DVT

Question 1

Deep vein thrombosis

Answer 1

Formation of a thrombus or clot with associated inflammation; can have either a superficial (saphenous) or deep component (iliac or femoral vein)

Question 2

Etiology and thrombus formation

Answer 2

Virchow’s triad:

1. Venous stasis
2. Hypercoagulability
3. Endothelial damage

These 3 factors lead to: (1) Platelet aggregation, (2) clotting factors stimulated to produce fibrin, and (3) fibrin entrapment of RBCs and WBCs, and platelets adhering to vessel wall

Question 3

Risk factors

Answer 3

DVT risk factors:
1. Previous VT or PE

2. Severe infection, HF
3. Oral contraceptives
4. ERT or pregnancy
5. Immobility – bed rest, flight travel, fractures
6. Surgery
7. CA
8. Inherited thrombophilia

Question 4

Clinical manifestations

Answer 4

Lower extremity VT (most common) – may or may not have unilateral leg pain, edema, pain upon touch, paresthesia, febrile (i.e. Thigh or calf)

Inferior vena cava – both legs may be edematous and cyanotic (can extend to superior vena cava)

Question 5

Diagnostics

Answer 5

Tests:
1. Compression ultrasound (outpatient), then repeated 5-7 days later

2. D-dimer (High = Clot buildup/breakdown somewhere)
3. Well’s score (risk for PE development)

Question 6

Medical management

Answer 6

PREVENTION (Low-risk immobile pts):

1. Get OOB and ambulate 4-6x/day
2. Change position q2h
3. Elastic compression stockings – TEDs
4. SCDs
5. Heparin or enoxaparin SC bid/tid

ACUTE THROMBUS:

1. Anticoagulants – Clot busters (Streptokinase, urokinase; must start within 3 hrs. that suspected clot is confirmed), heparin (monitor aPTT; Normal = 25-35 sec., Ideal = 46-70 sec.)
2. Monitor aPTT, H&H, platelets (CBC) and D-dimer (Normal = 250 ng/dl, elevation suggests VTE)

Question 7

Nursing management

Answer 7

1. Pain management – analgesics
2. Mobilize pt
3. Assessment – monitor bleeding (gums, stool, urine, excessive bruising), VS, CBC, MS change, vision changes, respiratory changes
4. Self-care – soft tooth brush, fall prevention
5. Hydrate – stool softener
6. Monitor specific labs – aPTT (Heparin), Antidote: protamine sulfate; and INR/PT (Warfarin), Antidote: vitamin K
7. Notify PCP if – new bleed, changes in VS/LOC/resp. difficulty, new pain in thrombotic extremity, absence of pulse

Question 8

Pt education

Answer 8

Promote:
1. TEDs – worn ~2 yrs. after event

2. Exercise
3. Hydration – decrease blood viscosity
4. Diet
5. Long-term anticoagulants (Warfarin) – monthly lab work, know when to call PCP (S/S: Severe HA, chest pain, facial drooping, slurred speech, change in MS), and avoidance of other drugs that cause bleeding (i.e. Aspirin, NSAIDs, herbal supplements)

Question 9

Complications

Answer 9

1. Thrombus – Usually pain in leg, claiming 100,000 people/yr.
2. Post-thrombotic syndrome
3. PHLEGMASIA CERULEAN DOLENS – Uncommon, severe form of VT (usually in the upper leg) causing near total blockage of blood flow, swelling, deep pain, and cyanosis; Found in late stages of CA and can lead to arterial occlusion, gangrene, and amputation
4. PE – Characterized by sudden SOB, medical emergency

Question 10

Post-thrombotic syndrome

Answer 10

Occurs after recovery of VT in 20-50% of pts despite anticoagulation therapy; often a result of chronic venous HTN

S/S: Pain, aching, heaviness, swelling, cramps, itching, paresthesia

Clinical signs: Persistent edema, hyperpigmentation, eczema, varicosities, lipodermatopigmentation

Treatment:

1. Elevation of extremity at rest and night
2. Grade 2 compression stockings
3. Weight loss
4. Increased exercise with strengthening of extremity muscles
5. Pain management
6. Compression pump
7. Vascular interventional radiology procedure – balloon opening and stenting of narrowed vein
8. Diet – encourage hydration