Included In This Lesson
Outline
Pathophysiology
Blood clots formed from any source, lodging in the patient leg or arm, impeding blood flow and causing inflammation. This backup of blood pools in the extremity causing swelling, redness, warmth, and pain. These clots can dislodge and become embolic, lodging in the heart, lungs, or brain.
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. Virchow’s triad explains the 3 major contributors to the development of thrombophlebitis: venous stasis, damage to the inner lining of the vessel, and hypercoagulability.
Desired Outcome
Stabilization of the blood clot or disintegration of the blood clot as well as prophylaxis treatment for future blood clots. Prevention of complications such as embolic strokes, myocardial infarction, or pulmonary embolism.
Thrombophlebitis / Deep Vein Thrombosis (DVT) Nursing Care Plan
Subjective Data:
- Unilateral findings on affected extremity:
- Painful
- Numbness
- Tingling
- Symptoms of Embolism
- Lungs → Pulmonary Embolism (PE)
- Anxiety
- Shortness of Breath (SOB)
- Chest Pain (CP)
- Heart → Myocardial Infarction (MI)
- Chest Pain (CP)
- Brain → Stroke
- Facial asymmetry
- Confusion
- One-sided deficit
- Lungs → Pulmonary Embolism (PE)
Objective Data:
- Unilateral findings on affected extremity:
- Warmth
- Redness
- Swelling (firm)
- Decreased peripheral pulse
- Positive D-Dimer
- Evidence of Clot on Ultrasound
- Possible Positive Homan’s Sign (pain with dorsiflexion of the foot) *caution – this maneuver may dislodge the clot*
*Note – the evidence shows that Homan’s Sign is an unreliable and nonspecific finding. It is only present in 33% of those with a DVT and should not be used as standard practice in isolation.
Nursing Interventions and Rationales
- Assess for evidence of embolus
- Neuro Status
- Respiratory Status
- Chest Pain / ECG
- Administer Heparin-Transition into a SubQ or oral anticoagulant to prevent future clots.
- Administer Enoxaparin (Lovenox) and/or Warfarin (Coumadin)
- Encourage ambulation / Compression socks / SCDs (Prevention)
- Educate about avoiding vitamin K (both supplements as well as food)
- Continuous monitoring:
- 3 or 5 lead cardiac monitoring
- Pulse oximetry monitoring
- 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 a 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 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 bleeds: Have patients and the people who are around them look for S/Sx such as confusion, facial droop, one-sided weakness.
A Nursing Care Plan (NCP) for Thrombophlebitis / Deep Vein Thrombosis (DVT) starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.
References
- http://www.medscape.com/viewarticle/705799_3
- http://reference.medscape.com/drug/calciparine-monoparin-heparin-342169
- http://www.medscape.com/viewarticle/532115
- http://www.mayoclinic.org/diseases-conditions/deep-vein-thrombosis/basics/lifestyle-home-remedies/con-20031922
- http://www.nhs.uk/Conditions/deep-vein-thrombosis/Pages/causes.aspx
- https://www.uptodate.com/contents/deep-vein-thrombosis-dvt-beyond-the-basics
- http://reference.medscape.com/drug/coumadin-jantoven-warfarin-342182
- http://reference.medscape.com/drug/lovenox-enoxaparin-342174
Transcript
Hey everyone, we’re going to be talking about DVT, or deep vein thrombosis, and how to put this into a nursing care plan. First for our care plan, we have to collect our information. That’s our first step, our assessment pieces and gathering all our data.
Our subjective data, which is that data that we get from the patient, so the assessment pieces that they give us, or things that they’re experiencing. So, for having a DVT, this patient might come to us with some information that they are having pain, some numbness, tingling in their extremity, because they have a blood clot, and Mayer, so blood flow is all messed up, maybe if it’s gotten worse and they are experiencing a PE, they could be having the shortness of breath and anxiety, or worse, they could be having a stroke from the DVT, so they might start to show some stroke symptoms. They might be experiencing some of that themselves, like the facial asymmetry, confusion, that one-sided deficit.
So the objective data, or the things that the nurse observes, data collected by labs, things like that. So, for this patient with our DVT, you’re going to have the unilateral findings of the affected extremity. We might assess some warmth, redness right to that extremity as that blood flow is getting backed up, swelling, ,decreased peripheral pulses on that one side, and then how about a positive D-dimer on the lab showing us that there is a high likelihood that there’s a blood clot.
Now, we have to analyze this information that we’ve collected, and this is going to help us to diagnose and prioritize. So what is the problem here? For this patient, we have a blood clot and we’ve noted there to be a swollen red calf. Let’s say for our hypothetical patient, what needs to be improved? Well, blood flow, right, and perfusion and then also just prevention, right? We want to prevent further complications.
These would be the things that we’ll get to, the things that we can do to help prevent further complications from happening, and then what is our priority? So, our priority is to fix the perfusion that is being blocked from that blood clot, and we can do things like anticoagulants to help fix that perfusion.
Now we have to ask ourselves how, so this will be our plan, implementation, and evaluation. So, how did we know it was a problem? Well, this is where whatever data that you have on your patient, you’re going to link that data. We’ll link the data together, all those assessment findings, link it together. So we have a blockage. We see that there’s a clot, visualize a clot on a doppler, whatever it may be, but link all that data together, and that’s how we knew it was a problem. How are we going to address it? So for this client, we can give some medication to thin the blood, right? So our anticoagulate like heparin, things like that. How would I know it gets better? Well, if the blood clot is not worsening, we’re not growing a bigger clot, it hasn’t been released into the bloodstream, no new blood clots form, circulation improves and that perfusion improves.
Now, we’re going to translate. This is where we come up with our high-level nursing concepts. There can be so many different ones to pick from. For this patient with DVT, we have perfusion, like we’ve mentioned, and some patient education that we can pull together for our problems and priorities.
Let’s get into our transcribing. This is where you’re going to put all the pieces together for your care plan. We have perfusion, clotting, and patient education. First let’s look at our perfusion. Our signs and symptoms are subjective and objective data here okay, that’s what we’re putting in this column. So perfusion, we know it’s a problem because there’s swelling in the calf and redness. That’s noted, then how are we going to intervene? What are we going to do to fix this?
We can give some anticoagulants. I don’t know why that’s so hard to say today, and this is going to be as prescribed or as ordered, right, because we are not just going to the Pyxis, the medstation and pulling some heparin, and we are giving it as ordered.
Then our rationale. So why, why is this intervention going to be helpful or why should it be helpful? Well, it’s going to thin the blood and help our perfusion. Our expected outcome. So the blood is thin and our perfusion improves. That’s what we expect to see. Alright, let’s look at clotting. So clotting, let’s say on this hypothetical patient, we have doppler confirmation that there is a clot. So what can we do?
Our intervention? So for this, it’s also going to be our anticoagulants as ordered and that’s going to help reduce or prevent further clots from forming, and then surgery. Now, we’re not surgeons, we’re not performing the surgery. We are the prep people. So, we can help prep the patient for surgery. Maybe they need to have one of the filters placed, whatever it is to get rid of that clot or catch that clot, prevent it from dislodging, that the providers have decided to do, so that can help with our clotting problem.
And then why? So, prophylaxis for the anti-coagulants, we’re preventing further clots from forming, we’re preventing the growth of this one clot that we have, and then surgery, just to remove that clot, catch it, or keep it from moving through the bloodstream and causing bigger problems.
So, for our expected outcome, we’re going to have no additional blood clots and the clot will be dissolved or removed.
So patient education. So let’s say that with our hypothetical patient, our data collected shows that this patient is a smoker, and they have some diet concerns that we can talk about. How are we going to intervene? Well, smoking cessation, right, that will help, diet, a low cholesterol diet, and the rationale behind this, is it’s going to stop the narrowing of those vessels, right? So you have your vessel and we’re not getting narrower, and improve plaque buildup there on the sides where then a clot is getting in there, and we are not having good circulation through the system.
In our expected outcomes, with patient education, we expect that the patient will verbalize or demonstrate an understanding of this education.
Alright guys, let’s look at our key points and review. So you’re collecting information, that’s your data, that’s your subjective and objective data. Then we’re going to analyze, and that’s how we diagnose and prioritize. We ask our how questions and that’s how we’re going to plan, implement and evaluate what we’re doing. Translating, so that’s just coming up with those concise terms, those concepts, and then we’re going to transcribe. So whatever form you prefer just to get your care plan on paper.
I hope that was helpful to learn about our deep vein thrombosis and how to put that in a care plan. Check out all the care plan lessons that we have for you and the videos attached to them. We love you guys. Now, go out and be your best selves today and as always, happy nursing!
Miriam Wahrman, MSN/Ed, RNC-MNN 
Nichole Weaver, MSN/Ed, RN, CCRN 
