detecting early signs of venous disorders of the lower extremities may be possible through:
  • Doppler ultrasound. The tip of the Doppler transducer is positioned at a 45- to 60-degree angle over the expected location of the artery and angled slowly to identify arterial blood flow.
  • Computed tomography.  Computed tomography provides cross-sectional images of soft tissue and visualizes the area of volume changes to an extremity and the compartment where changes take place.

Medical Management

The objectives for treatment of DVT are to prevent thrombus from growing and fragmenting, recurrent thromboemboli, and postthrombotic syndrome.
  • Endovascular management. Endovascular management is necessary for DVT when anticoagulant or thrombolytic therapy is contraindicated, the danger of pulmonary embolism is extreme, or venous drainage is so severely compromised that permanent damage to the extremity is likely.
  • Vena cava filter. A vena cava filter may be placed at the time of thrombectomy; this filter traps late emboli and prevents pulmonary emboli.

Pharmacologic Therapy

Measures for preventing or reducing blood clotting within the vascular system are indicated in patients with deep vein thrombosis.
  • Unfractionated heparin. Unfractionated heparin is administered subcutaneously to prevent development of DVT, or by intermittent or continuous IV infusion for 5 days to prevent the extension of a thrombus and the development of new thrombi.
  • Low-molecular-weight heparin (LMWHs). Subcutaneous LMWHs that may include medications such as dalteparin and enoxaparin are effective treatments for some cases of DVT; they prevent the extension of a thrombus and development of new thrombi.
  • Oral anticoagulants. Warfarin is a vitamin K antagonist that is indicated for extended coagulant therapy.
  • Factor Xa inhibitor. Fondaparinux selectively inhibits factor Xa.
  • Thrombolytic therapy. Unlike heparins, catheter-directed thrombolytic therapy lyses and dissolves thrombi in at least 50% of patients.

Nursing Management

Nursing management for deep vein thrombosis entails the following:

Nursing Assessment

Assessment of a patient with deep vein thrombosis include:
  • Presenting signs and symptoms. If a patient presents with signs and symptoms of DVT, carrt out an assessment of general medical history and a physical examination to exclude other causes.
  • Well’s diagnostic algorithm. Because of the unreliability of clinical features, Well’s diagnostic algorithm has been validated whereby patients are classified as having a high, intermediate, or low probability of developing DVT.

Nursing Diagnosis

Based on the assessment data, the major nursing diagnoses are:

Nursing Care Planning & Goals

The major goals for the patient include:
  • Demonstrate increased perfusion as individually appropriate.
  • Verbalize understanding of condition, therapy, regimen, side effects of medications, and when to contact the healthcare provider.
  • Engage in behaviors or lifestyle changes to increase level of ease.
  • Verbalize sense of comfort or contentment.
  • Maintain position of function and skin integrity as evidenced by absence of contractures, footdrop, decubitus, and so forth.
  • Maintain or increase strength and function of affected and/or compensatory body part.

Nursing Interventions

The major nursing interventions that the nurse should observe are:
  • Provide comfort. Elevation of the affected extremity, graduated compression stockings, warm application, and ambulation are adjuncts to the therapy that can remove or reduce discomfort.
  • Compression therapy. Graduated compression stockings reduce the caliber of the superficial veins in the leg and increase flow in the deep veins; external compression devices and wraps are short stretch elastic wraps that are applied from the toes to the knees in a 50% spiral overlap; intermittent pneumatic compression devices increase blood velocity beyond that produced by the stockings.
  • Positioning and exercise. When patient is on bed rest, the feet and lower legs should be elevated periodically above the level of the heart, and active and passive leg exercises should be performed to increase venous flow.

Evaluation

Expected patient outcomes are:
  • Demonstrated increased perfusion as individually appropriate.
  • Verbalized understanding of condition, therapy, regimen, side effects of medications, and when to contact the healthcare provider.
  • Engaged in behaviors or lifestyle changes to increase level of ease.
  • Verbalized sense of comfort or contentment.
  • Maintained position of function and skin integrity as evidenced by absence of contractures, footdrop, decubitus, and so forth.
  • Maintained or increased strength and function of affected and/or compensatory body part.

Discharge and Home Care Guidelines

The nurse must also promote discharge and home care to the patient.
  • Drug education. The nurse should teach about the prescribed anticoagulant, its purpose, and the need to take the correct amount at the specific times prescribed.
  • Blood tests. The patient should be aware that periodic blood tests are necessary to determine if a change in medication or dosage is required.
  • Avoid alcohol. A person who refuses to discontinue the use of alcohol should not receive anticoagulants because chronic alcohol intake decreases their effectiveness.
  • Activity. Explain the importance of elevating the legs and exercising adequately.

Documentation Guidelines

The focus of documentation include:
  • Nature, extent, and duration of the problem, effect on indepence and lifestyle.
  • Characteristics of discomfort.
  • Pulses and BP.
  • Factors impacting sense of discomfort.
  • Medication use and nonpharmacological measures
  • Plan of care
  • Teaching plan.
  • Response to interventions, teaching, and actions performed.
  • Attainment or progress towards desired outcomes.
  • Modifications to plan of care.

Practice Quiz: Deep Vein Thrombosis

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1. A client is brought to the emergency department states that he has accidentally been taking two times his prescribed dose of Warfarin (Coumadin). After observing that the client has no evidence of any obvious bleeding, the nurse should do which of the following? A. Draw a sample for activated partial thromboplastin time (aPTT) level. B. Draw a sample for prothrombin time (PT) level and international normalized ratio (INR). C. Prepare to administer Vitamin K. D. Prepare to administer Protamine sulfate. 1. Answer: B. Draw a sample for prothrombin time (PT) level and international normalized ratio (INR).
  • B: The next action for the nurse to take is to draw a sample for INR and PT level to check the client’s anticoagulation status and risk for bleeding.
  • A:  The aPTT determines the effects of heparin therapy.
  • C: The results of the INR and PT level will be needed first.
  • D: Protamine sulfate is the antidote for heparin overdose.
2. A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client’s activated partial thromboplastin time is 77 seconds. Based on this result, the nurse anticipate which of the following prescription? A. Maintain the rate of the heparin infusion. B. Decrease the rate of the heparin infusion. C. Increase the rate of the heparin infusion. D. Discontinue the heparin infusion. 2. Answer: A. Maintain the rate of the heparin infusion.
  • A: The normal activated partial thromboplastin time is between 20 to 36 seconds. In the treatment of deep vein thrombosis, the therapeutic range is to maintain the aPTT level between 1.5 and 2.5 times the normal. This means that the client’s aPTT level should not be less 30 seconds or greater than 90 seconds. Thus the client’s aPTT of 77 seconds is within the normal therapeutic range, and the dose/rate should not be changed.
  • B, C, D: These options are incorrect as they suggest altering the rate of heparin infusion.
3. Nurse Justin is taking care a client with deep vein thrombosis. Which position should be provided to the client? A. Bed rest with the affected extremity remain flat at all times. B. Bed rest with the unaffected extremity on top of the affected extremity. C. Bed rest with the affected extremity in a dependent position. D. Bed rest with the affected extremity elevated. 3. Answer: D. Bed rest with the affected extremity elevated.
  • D: Bed rest is indicated to prevent emboli while the elevation of the affected leg facilitates blood flow by the force of gravity and reduces pain and edema.
  • A, B, C: The extremity must only be elevated to facilitate blood flow.
4. A nurse is caring for a client receiving a heparin intravenous (IV) infusion. The nurse expects that which of the following laboratory will be prescribed to monitor the therapeutic effect of heparin? A. Prothrombin time (PT). B. Activated partial thromboplastin time (aPTT). C. Hematocrit (Hgb). D. Hemoglobin (Hct). 4. Answer: B. Activated partial thromboplastin time (aPTT).
  • B: Activated partial thromboplastin time assess the therapeutic level of heparin.
  • A: Assess the therapeutic level of warfarin sodium (Coumadin).
  • C, D: Measures the aspect of the red blood cells.
5. A client with deep vein thrombosis is receiving Streptokinase (Streptase). The nurse would notify the physician if which of the following assessment is noted? A. A temperature of 99.2° Fahrenheit. B. A pulse rate of 99 beats per minute. C. A respiratory rate of 25 breaths per minute. D. A blood pressure of 185/110 mm Hg. 5. Answer: D. A blood pressure of 185/100 mm Hg.
  • D: Thrombolytic therapy is contraindicated with uncontrolled hypertension (systolic BP >180 mmHg and/or diastolic BP >110 mm Hg) because of the risk of cerebral hemorrhage.
  • A, B, C: Options A, B, and C may be present during the therapy but will not warrant the immediate knowledge of the physician before starting the therapy.
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