DVT

Question 1

DVT sign’s and symptom’s?

Answer 1

Pain and tenderness (commonly in the calf)
Redness
Swelling (calf)

Question 2

DVT pathophysiology?

Answer 2

A DVT is formed when RBC, fibrin and platelet’s bind together and create a clot. Increased number’s of fibrin and blood cell’s build up behind the thrombus and attach to it increasing the size of clot

Question 3

Cause’s of DVT?

Answer 3

Venous stasis - occur’s with decreased blood flow - immobility, medication’s and in heart failure

Hyper-coagulability - occurs with deficient fluid volume, pregnancy, oral contraceptive use, smoking

Venous wall damage - may occur due to venipuncture, medication, trauma and surgery

Question 4

DVT nursing diagnose’s?

Answer 4

Acute pain r/t oedema and inadequate tissue perfusion

Risk of developing PE r/t potential for thrombus to dislodge

Question 5

DVT assessment’s?

Answer 5

COLDSPA - assessing for pain and tenderness (particularly in the calf)

Peripheral vascular - colour, warmth, oedema, sensation (pain or tenderness)

Question 6

DVT Nursing intervention’s, rationale and evaluation

Answer 6

Administer anticoagulant’s, to breakdown clot and prevent further clot formation

Apply TED stocking as prescribed, to enhance circulation by providing a graduated pressure on the leg to help return venous blood to the heart

Monitor for change’s in vital sign’s, dyspnoea or chest pain, for early detection of PE