Deep vein thrombosis (DVT) refers to the formation of a blood clot (thrombus) within a deep vein, usually in the leg (thigh or calf). Once the blood clot forms, it can partially or completely block the flow of blood through that vein.
Some common causes of DVT include immobility, trauma or damage to the vein, family history, pregnancy, recent surgery, and certain medications. A clot can become life-threatening if it dislodges and travels to the heart and lungs, causing a pulmonary embolism.
DVT may present with pain, swelling, and skin that’s warm to the touch. However, it can also be asymptomatic until progressing to a pulmonary embolism. DVT can be diagnosed with a combination of lab tests, ultrasounds, and MRI. Treatment involves the use of anticoagulants which cannot break up existing clots but prevent them from worsening or more from forming.
The Nursing Process
Nurses will be involved in caring for patients with DVT in the inpatient setting. Depending on the severity of the clot, patients may need to be hospitalized to receive IV anticoagulants which require frequent lab monitoring to ensure efficacy. Nurses are aware of the risk of DVT in certain patient populations and the importance of implementing interventions to prevent the occurrence of DVT.
Nursing Care Plans Related to Deep Vein Thrombosis
Ineffective Peripheral Tissue Perfusion Care Plan
Patients with deep vein thrombosis have ineffective peripheral tissue perfusion due to decreased blood flow and damage to the vessels.
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
Expected Outcomes:
- Patient will be free of pulmonary embolism as evidenced by the absence of shortness of breath or chest pain
- Patient will maintain optimal tissue perfusion in the affected area as evidenced by decreased pain, sufficient capillary refill, and strong peripheral pulses
Ineffective Peripheral Tissue Perfusion Assessment
1. Assess for signs and symptoms.
DVT may be asymptomatic but some patients show signs and symptoms in the affected area. Assess for edema, pain, tenderness, color changes and temperature of the skin, capillary refill, and palpate pulses.
2. Assess the patient’s risk factors.
Assess for possible causes of DVT such as recent surgery, immobility, trauma, obesity, pregnancy, and dehydration. Since some patients are asymptomatic, assessing risk factors is important for early detection.
3. Measure leg circumference.
Measure the affected leg below the tibial tuberosity and above the patella. If there is a difference of more than 3 cm, it may indicate DVT in some patients. This is useful for determining the need for additional testing such as ultrasound and lab work.
Ineffective Peripheral Tissue Perfusion Interventions
1. Administer anticoagulants as ordered.
Anticoagulants are ordered to prevent clot formation. Patients may receive IV heparin while in the hospital and then transition to PO medications they can take at home. Therapeutic levels must be achieved and maintained by evaluating the patient’s lab values routinely.
2. Apply compression stockings as ordered.
The use of compression stockings and pneumatic compression devices promotes venous circulation and decreases venous stasis. This is important to help decrease inflammation and reduce the risk of blood clot formation.
3. Ensure adequate hydration.
Dehydration causes increased blood viscosity, which can contribute to venous stasis and blood clot formation. Ensure the patient is adequately hydrated to reduce blood viscosity. Encourage the patient to drink adequate amounts of water or other hydrating fluids or administer IV fluids if they are not able to consume liquids.
4. Obtain an ultrasound.
A Doppler ultrasound can be performed at the bedside and is useful in determining abnormalities in blood flow as well as the presence of DVT.
Risk For Bleeding Care Plan
Patients with deep vein thrombosis are at risk for bleeding due to anticoagulant treatment.
Nursing Diagnosis: Risk For Bleeding
Related to:
- Use of anticoagulants
- Abnormal blood profiles
Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not occurred yet and the goal of nursing interventions is aimed at prevention.
Expected Outcomes:
- Patient will maintain therapeutic levels of blood clotting factors
- Patient will verbalize safety measures to prevent bleeding
- Patient will not experience bleeding
Risk For Bleeding Assessment
1. 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.
2. Monitor labs.
Patients with deep vein thrombosis receiving anticoagulant therapy will need regular labs drawn to monitor clotting factors. Monitor platelet count and coagulation profiles (PT, PTT, INR) to reduce the patient’s risk of bleeding.
3. Monitor heparin-induced platelet aggregation (HIPA) status.
Heparin reduces a patient’s platelet count, which puts them at increased risk for bleeding. HIPA causes heparin-induced thrombocytopenia (HIT) which is characterized by a sudden drop in platelets.
Risk For Bleeding Interventions
1. Provide education to reduce bleeding risk.
Educate the patient on ways to reduce their risk of bleeding. Instruct patients to use a soft toothbrush, only use electric razors for shaving, and avoid forceful coughing or nose blowing.
2. Take immediate action if bleeding occurs.
If a patient is on IV heparin and bleeding is found, the nurse should immediately stop the heparin infusion, notify the doctor, evaluate labs (PTT), and re-evaluate the heparin dosage based on lab results.
3. Provide education on bleeding precautions.
If continuing to take oral anticoagulants at home, stress the importance of safety as the patient may easily bruise and bleed if they cut themselves or bump into something. If a head injury occurs the patient must seek immediate assistance as this can become a life-threatening brain bleed.
4. Have antidotes available to reverse anticoagulants.
Protamine sulfate reverses the effect of heparin and vitamin K reverses the effect of warfarin. These should be available in the event of severe bleeding.
Deficient Knowledge Care Plan
Patients require education on the risk, management, and prevention of DVT.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Unfamiliarity with diagnosis or prevention
- Poor knowledge of risk factors
- Lack of interest
As evidenced by:
- Verbalization of questions about diagnosis
- Misadministraction of medications
- Poor follow-through with routine lab work
- Recurrent DVT
Expected Outcomes:
- Patient will verbalize an understanding of diagnosis and treatment
- Patient will verbalize the importance of medications and follow-up lab tests
- Patient will identify their risk factors and three ways to prevent recurrent DVT
Deficient Knowledge Assessment
1. Assess knowledge about risk factors.
Patients may be aware that they are at risk for DVT, but unsure of how to lower their risk. On the other hand, they may not have any knowledge of what the risk factors are. Don’t assume the patient understands and assess their knowledge by asking questions.
2. Evaluate readiness to adhere to medications.
Anticoagulants are potentially high-risk medications and the patient should have a thorough understanding of their regimen and side effects.
3. Assess understanding of follow-up care.
Certain anticoagulants such as warfarin require weekly INR testing to ensure therapeutic levels. Assess the patient’s knowledge and understanding of the importance of this testing.
Deficient Knowledge Interventions
1. Explain the signs of pulmonary embolism.
Instruct on the signs of pulmonary embolism such as sudden chest pain, tachycardia, sudden shortness of breath, tachypnea, and restlessness. Explain why this is a medical emergency and to seek immediate medical attention.
2. Discuss individual risk factors.
Help the patient recognize their risk factors for developing DVT and discuss ways they can decrease their risk. Smoking is a huge, preventable risk factor for DVT. Immobility can also lead to the development of DVT so patients can be encouraged to ambulate frequently or adhere to compression devices if unable.
3. Provide education about medications.
Review medications to continue at discharge thoroughly. Ask the patient to verbalize each medication and to explain the proper dose, frequency, and reason for each one to evaluate effective teaching.
4. Teach ways to prevent a recurrence.
Instruct on easy ways patients can decrease their risk of recurrent DVT. Do not sit with legs or ankles crossed as this can hinder circulation. Higher altitudes such as when flying can increase the risk of DVT as well as sitting on long car rides. Stand and walk frequently on long flights and stop for rest breaks to stretch the legs on car rides.
References and Sources
- Anticoagulant Treatment of Deep Vein Thrombosis and Pulmonary Embolism: The Present State of the Art. (2015, July 14). Frontiers. Retrieved March 31, 2022, from https://www.frontiersin.org/articles/10.3389/fcvm.2015.00030/full
- Deep vein thrombosis physical examination. (2014, July 13). wikidoc. Retrieved March 29, 2022, from https://www.wikidoc.org/index.php/Deep_vein_thrombosis_physical_examination
- Dhakal P, Rayamajhi S, Verma V, Gundabolu K, Bhatt VR. Reversal of Anticoagulation and Management of Bleeding in Patients on Anticoagulants. Clin Appl Thromb Hemost. 2017 Jul;23(5):410-415. doi: 10.1177/1076029616675970. Epub 2016 Oct 26. PMID: 27789605.
- Medications for Deep Vein Thrombosis (DVT). (n.d.). Stanford Health Care. Retrieved March 29, 2022, from https://stanfordhealthcare.org/medical-conditions/blood-heart-circulation/deep-vein-thrombosis/treatments/medications.html
- Pulmonary Embolism. (n.d.). American Thoracic Society. Retrieved March 31, 2022, from https://www.thoracic.org/patients/patient-resources/resources/pulmonary-embolism.pdf
- Rebarber, A. (2021, May 17). Deep Vein Thrombosis (DVT) in Pregnancy and Postpartum: Symptoms & Causes. What to Expect. Retrieved March 31, 2022, from https://www.whattoexpect.com/pregnancy/pregnancy-health/complications/deep-venous-thrombosis.aspx
- Waldron, B. (2014, 04 29). A Patient’s Guide to Recovery After Deep Vein Thrombosis or Pulmonary Embolism. AHA Journals. https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.113.006285
- What is Venous Thromboembolism? (n.d.). CDC. Retrieved March 29, 2022, from https://www.cdc.gov/ncbddd/dvt/facts.html
