Deep Vein Thrombosis (DVT)

Deep Vein Thrombosis (DVT)

A disorder involving a thrombus in a deep vein, most commonly the ileac and femoral veins. It occurs in at least 5% of all surgical patients. More serious than superficial thrombophlebitis because of the risk for pulmonary embolism.

Signs and symptoms

• May be asymptomatic

• Possible unilateral edema, pain, warm skin, and erythema

• If calf involve, tenderness is present

Interventions

• Provide bed rest

• Elevate extremity above the level of the heart as prescribed

• Administer intermittent or continuous warm moist compress

• Assess neurovascular signs of the affected limb

• Apply anti-embolic stockings (thigh-high or knee-high) as prescribed, usually applied when edema subsides, this will help reduce venous stasis and assist in the venous return of blood to the heart

• Avoid putting pillows under the knee

• Monitor for sudden shortness of breath and chest pain for possible pulmonary embolism

• Advise patient not to massage the extremity

Medical interventions:

1. Thrombolytic therapy (t-PA), initiated within 5 days after the onset of symptoms

2. Heparin therapy, prevents enlargement of the existing clot and formation of a new clot

3. Warfarin therapy, prescribed following heparin therapy when symptoms of DVT have resolved

4. Administer analgesics for pain

5. Administer diuretics to reduce lower extremity edema (measure circumference of thighs and calves)

Main causes “VIRchow’s Triad”

Vascular trauma:

1. Abdominal and pelvic surgery (e.g., gynecological or urological)

2. Venipuncture

3. Fracture of pelvis, hip or leg

4. Trauma

5. In-dwelling femoral vein catheter

6. History of previous DVT
   

Increase coagulation:

1. Cigarette smoking

2. Dehydration or malnutrition

3. Oral contraceptives (common in women > 35-years-old who smoke cigarette)

4. High dose estrogen therapy

5. Polycythemia Vera
   

Reduce blood flow:

1. Pregnancy and postpartum period

2. Prolonged immobility (bed rest, fractured leg or hip, long trip without exercise, spinal cord injury, stroke, advanced age, orthopedic sugery)

3. Obesity

4. Varicose veins

5. Atrial fibrillation, congestive heart failure

Potential complications

• Pulmonary embolism
  

Laboratory assessments/Diagnostic Test

• Venous doppler evaluation – determine venous flow in deep femoral, popliteal, and posterior tibial veins

• Duplex scanning – determine location and extent of thrombus within veins “ultrasound imaging + Doppler” (most common test used to diagnose DVT)

• Venogram (phlebogram) – determine the location and extent of clot using a contrast media

• Spiral CT scan – obtains continuous slices allowing visualization of entire anatomic areas such as the lungs

• D-dimer – elevation may suggest pulmonary embolus but is not diagnostic

• Platelet count, bleeding time, INR, aPTT – possible alteration due to drug therapy

Education

Instruct the patient concerning the hazards of anticoagulation therapy “BBRANDDIM”

1. Bleeding signs and symptoms (e.g., ecchymosis, gum & nose bleeding, hematuria, etc.)

2. Blood test monitoring (e.g., PT, aPTT, INR)

3. Razor electric and soft-bristled toothbrush must be used

4. Avoid ASA, NSAID, and other herbs (e.g., garlic, ginseng, ginkgo biloba, st. John’s wort etc.)

5. No contact sports (e.g., basketball, football, boxing etc.)

6. Diet must have regular intake of foods rich in vitamin K (e.g., broccoli, cabbage, brussels sprouts, green leafy vegetables), avoid grapefruit may increase bleeding risk

7. Dentist and other health care provider should know that the patient is on anticoagulant

8. Intramuscular injections must be avoided if possible

9. Medical alert bracelet must be worn at all times

• Avoid prolonged sitting or standing, crossing legs when seated and wearing constrictive clothing

• Elevate the legs for at least 10 to 20 minutes every few hours each day

• Plan a progressive walking program

• Check the legs for edema, and measure the leg circumference

• Wear antiembolism stockings as prescribed

• Avoid smoking