Deep Vein Thrombosis (DVT) -thrombophlebitis of the deep veins Etiology and Risk Factors -attributed to Virchows Triad

1. venous stasis caused by immobilization or absence of the calf muscle pump. Risk factors: age over 40 years, surgery, immobility, prolonged travel, stroke, obesity, paralysis and cardiac disease (heart failure, MI, cariomyopathy) 2. hypercoagubility often accompanies malignant neoplasms (tumors). Dehydration and blood dyscrasia may raise platelet count/increase blood viscosity. Oral contraceptives and hematologic disorders may also increase blood coagubility 3.injury to the venous wall/ endothelial damage damage to vein wall attracts platelets, and blood debris accumulates. Risk factors: IV injections, fractures and dislocations, severe blow to an area, chemical injury from sclerosing agents, contrast x-rays ***at least two out of three preceding conditions must be present for thrombus formation PATHOPHYSIOLOGY venous return is aided by calf muscle pump leg is inactive/pump is ineffective blood pools by gravity in the veins Thrombus development (facilitated through Virchows Triad) vein obstruction valves of the veins can be destroyed due to resulting inflammatory process venous insufficiency

DIAGNOSTIC TESTS: a. Homans Sign: discomfort in the upper calf during forced dorsiflexion of the foot -does not always indicate DVT. b. Venous duplex scanning: allows visualization of the vein, which provides an extremely reliable diagnosis of venous thrombus NSG RESP: non-invasive; usually requires no preparation for the patient b. Doppler ultrasonographic flowmeter: determines blood flow in the larger blood vessels and the patency of the vessels NSG RESP: Position patient supine with head of bed 20-30 degrees elevated, legs externally rotated to access medial malleolus Apply acoustic gel to allow uniform transmission of ultrasound waves Avoid putting excessive pressure d. D-dimer test: being used more frequently in evaluation of DVT. D-dimer is a product of fibrin degradation and is indicative of fibrinolysis that occurs with thrombosis. e. Plethysmography: done by recording volume changes in a limb during venous filling and emptying. Impedance pletysmography measures maximal venous filling capacity by applying a pneumatic cuff at thigh level then recording the rate of venous emptying after cuff release. Changes in volume are measured with the patients legs elevated, with the patient supine and standing, and after the patient performs toe-ups (patient extends ankle while standing; stands on tip-toes). NSG RESP: Assist the client in positioning CLINICAL MANIFESTATIONS: -Unilateral swelling distal to the site -pain, redness or warmth of the leg, dilated veins and low grade fever MANAGEMENT: MEDICAL MANAGEMENT A. ANTICOAGULATION: detect thrombus early, prevent extension or embolization of the thrombus and prevent thrombus formation. Unfractionated Heparin: prevents activation of clotting factor IX and inhibits the action of thrombin in forming fibrin threads.

REFERENCES: Black, Hawks, Keene; Medical-Surgical Nursing: Clinical Management for Positive Outcomes Smeltzer; Brunner & Suddarths Textbook of Medical-Surgical Nursing

administered subcutaneously to prevent development of deep vein thrombosis, or by intermittent intravenous infusion or continuous infusion for 5 to 7 days to prevent the extension of a thrombus and the development of new thrombi. -Oral anticoagulants, such as warfarin (Coumadin), are administered with heparin therapy. -Medication dosage is regulated by monitoring the partial thromboplastin time, the international normalized ratio (INR), and the platelet count -antidote is protamine sulfate NSG CONSIDERATIONS: Contraindicated in any conditions of bleeding or disorders that increase the risk of bleeding. Low-molecular-weight heparin: inactivates factor Xa. Advantages include decreased bleeding complications, subcutaneous route, no need for laboratory testing and ability of the client to be ambulatory. Warfarin: inhibits hepatic synthesis of vitamin K dependent clotting factors. -INR for DVT is 2.0 to 3.0 -antidote is vitamin K -Heparin is used initially with warfarin begins to take effect. Fibrinolytic Agents: dissolves thrombi by stimulating the conversion of plasminogen to plasmin, an enzyme that decomposes fibrin (e.g., streptokinase and urokinase) B. SURGICAL MANAGEMENT: If anticoagulants are contraindicated Thrombectomy: removal of thrombosis Vena Cave Filters: a filter is inserted in the vena cave to trap large emboli. Devices look like umbrellas and those that are complex web of threads. The device is inserted by threading the device through the femoral or jugular vein (with the use of local anesthesia) NURSING MANAGEMENT A. ELEVATE THE CLIENTS LEGS -above the level of the heart facilitates blood flow by the force of gravity, thus preventing venous stasis -also decreases venous pressure which relieves edema and pain -Trendelenburg position with a slight knee bend to prevent popliteal pressure B. RELIEVE DISCOMFORT -Elevation of the extremity and application of warm packs usually relieve discomfort. NSG RESP: Never massage! C. ENCOURAGING EXERCISES - Active and passive leg exercises, particularly those involving calf muscles, should be performed to increase venous flow. -Early ambulation is most effective in preventing venous stasis. -Deep-breathing exercises are beneficial because they produce increased negative pressure in the thorax, which assists in emptying the large veins. -Once ambulatory, patients are instructed to avoid sitting for more than 2 hours at a time. -The goal is to walk at least 10 minutes every 1 to 2 hours. Patients are also instructed to perform active and passive leg exercises when they are not able to ambulate as frequently as necessary, such as during long car, train, and plane trips. D. APPLYING ELASTIC COMPRESSION STOCKINGS -Elastic compression stockings usually are prescribed for patients with venous insufficiency. These stockings exert a sustained, evenly distributed pressure over the entire surface of the calves, reducing the caliber of the superficial veins in the legs and resulting in increased flow in the deeper veins. Thigh-high stockings are difficult for the patient to wear, because they have a tendency to roll down. The roll of the stocking further restricts blood flow rather than the stocking providing evenly distributed pressure over the thigh. E. MONITOR ANTICOAGULANT THERAPY -OBSERVE THE CLIENT FOR THE FOLLOWING: Bleeding, evidenced by pink-tinged or frank blood in the urine, tarry or frank blood in the stool, and bleeding after brushing the teeth Subcutaneous bruising Flank Pain F. MONITOR THE CLIENT FOR DEVELOPMENT OF PULMONARY EMBOLISM

REFERENCES: Black, Hawks, Keene; Medical-Surgical Nursing: Clinical Management for Positive Outcomes Smeltzer; Brunner & Suddarths Textbook of Medical-Surgical Nursing

-Chest pain is the most common clinical manifestation of PE (pleuritic pain due to inflammatory reaction of the lung parenchyma or pulmonary ischemia caused by obstruction of small pulmonary arterial branches; sudden in onset and is worsened by breathing) -Hemoptysis can occur (may be due to alveolar hemorrhage) -cough, diaphoresis, dyspnea PREVENTION -promoting venous stasis, treating hypercoagubility and reducing risk of injury to the venous wall. Promoting Venous stasis: -improved by any activity that causes leg muscles to contract -Passive or active contraction (such as leg exercises and ambulation) to promote venous return -sequential intermittent pneumatic compression (IPC) devices: leggings are attached by polyethylene tubing to an electric pump attached to the foot of the bed. Air is pumped sequentially into 3 chambers (ankle, calf, and thigh) at a pressure of 45 60mmHg for 15-20 seconds; Effective for patients who cannot tolerate anticoagulation therapy. NSG CONSIDERATION: Theses devices should not be used in clients with known DVT. -elevating the foot of bed -applying compression stockings -using motorized foot devices -providing passive ROM exercises Reducing hypercoagubility: - warfarin, platelet antiaggregation agents (aspirin, most common), heparin, dextran. PATIENT TEACHING: avoid using pillows on clients knees postoperatively; teach client to avoid sitting or standing in one position for prolonged periods. Preventing Injury: -avoidance of infiltration in IV therapy, pressure on calf veins during prolonged surgery, trauma to veins in procedures requiring prolonged positioning.

PATIENT EDUCATION Taking Anticoagulant Medications Take the anticoagulant at the same time each day, usually between
8:00 and 9:00 AM.

Wear or carry identification indicating the anticoagulant being

taken.

Keep all appointments for blood tests. Because other medications affect the action of the anticoagulant,
do not take any of the following medications or supplements without consulting with the primary health care provider: vitamins, cold medicines, antibiotics, aspirin, mineral oil, and anti-inflammatory agents, such as ibuprofen (Motrin) and similar medications or herbal or nutritional supplements. The primary health care provider should be contacted before taking any over-the-counter drugs. Avoid alcohol, because it may change the bodys response to an anticoagulant. Avoid food fads, crash diets, or marked changes in eating habits. Do not take warfarin (Coumadin) unless directed. Do not stop taking Coumadin (when prescribed) unless directed. When seeking treatment from physician, a dentist, a podiatrist, or another health care provider, be sure to inform the caregiver that you are taking an anticoagulant. Contact your primary health care provider before having dental work or elective surgery. If any of the following signs appear, report them immediately to the primary health care provider: Faintness, dizziness, or increased weakness Severe headaches or abdominal pain Reddish or brownish urine

REFERENCES: Black, Hawks, Keene; Medical-Surgical Nursing: Clinical Management for Positive Outcomes Smeltzer; Brunner & Suddarths Textbook of Medical-Surgical Nursing

Any bleedingfor example, cuts that do not stop bleeding Bruises that enlarge, nosebleeds, or unusual bleeding from any part of the body Red or black bowel movements Rash Avoid injury that can cause bleeding. For women: Notify the primary health care provider if you suspect pregnancy.

REFERENCES: Black, Hawks, Keene; Medical-Surgical Nursing: Clinical Management for Positive Outcomes Smeltzer; Brunner & Suddarths Textbook of Medical-Surgical Nursing