Deep vein thrombosis (DVT)

Deep vein thrombosis (DVT) is a medical condition that occurs when a

blood clot forms in one or more of the deep veins in the body.
These clots usually develop in the
• Lower leg
• Thigh
• Pelvis
• Also occur in the arm.
• Deep vein thrombosis is a part of a condition called venous
thromboembolism.
• Blood clots in the vein can break loose travel through the blood stream and
obstruct the lungs blocking blood flow
• Deep vein thrombosis can be serious because blood clots in the veins
can break loose.
• The clots can then travel through the bloodstream and get stuck in the
lungs, blocking blood flow (pulmonary embolism). When DVT and
pulmonary embolism occur together, it's called venous
thromboembolism (VTE).
PATHOPHYSIOLOGY
 The clinical conditions most closely associated with DVT

• Surgery or trauma
• Malignancy
• Prolonged immobility, pregnancy
• Congestive heart failure
• Varicose veins
• Obesity
• Advancing age
• History of DVT
Pathophysiology
Venus stasis

Venus stasis occurs when blood flow is reduced , when veins are dilated, and skeletal
muscles are dilated

damage
Damage to intimal lining of blood vessel creates a site for clot formation

phlebitis

formation of thrombus frequently accompanies phlebitis , which is an inflammation of vein

wall
 Plate aggregates

Venus thrombi are aggregates of platelets attached to the vein wall which
have a tail like appendage containing fibrin , white blood cells and many
red blood cells
Tail

tail can grow or propagate in the direction of blood flow

fragmentation
fragmentation of the thrombus can occurs spontaneously
CLINICAL MANIFESTATIONS

• Edema. Edema and swelling of the extremity because the out flow of
Venus blood is inhibited .
• Tenderness. Tenderness, which usually occurs later, is produced by
inflammation of the vein wall
• Leg swelling
• Leg pain, cramping or soreness that often starts in the calf
• Change in skin color on the leg — such as red or purple, depending on
the color of your skin
• A feeling of warmth on the affected leg
Risk Factors for DVT
Following is a list of factors that increase the risk of developing
DVT:

• Fractures,
• Severe muscle injury, or Chronic Medical Illnesses,
• Major surgery (abdomen, pelvis, hip, or legs).• Heart disease,Lung disease ,Cancer and its
treatment
• Slow blood flow, caused by: • Inflammatory bowel disease (Crohn’s
• Confinement to bed disease or ulcerative colitis)
• Previous DVT or PE
• Limited movement • Family history of DVT or PE
• Sitting for a long time, • Age (risk increases as age increases)
• Obesity
(especially with crossed legs)Paralysis. • A catheter located in a central vein
• Increased estrogen, often caused by: • Inherited clotting disease

• Birth control pills ,hormone replacement therapy,

• Pregnancy, for up to 3 months after giving birth
 Who is prone to DVT?
• You are overweight or obese
• You have a family history of DVT
• You are taking birth control pills
• You have any injury which could damage the veins
• You smoke
• You sit for long periods
• You are undergoing any hormone therapy
• You are on bed rest
• You are pregnant
• You have irritable bowel disease or cancer
• You have hereditary blood clotting disorder
• You have heart disease
Diagnosis
• A thorough physical examination
• Ultrasound,
• X- ray
• MRI
• CT scans, to detect the blood clot and its growth.
• blood test called a D-dimer test can also be done to help detect blood
clots.
If the doctor thinks there is a risk that part of the blood clot has travelled
to your lungs, they may order a chest CT scan.
Prevention of DVT

• 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.
 Preventing DVT
• Move around as soon as possible after having been confined to bed, such as after surgery,
illness, or injury.
• compression stockings
• Medication (anticoagulants) to prevent DVT.
• When sitting for long periods of time, such as when traveling for more than four hours:
• Get up and walk around every 1 to 2 hours.
• Exercise your legs while you’re sitting by:
• Raising and lowering your heels while keeping your toes on the floor
• Raising and lowering your toes while keeping your heels on the floor
• Tightening and releasing your leg muscles
• Wear loose-fitting clothes.
Everyday Living
• Exercise regularly -- daily, if possible. Walking, swimming, and
bicycling are all great activities.
• will eating a healthy, high-fiber diet with lots of vegetables and fruits.
• If you smoke, quit! Nicotine patches, gums, or sprays
• Check your blood pressure at least once a year; quitting smoking will
help control your blood pressure, too.
After Surgery or While on Bed Rest

doctor may prescribe blood thinners, also called anticoagulants:

• HEPARIN
• WARFARIN
• EPIXABAN
Did you know

• DVT does not cause heart attack or stroke. There are two main types
of blood clots.
• How a clot affects the body depends on the type and location of the
clot
• A blood clot in a deep vein of the leg, pelvis, and sometimes arm, is
called deep vein thrombosis (DVT). This type of blood clot does not
cause heart attack or stroke.
• A blood clot in an artery, usually in the heart or brain, is called arterial
thrombosis. This type of blood clot can cause heart attack or stroke.
When Traveling

• On flights longer than 4 hours, get up and move around.

• If traveling by car, stop when you can to walk around.
• If stuck in seat, work the muscles in legs throughout trip:
• Stretch your legs.
• Flex your feet.
• Curl or press your toes down.
• Drink plenty of fluids, avoid coffee and alcohol. They'll dehydrate
which makes veins narrower and blood thicker, more likely to get clot.
Treatments for DVT and PE

• Medication is used to prevent and treat DVT.

• Compression stockings ) are sometimes recommended to prevent DVT
and relieve pain and swelling. These might need to be worn for 2 years
or more after having DVT.
• In severe cases, the clot might need to be removed surgically.
 Pharmacologic Therapy

• Un fractionated 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 ---
preventing 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. catheter-directed thrombolytic therapy lyses and
dissolves thrombi
Complications of DVT
• part of the clot breaks off and travels through the bloodstream to the lungs,
---pulmonary embolism (PE). If the clot is large, it can stop blood from
reaching the lungs and is fatal.

• caused by the damage the clot does to the valves in the vein called post-
thrombotic syndrome (PTS).
• People with PTS have symptoms such as swelling, pain, discoloration, and
in severe cases, scaling or ulcers in the affected part of the body. In some
cases, the symptoms can be so severe that a person becomes disabled.

• For some people, DVT and PE can become a chronic illness; about 30%
of people who have had a DVT or PE are at risk for another episode.
Complication of DVT
• Pulmonary Embolism
If blood clot comes loose from the vein and moves through your
bloodstream so it ends up partly or completely blocking an artery in the
lungs, it's called a pulmonary embolism (PE).

About 1 in 10 people with deep vein thrombosis will have a PE.

Pulmonary embolism
• Sudden cough, which may be bloody
• Rapid breathing or sudden shortness of breath, even while resting
• Chest pain: sharp or stabbing, burning, aching, or dull (might get worse
with deep breaths, coughing, eating, or bending)
• Sudden rapid heart rate
• Irregular heartbeat (heart palpitations)
• Heart failure, when your heart can't keep up with the body's demands
• Trouble breathing
• High blood pressure in the lungs, called pulmonary hypertension
• Sudden death in up to 1 in 4 people with a PE
Post-Thrombotic Syndrome or Chronic
Venous Insufficiency
• When a clot stays in your leg or arm for too long, it can damage the vein or its valves.
Valves that don't work right let blood flow backwards and pool, instead of pushing it
toward your heart.

• Up to half of people with DVT end up with long-term effects where the clot was:

• Pain
• Swelling
• Darkened skin color
• Skin sores
• Varicose veins -- swollen, sometimes twisted or blue veins you can see under the skin
Phlegmasia Cerulea Dolens
• PCD is a serious condition where the clot, or “thrombosis,” causes extreme
buildup of fluid -- even more than DVT -- in a major vein and sometimes in
smaller “collateral” veins around it as well.

• Your skin whitens as fluid builds, and may eventually start to turn blue.
• Blisters on the skin (bullae)
• Burning, prickling, or tingling in the skin (paresthesia)
• Weakness in your muscles and when you move
• Untreated, it can start to kill tissue (gangrene), which could turn your skin
even darker (black).
Nursing Assessment

Assessment of a patient with deep vein thrombosis include:

Presenting signs and symptoms. Medical history and a physical
examination
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

• major nursing diagnoses are:

• Ineffective tissue perfusion related to interruption of venous blood
flow.
• Impaired comfort related to vascular inflammation and irritation.
• Risk for impaired physical mobility related to discomfort and safety
precautions.
• Deficient knowledge regarding pathophysiology of condition related
to lack of information and misinterpretation.
goals
• Demonstrate increased perfusion
• Verbalize understanding of condition, therapy, regimen, side effects of
medications, and when to contact the healthcare provider.
• Engage in behaviors or lifestyle changes
• Verbalize sense of comfort or contentment.
• Maintain position of normal body function by absence of contractures,
footdrop, decubitus, and so forth.
• Maintain or increase strength and function of affected and/or
compensatory body part.
 Nursing Interventions
• Provide comfort.
• Elevation of the affected extremity
• compression stockings
• warm application
• ambulation.
Compression therapy.
• 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
• intermittent pneumatic compression devices increase blood velocity beyond that
produced by the stockings.
The Wells score emphasizes accurate assessment of a patient's
probability combines both risk factors and clinical findings.
The probability of embolism is high if the patient has typical signs
(tachycardia, leg swelling) and risk factors (e.g., cancer,
immobilization) and lacks an alternative diagnosis.
The probability is low if the presentation is atypical, there are no risk
factors, and there is a likely alternative diagnosis (e.g., angina,
congestive heart failure).
• Positioning and exercise.
• When patient is on bed rest, the feet and lower legs should be elevated
periodically above the level of the heart
• active and passive leg exercises to increase venous flow.
Risk For Bleeding Care Plan

• Due to anticoagulant treatment.

Nursing Diagnosis: Risk For Bleeding
• Related to:
• Use of anticoagulants ,Abnormal blood profiles
Expected Outcomes:
• Patient will maintain therapeutic levels of blood clotting factors
• Patient will verbalize safety measures to prevent bleeding
• Patient will not experience bleeding
Interventions
1.Provide education to reduce bleeding risk.
.
2. Take immediate action if bleeding occurs.

3. Provide education on bleeding precautions.

4. Have antidotes available to reverse anticoagulants.

Nursing Diagnosis: Ineffective Tissue Perfusion

• Related to:
Venous stasis
Damage to the vessel wall
Blood hypercoagulability
• As evidenced by:
Edema
Pain
Increased warmth to the site of the clot
Tenderness
• Assess for signs and symptoms.
Assess for edema,
pain
tenderness
color changes
and temperature of the skin
capillary refill
and palpate pulses.
• Administer anticoagulants as ordered.
• Apply compression stockings as ordered.
• Ensure adequate hydration.
• Obtain an ultrasound.
Risk For Bleeding Care Plan
• Assess vital signs and symptoms of bleeding.
Hypotension, tachycardia, hypothermia, and dizziness are signs of
bleeding. Other outward signs of bleeding include nosebleeds, gum
bleeding, and bruising.
Monitor labs.
• Provide education to reduce bleeding risk.

• 2. Take immediate action if bleeding occurs.

• 3. Provide education on bleeding precautions.

• 4. Have antidotes available to reverse anticoagulants.