DEEP VEIN THROMBOSIS [DVT]

Introduction
Deep vein thrombosis, or deep venous thrombosis, (DVT) is the formation of a blood clot (thrombus) in
a deep vein, predominantly in the legs. Venous thromboses are comprised mainly of fibrin and red blood cells.
DVT can occur in the upper extremities, cerebral sinuses, hepatic, and retinal veins.

Definition
Deep vein thrombosis (DVT) is a condition in which a blood clot (thrombus) forms in one or more of the
deep veins in your body, usually in your legs or pelvic area. Deep vein thrombosis can cause leg pain, but often
occurs without any symptoms.

Causes
The three factors discovered by German pathologist named as Virchow's triad - Venous stasis, Vein wall
trauma/ dilation (changes in the endothelial blood vessel lining ) and hypercoagulability

Venous stasis: immobility reduces the effectiveness of the calf muscle pump and can lead to stasis
(slowing of blood flow) and pooling of blood behind the valve cusps;
Vein wall trauma/dilation: local trauma (for example, orthopaedic surgery or leg fracture) to
the endothelial lining of the vein wall activates clotting by triggering the release of tissue factor.
Venous dilation, which may occur intraoperatively, can cause endothelial damage resulting in
the exposure of collagen and activation of clotting;
Hypercoagulability: a variety of hereditary and acquired causes of increased coagulability, such
as pregnancy, malignancy, and thrombophilia.
DVT is generally caused by a combination of two or three underlying conditions:
Slow or sluggish blood flow through a deep vein
Tendency for a persons blood to clot quickly
Irritation, inflammation or injury to the inner lining of the vein
Other related causes include
o activation of immune system components,
o the state of microparticles in the blood,
o the concentration of oxygen,
o possible platelet activation.

Risk factors
Various risk factors contribute to DVT, though many at high risk never develop it.
STRONG RISK FACTORS
Fracture (hip or leg)
Hip or knee replacement
Major general surgery
Major trauma
Spinal cord injury

MODERATE RISK FACTORS

Arthroscopic knee surgery
Central venous lines
Congestive heart failure
Respiratory failure Hormone
replacement therapy
Intravenous drug abuse
Malignancy
Oral contraceptives
Paralytic stroke
Pregnancy/postpartum
Previous venous
thromboembolism
Thrombophilia

WEAK RISK FACTORS

Bed rest <3 days
Immobility due to sitting, such
as in prolonged car or air travel
Increasing age
Laparoscopic surgery
Obesity
Varicose veins

Symptoms

Calf pain and/or tenderness;

Swelling with pitting oedema;
Swelling below the knee in distal DVT and up to the groin in proximal DVT;
Increased skin temperature;
Superficial venous dilation;
Cyanosis can occur with severe obstruction. Change in color (blue, red or very pale)
Fullness of the veins just beneath the skin

Even patients with extensive venous thrombosis may have minimal leg symptoms, while pain, tenderness,
and swelling of the leg may be caused by other disorders The most common symptom is leg pain and tenderness
in the calf muscles.

Diagnosis
Pre-test probability
HISTORY
Paralysis, paresis or recent plaster immobilisation
Bedridden for >3 days
Major surgery in last 4 weeks
Recent airline flight >4 hours
Active cancer treatment in the past six months or palliative cancer treatment
Strong family history of DVT (two or more affected first-degree relatives)
ON EXAMINATION
Entire leg swollen
Symptomatic calf more than 3cm larger than other leg measured 10cm below tibial tuberosity
Tenderness along deep venous system
Collateral superficial veins (non varicose)
[Score 1 point for each of the following and Subtract 2 points if another diagnosis is more likely]
[3 = High risk; 12 = Moderate risk; 0 = Low risk]
D-dimer
A specific blood test may also be performed to measure D-dimer which is a sign of recent
clotting. When this test is negative, it is unlikely that DVT has occurred. D-dimer is a fibrin
degradation product (or FDP), a small protein fragment present in the blood after a blood clot is
degraded by fibrinolysis. It is so named because it contains two crosslinked D fragments of
the fibrin protein
Ultrasonography
Duplex ultrasonography is a non-invasive method of detecting DVT. Proximal DVT can be
detected with a sensitivity and specificity of 96 per cent and 98 per cent respectively It is, however, less
sensitive for distal DVT and pelvic DVT.
Venography
This is the gold-standard investigation for DVT but due to its invasive nature it is no longer a
first-line investigation. Radiopaque contrast is injected into a dorsal foot vein to visualise thrombi under
X-ray control. The procedure carries a small risk of venous thrombosis or allergic reaction to the dye, and
may be technically difficult in patients who have poor venous access
Plethysmography
This non-invasive method records changes in limb size due to accumulation of tissue fluid or
pooled blood. Plethysmography is of limited value in the detection of older thrombi or in cases of nonocclusive thromboses.
Magnetic resonance direct thrombus imaging
This is a novel non-invasive technique in which the thrombus is visualised by the detection of
methaemoglobin. The technique detects recent thrombi, and is therefore also useful for the diagnosis of
recurrent DVT.

Complications of DVT
After diagnosis of DVT the thrombus may dissolve without causing any problems but in a
minority of patients Pulmonary Embolism may occur, which can be fatal. It occurs when a part of the
thrombus becomes detached from the vein wall and lodges in the pulmonary circulation. It can cause
respiratory difficulties such as shortness of breath, pain on inspiration, and haemoptysis.
Post-thrombotic syndrome is a long-term complication of DVT. It occurs due to damage and
incompetence of venous valves causing blood to pool in the lower leg. The clinical signs include chronic
swelling and skin changes in the affected limb.
Recurrent DVT or Pulmonary Embolism is common, particularly after idiopathic thrombosis or
in the presence of persisting risk factors.
Venous leg ulcers develop as a result of DVT. These chronic wounds can make a significant
impact on quality of life as well as on health care resources

Treatment
The objectives of treatment for DVT include the prevention of: local thrombus extension; embolisation; and
recurrent DVT.
Mobilisation
Mobile patients with acute proximal DVT treated with LMWH should be encouraged to walk with
compression stockings. Pain and swelling resolve significantly faster, with no evidence of an associated
increase in risk of pulmonary embolism.
Anticoagulation
Anticoagulation with heparin and warfarin is the standard treatment for DVT; LMWH has been
demonstrated to be safe, effective, and convenient, and has allowed patients to be managed in an outpatient
setting
Oral anticoagulants such as warfarin inhibit the vitamin K-dependent clotting factors.
Compression stockings
Once a patient has been diagnosed with a DVT, compression stockings (Class I, II, or III) are applied
to reduce the risk of recurrence and the development of post-thrombotic syndrome. Some manufacturers of
high compression stockings (2040mmHg at the ankle: Class I, II, and III) recommend that an
ankle:brachial ratio check (the ratio of ankle systolic pressure to highest brachial systolic pressure) should
be performed before fitting.

Thrombolysis
The health care providers may also recommend thrombolysis, using an intravenous agent that
dissolves clots. The clotbuster is injected slowly through a catheter with many tiny holes into the
area of the DVT, much like a soaker hose. Sometimes a tiny vacuum cleaner is used to suck out
the softened clot. Once the clot is gone, balloon angioplasty or stenting may be necessary to
open the narrowed vein, but this is common only in the iliac veins, located in the pelvic area.
With this approach, the patient will also need anticoagulant medication (heparin) to prevent new
blood-clot formation while the existing clot is being dissolved.
Surgical intervention
For a few patients who have valid reasons for clot removal but for whom clot-dissolving drugs
cannot be used, extraction of the clot, through a small incision at the groin, may be recommended. Both
approaches are designed to remove the clot and restore the venous system to normal, but they involve
additional risk and expense and therefore are applied selectively by the appropriate vascular specialist.

Prevention of DVT
The basis of DVT prophylaxis is to target the triad of predisposing factors: venous stasis; vein wall
trauma/dilation; and hypercoagulability.

 Mobilisation and breathing exercises

Nurses can encourage mobilisation and leg exercises in at-risk patients in order to activate
the calf muscle pump. Breathing exercises will also help venous return. Patients should be advised
to observe for signs and symptoms that suggest DVT and inform nurses if concerned.
Antiembolism stockings
Antiembolism stockings (AES) provide continuous stimulation of linear blood flow, prevent
venous dilation and stimulate endothelial fibrinolytic activity
The nurses role is to assess for contraindications to wearing AES by physical assessment
and clinical history and to measure and fit the correct stockings according to the information
supplied by the manufacturer. The patients skin integrity should be checked regularly and the
patient should be given written and verbal information on how to wear and care for AES. The patient
should be told that:
Stockings should be smooth when fitted;
The toe hole should lie underneath the toes;
The heel patch should be in the correct position;
The thigh gusset should be on the inner thigh;
Rolling down the stocking may have a tourniquet effect.
Patients should be asked to report any numbness or tingling, which may suggest arterial impairment.
Anticoagulants
Anticoagulants such as low-molecular-weight heparin (LMWH) increase the action of
antithrombin and inhibit a number of coagulation proteins. LMWH can be administered in a
prophylactic dose, usually via subcutaneous injection, with a predictable anticoagulant response. In
moderate-risk patients use of AES may be combined with anticoagulants to minimise risk.
Patients require careful observation as anticoagulants can cause bleeding, and any sideeffects should be reported. An obvious drop in the platelet count may indicate heparin-induced
thrombocytopaenia (HIT). Nurses should observe for local reactions at injection sites, which may
necessitate switching to another brand of LMWH.
Intermittent pneumatic compression
Intermittent pneumatic compression (IPC) is an established method of DVT prophylaxis
with no risk of haemorrhagic complications. There is a variety of devices on the market ranging
from calf and thigh cuffs to foot pumps. They may be combined with the use of AES and LMWH
in high-risk patients.

Some Tips to Avoid DVT

Do not sit for long periods of time

Elevate legs if you are sitting for moderate periods of time
If you are on an airplane for more than four hours-get up
and walk in the aisles, pump your feet up and down
If you are flying, drink plenty of non-alcoholic beverages
Keep hydrated-drink six glasses of water a day
Talk to your doctor about the need for medications or graduated
elastic compression stockings for long airplane flights
If you have varicose veins, wear support hose (especially if pregnant)
Do not wear constricting garments around the legs or waist (elastic bands or garters)

Nursing Priorities
1. Maintain/enhance tissue perfusion, facilitate resolution of thrombus.
2. Promote optimal comfort.
3. Prevent complications.
4. Provide information about disease process/prognosis and treatment regimen.

Nursing Care Plan

sing diagnosis
Ineffective
peripheral
Tissue Perfusion
May be related to
Decreased
blood
flow/venous
stasis
(partial or complete
venous obstruction)
Possibly evidenced by
Tissue edema, pain
Diminished
peripheral
pulses,
slow/diminished
capillary refill
Skin color changes
(pallor, erythema)

Outcome
CLIENT WILL:
Tissue
Perfusion:
Peripheral
Demonstrate
improved perfusion
as
evidenced by peripheral
pulses present/equal, skin
color
and
temperature
normal,
absence
of
edema.
Engage
in
behaviors/action
s
to
enhance
tissue perfusion.
Display
increasing
tolerance
to
activity.

Plan of action
Evaluate circulatory and neurologic
studies of involved extremityboth
sensory and motor.
Inspect for skin color and temperature
changes, as well as edema (from groin
to foot).
Note symmetry of calves; measure and
record calf circumference & Report
proximal progression of inflammatory
process, traveling pain.

Examine
extremity
for
obviously
prominent veins. Palpate gently for
local tissue tension, stretched skin,
knots/bumps along course of vein.
Assess capillary refill and check for
Homans sign.

Promote early ambulation.

Elevate legs when in bed or chair, as

indicated.

Rationale
Symptoms help distinguish between
thrombophlebitis and DVT.
Redness,
heat,
tenderness,
and
localized edema are characteristic of
superficial involvement.
Unilateral edema is one of the most
reliable physical findings in DVT.
Calf vein involvement is associated
with absence of edema; femoral vein
involvement is associated with mild
to moderate edema; iliofemoral vein
thrombosis is characterized by severe
edema.
Distention of superficial veins can
occur in DVT because of backflow
through
communicating
veins.
Thrombophlebitis in superficial veins
may be visible or palpable.
Diminished capillary refill usually
present in DVT. Positive Homans
sign (deep calf pain in affected leg
upon dorsiflexion of foot) is a classic
but unreliable sign because many
clients with DVT do not have a
positive Homans sign.
Short frequent walks are determined
to be better for extremeties and
prevention
of
pulmonary
complications than one long walk. If
client is confined to bed, ensure
range-of-motion exercises.
Reduces tissue swelling and rapidly
empties superficial and tibial veins,
preventing overdistention and thereby
increasing venous return.

 Initiate active or passive exercises

while in bed (e.g., flex/extend/rotate
foot periodically). Assist with gradual
resumption of ambulation (e.g., walking
10 min/hr) as soon as client is permitted
out of bed.
Caution client to avoid crossing legs or
hyperflexion at knee (seated position
with legs dangling, or lying in jackknife
position).
Instruct
client
to
avoid
rubbing/
massaging the affected extremity.
Encourage deep-breathing exercises.
Increase fluid intake to at least 2000
mL/day, within cardiac tolerance.
Apply warm, moist compresses or heat
cradle to affected extremity if indicated.
Administer
anticoagulants,
e.g.:heparin
sodium,
or
lowmolecular-weight
heparin
(LMWH)
preparations,
such
as
enorxaparin
(Lovenox),
dalteparin
(Fragmin),
tinzaparin (Innohep) via continuous or
intermittent
IV,
intermittent
subcutaneous (SC) injections, followed
by oral coumarin derivatives, e.g.,
warfarin
(Coumadin)
or
dicumarol
(Sintrom);

These measures are designed to

increase venous return from lower
extremities and reduce venous stasis,
as well as improve general muscle
tone/strength.
They also
promote
normal organ function and enhance
general well-being.
Physical restriction of circulation
impairs blood flow and increases
venous stasis in pelvic, popliteal, and
leg vessels, thus increasing swelling
and discomfort.
This activity potentiates risk of
fragmenting/dislodging
thrombus,
causing
embolization,
and
increasing risk of complications.
Increases
negative
pressure
in
thorax, which assists in emptying
large veins.
Dehydration
increases
blood
viscosity
and
venous
stasis,
predisposing to thrombus formation.
May be prescribed to promote
vasodilation and venous return and
resolution of local edema.
Heparin may be used initially because
of
its
prompt,
predictable,
antagonistic action on thrombin as it
is formed and also because it
removes
activated
coagulation
factors XII, XI, IX, and X (intrinsic
pathway),
preventing
further
clot
formation. LMWH is the anticogulant
of choice after major orthopedic
sugery and major trauma due to a
lower
risk
of
bleeding,
more
predictable dose response and longer
half-life than heparin. Coumadin has
a potent depressant effect on liver

 Thrombolytic
agents;
streptokinase, urokinase.

Monitor
laboratory
indicated:
PT, PTT, aPTT

e.g.,

studies

as

Platelet
count,
function/aggregation test,
antibody assay.

platelet
antiheparin

Apply/regulate graduated
stockings,
intermittent
compression if indicated.

compression
pneumatic

Apply elastic support hose following

acute phase. Take care to avoid
tourniquet effect.

Prepare for surgical intervention when

indicated.

formation
of
prothrombin
from
vitamin K and impairs formation of
factors VII, IX, and X (extrinsic
pathway).
May be used in hemodynamically
unstable client with PE or massive
DVT to reduce risk of developing
PE, or the presence of valvular
damage
and/or
chronic
venous
insufficiency.
Heparin
is
usually
begun
several
hours
after
the
completion of thrombolytic therapy.
Monitors anticoagulant therapy and
presence
of
risk
factors;
e.g.,
hemoconcentration and dehydration,
which potentiate clot formation
On occasion, platelet count may
decrease as a result of an immune
reaction
leading
to
platelet
aggregation or the formation of
white clots.
Sequential compression devices may
be used to improve blood flow
velocity
and
empty
vessels
by
providing artificial muscle-pumping
action.
Properly fitted support hose are
useful (once ambulation has begun)
to minimize or delay development of
postphlebotic
syndrome
&
distributed
pressure
over
entire
surface of calves and thighs to reduce
the caliber of superficial veins and
increase blood flow to deep veins.
Thrombectomy
(excision
of
thrombus) is occasionally necessary
if inflammation extends proximally
or circulation is severely restricted.
Multiple/recurrent
thrombotic

Acute Pain/[Discomfort]
May be related to
Diminished
arterial
circulation
and
oxygenation of tissues
with
production/accumulation
of lactic acid in tissues
Inflammatory process
Possibly evidenced by
Reports of pain,
tenderness,
aching/burning
Guarding of affected
limb
Restlessness,
distraction behaviors

CLIENT WILL:
Pain Control
Report
that
pain/discomfort
is
alleviated or controlled.
Verbalize methods that
provide relief.
Display relaxed manner;
be able to sleep/rest and
engage in desired activity.

Assess degree and characteristics of

discomfort/pain.
Palpate
leg
with
caution.

Maintain bedrest during acute phase.

Elevate affected extremity.
Provide foot cradle.
Encourage client
frequently.
Monitor vital
temperature.

to

change

position

signs,

noting

elevated

Investigate reports of sudden and/or

sharp chest pain, accompanied by
dyspnea,
tachycardia,
and
apprehension, or development of a new
pain with signs of another site of
vascular involvement.
Administer medications, as indicated:

episodes unresponsive to medical

treatment (or when anticoagulant
therapy
is
contraindicated)
may
require insertion of a vena caval
screen/umbrella.
Degree of pain is directly related to
extent
of
circulatory
deficit,
inflammatory process, degree of
tissue ischemia, and extent of
edema associated with thrombus
development.
Changes
in
characteristics of pain may indicate
progression of problem/development
of complications.
Reduces discomfort associated with
muscle contraction and movement.
Encourages
venous
return
to
facilitate
circulation,
reducing
stasis/edema formation.
Cradle keeps pressure of bedclothes
off
the
affected
leg,
thereby
reducing pressure discomfort.
Decreases/prevents muscle fatigue,
helps
minimize
muscle
spasm,
maximizes circulation to tissues.
Elevations in heart rate may
indicate increased pain/discomfort or
occur in response to fever and
inflammatory process. Fever can
also increase clients discomfort.
These signs/symptoms suggest the
presence of pulmonary emboli as a
complication of DVT or peripheral
arterial occlusion associated with
heparin-induced
thrombocytopenia
and
thrombosis
(HITT).
Both
conditions require prompt medical
evaluation and treatment.

Analgesics (narcotic/nonnarcotic);
Antipyretic;
(Tylenol).
Apply moist
indicated

Deficient Knowledge
[Learning Need]
regarding condition,
treatment program, selfcare, and discharge needs
Related to
Lack of exposure or recall
Misinterpretation of
information
Unfamiliarity with
information resources
Possibly evidenced by
Request for
information, statement
of misconception
Inaccurate followthrough of instructions
Development of
preventable
complications

CLIENT WILL:
Knowledge: Disease
Process
Verbalize
understanding of
disease process,
treatment regimen,
and limitations.
Participate in
learning process.
Identify
signs/symptoms
requiring medical
evaluation.
Knowledge: Treatment
Regimen
Correctly perform
therapeutic actions
and explain reasons
for actions.

e.g.,
heat

acetaminophen
to

extremity

if

Disease Process
Review pathophysiology of condition
and
signs/symptoms
of
possible
complications;
e.g.,
pulmonary
emboli, chronic venous insufficiency,
venous stasis ulcers (postphlebitic
syndrome).
Explain
purpose
of
activity
restrictions and need for balance
between activity/rest.

Establish
appropriate
activity program.

exercise

Problem-solve
solutions
to
predisposing factors that may be
present;
e.g.,
employment
that
requires
prolonged
standing/sitting,
wearing
restrictive
clothing
(girdles/garters),
use
of
oral
contraceptives,
obesity,
prolonged
bed rest/immobility, dehydration.
Recommend
sitting
with
feet
touching the floor, avoiding crossing
of legs.
Review purpose and demonstrate
correct
application/
removal
of
antiembolic hose.

Relieves pain and decreases muscle

tension.
Reduces fever and inflammation.
Causes
vasodilation,
which
increases
circulation,
relaxes
muscles, and may stimulate release
of natural endorphins.
Provides a knowledge base from
which client can make informed
choices
and
understand/identify
healthcare
needs.
Up
to
33%
experience a recurrence of DVT.
Rest reduces oxygen and nutrient
needs of compromised tissues and
decreases risk of fragmentation of
thrombosis. Balancing rest with
activity prevents exhaustion and
further
impairment
of
cellular
perfusion.
Aids
in
developing
collateral
circulation,
enhances
venous
return, and prevents recurrence.
Actively
involves
client
in
identifying
and
initiating
lifestyle/behavior
changes
to
promote
health
and
prevent
recurrence
of
condition
/development of complications.
Prevents excess
popliteal space.

pressure

on

the

Understanding
may
enhance
cooperation with prescribed therapy

 Instruct in meticulous skin care of

lower
extremities;
e.g.,
prevent/promptly treat breaks in skin
and
report
development
of
lesions/ulcers or changes in skin
color.
Teaching: Prescribed Medication
Discuss
purpose,
dosage
of
anticoagulant. Emphasize importance
of taking drug as prescribed.
Identify safety precautions; e.g., use
of soft toothbrush, electric razor for
shaving,
gloves
for
gardening,
avoiding
sharp
objects
(including
toothpicks),
walking
barefoot,
engaging in rough sports /activities, or
forceful blowing of nose.
Review clients usual medications and
foods when on oral anticoagulants,
stress need to read ingredient labels of
OTC drugs and herbal supplements,
and
discuss
use
with
healthcare
provider
prior
to
starting
new
medications.

Identify
untoward
anticoagulant
effects requiring medical attention;
e.g., bleeding from mucous membranes
(nose, gums), continued oozing from

and
prevent
improper/ineffective
use.
Chronic
venous
congestion/
postphlebitic syndrome may develop
(especially in presence of severe
vascular
involvement
and/or
recurrent episodes), potentiating risk
of stasis ulcers/infection.
Promotes client safety by reducing
risk
of
inadequate
therapeutic
response/ deleterious side effects.
Reduces the risk of traumatic
injury,
which
potentiates
bleeding/clot formation.

Warfarin (Coumadin) interacts with

many foods and drugs, either
increasing
or
decreasing
the
anticoaglant effect. Salicylates and
excess alcohol decrease prothrombin
activity,
whereas
vitamin
K
(multivitamins, bananas, leafy green
vegetables)
increases
prothrombin
activity, and can cause a higher or
lower INR, possibly outside of the
therapeutic
range.
Barbiturates
increase metabolism of coumarin
drugs;
antibiotics
alter
intestinal
flora and may interfere with vitamin
K synthesis.
Early detection of deleterious effects
of therapy (prolongation of clotting
time) allows for timely intervention

cuts/punctures, severe bruising after

minimal
trauma,
development
of
petechiae.
Stress importance of medical followup/laboratory testing.

Encourage
wearing
of
medical
identification
bracelet/
tag,
as
indicated.

and
may
complications.

prevent

serious

Understanding that close supervision

of
anticoagulant
therapy
is
necessary (therapeutic dosage range
is narrow and complications may be
deadly)
promotes
client
participation.
Alerts
emergency
healthcare
providers to history of thrombotic
problems and/or current use of/or
need
for
anticoagulants
(e.g.,
prophylactic before and after any
procedure or event with an increased
risk of venous thromboembolism.

Conclusion
DVT can be associated with significant morbidity. Nurses should focus on prevention by the early recognition and adequate prophylaxis of those at increased
risk. Patients should be actively involved in their care wherever possible. An awareness of diagnostic and treatment strategies will enable nurses to inform
patients. This will help to improve both concordance with treatment and disease outcome.

*************

Topic presentation
On
Deep vein thrombosis {dvt} & its management

JOHN JACOB