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Nursing Care Plan for Deep Vein Thrombosis (DVT)

Pathophysiology

Blood clots formed from any source, lodging in the patient leg or arm, impeding blood flow. This backup of blood pools in the extremity causing swelling, redness, warmth and pain.

Etiology

Narrowing or occlusion of the vessels in an extremity. If caused by plaque (cholesterol and other substances) this could be from poor diet, lack of exercise, or genetics. However, blood stasis can cause aggregation of platelets and other blood products forming a clot that travels to the extremity (or heart, lungs or brain!). The most common cause of blood pooling (stasis) is Atrial Fibrillation (AFib). Other major causes are prolonged sitting, pregnancy, smoking, and birth control.

Desired Outome

Stabilization of the blood clot or disintegration of the blood clot as well as prophylaxis treatment for future blood clots.

Deep Vein Thrombosis (DVT) Nursing Care Plan

Subjective Data:

  • Painful extremity
  • Numbness and tingling on affected extremity
  • Potential subjective data to be concerned about and monitor for: (this is if the clot moves)!
  • Pulmonary Embolism (PE): Difficulty in Breathing (DIB)/Shortness of Breath (SOB), Chest Pain (CP)
  • Myocardial Infarction (MI): Chest Pain (CP)
  • Stroke: facial asymmetry, confusion, one sided deficit,  

Objective Data:

  • Warm, red, firm and swollen leg
  • Decreased peripheral pulse on affected extremity

Nursing Interventions and Rationales:

  1. Assess a full neuro exam, assess breathing-Pulse oximetry, difficulty in breathing, chest pain, obtain an EKG.
    • Assess and monitor for potential complications d/t the blood clot moving into another area such as the lungs (PE), heart (MI), or brain (CVA).
  2. Heparin- initial therapy to break up clot. Transition into a SubQ or oral anticoagulant to prevent future clots.
    • This is an anticoagulant that breaks up blood clots (as well as prevents them).

      Monitor aPTT or Anti-Xa Q6H to adjust and maintain therapeutic levels.

      Bolus: 80 units/kg

      Initial dose: 18 units/kg/hr
      -Adjust according to your organization's nomogram (Q6H- based on results of aPPT or Anti-Xa)
  3. Enoxaparin (Lovenox)/Warfarin (Coumadin)
    • Both SubQ and oral anticoagulant therapy use as prophylaxis (prevention) therapy.

      Patient will need to have frequent blood draws to monitor their INR. Therapeutic range is between 2 and 3.

      Enoxaparin: 1-1.5 mg/kg

      Warfarin: initial dose is 2-4 mg, and typically can range up to 10 mg.
  4. Educate about avoiding vitamin K (both supplements as well as food)
    • Vitamin K works to help increase clotting, this is opposite of what we are trying to do for this patient, unless of course they are bleeding out, in which case the treatment may be vitamin K with Fresh Frozen Plasma (FFP)
  5. Continuous monitoring: 3 or 5 lead cardiac monitoring pulse oximetry monitoring
    • This monitors for changes in the heart and allows for quick intervention if the clot moves and is stuck in the heart.

      This monitors for changes in oxygenation if the clot moves to the lungs.
  6. Bleeding/fall precautions because of anticoagulant therapy
    • This isn’t just for in the hospital, it is also for when the patient goes home. The patient is at major risk for bleeding out, thus educating about s/sx of internal bleeding as well as educating about fall precautions is vital.

      GI bleeding: Dark, tarry stool (Upper GI bleed) OR bright red bloody stools (lower GI bleed)

      Epistaxis: Nosebleeds are obvious, however, inform the patient that if they bleed through nasal packing for longer than 15 minutes they should go to the ER. Also they they feel dizzy, faint, or are losing color in their face they should go to the ER.

      Cuts that don’t stop bleeding: if the cut has had pressure applied for longer than 15 minutes and the gauze is being soaked through the patient should go to the ER.

      Brain bleed: Have patients and the people who are around them look for S/Sx such as confusion, facial droop, one-sided weakness.

References

Date Published - May 16, 2017
Date Modified - Jun 30, 2017