DVT Protocol

Wendy Ebner and Nora Gray

Definition

• A DVT is the formation of a blood clot that does not break down in a deep vein of the body.

• Because the clot does not bread down, it can become large and obstruct the normal flow of blood in the vein.

Considerations

• Deep veins of the lower extremities are the most common sites for a DVT.

• If the clot breaks into smaller pieces, it becomes an embolus which can travel to vital organs and cause life-threatening conditions such as a heart attack, stroke, or pulmonary embolism.

Virchow’s Triad=Risk

Risk Assessment

Patients at highest risk for DVT are those who;

• Have undergone major surgery including that of the hip or knee

• Suffered trauma

• Are older

• Have a history of having a DVT

Prevention/Interventions

• Mobility-foot pumps, exercise• Compression stockings• Early ambulation following

surgery• Close management of CHF,

HTN and/or Diabetes• Smoking cessation• Weight management• Prevent dehydration• Pharmacologic interventions

(see below)• Herbal remedies (see below)

• Elastic compression stockings • Foot pumps when immobilized

in bed or chair • Monitor anticoagulant therapy • Monitor Vit K intake (green

leafy vegetables, soybean oil, and canola oil)

• Increase fluids and avoid alcohol

Signs and Symptoms of DVT’sRecognize and report

signs/symptoms of a DVT including:

• Unilateral edema • Pain in extremity • Erythema • Calf tenderness• Pale leg & cool with diminished

arterial pulse• + Homan’s sign (discomfort in the

calf muscles on forced foot dorsiflexion w/ knee straight; NOTE: Homan’s sign is neither sensitive nor specific; Present in <1/3 of patients with confirmed DVT; Found in >50% of patients without DVT) (Schreiber, 2009)

SBAR-CUS

• Situation

• Background

• Assessment

• Recommendation

• Concerned and

• Uncomfortable about this patients’

• Situation or safety

Signs/Symptoms of PE

• Recognize and report (call 911) for signs/symptoms of a pulmonary emboli (PE) including:

• Unexplained sudden onset of shortness of breath

• Chest pain or discomfort that worsens with deep breath or cough

• Lightheadedness or dizziness • Hemoptysis • Anxiety

Goals of Pharmacologic Intervention

• Prevent clot formation• Stop clot from getting

bigger• Prevent clot from

breaking loose and resulting in an embolus

• Prevent DVT from re-occurring.

Herbal Remedy Considerations

• Herbal products may include ingredients that contain coumarin, inhibit platelet activity, or inhibit platelet aggregation – check with physician before use of these agents alone or in combination with anticoagulants, antiplatelets, or vitamin K antagonists

Patient/Family Education• Basic disease instruction including S/S of DVT extension &

pulmonary embolism; complications• Lifestyle modification related to smoking and weight management• Indications & actions of medications/herbals; dose & schedule;

target INR & lab work; missed dose strategy)• Medication interactions (that increase or decrease INR); diet (foods

to avoid, limit, & eat)• Self-care (i.e., leg elevation, avoid crossing legs & standing for long

periods); anticoagulant safety issues (avoid sharp objects & injury; monitor common bleeding sites – gums, nose, GI, GU, skin; actions to take if bleeding)

• Dental considerations (soft bristle toothbrush; notifying dentist)• Cultural considerations of animal derived products (heparin) and

alternative synthetic options for whom animal derived products are objectionable

Nursing Diagnosis/Problems• Need for assessment of circulatory

system (A963)• Need for skilled teaching related to

circulatory system (A964)• Need for skilled teaching related to

prescribed medications (A460)• Need for Coumadin (warfarin)

therapy (A946)• Need for other anticoagulant

therapy (excluding coumadin) (A948)

• Need for skilled teaching related to injection therapy (A631)

• Need for skilled administration of injection (A632)

• Need for venipuncture (A800)

References• References:• Agency for Healthcare Research and Quality. (January 2003). Diagnosis and Treatment of Deep Venous

Thrombosis and• Pulmonary Embolism. Evidence Report/Technology Assessment, 1-6.• Esmon, C. (2009). Basic mechanisms and pathogenesis of venous thrombosis. Blood Reviews, 23(5), 225-229.

DOI: 10.1016/j.blre.2009.07.002• Mayo Clinic (2009). Deep vein thrombosis (DVT). Retrieved May 27, 2010, from• http://www.mayoclinic.com/health/deep vein-thrombosis/DS01005• NICE clinical guideline 92. (2008). Reducing the risk of venous thromboembolism (deep vein thrombosis and

pulmonary embolism) in patients admitted to hospital. Retrieved July 8, 2010, from http://www.nice.org.uk/nicemedia/live/12695/47195/47195.pdf

• Schreiber, D. (2009). Deep venous thrombosis and thrombophlebitis. Retrieved May 27, 2010, from• http://emedicine.medscape.com/article/758140-overview• Selby, R., & Geerts, W. (2009) Prevention of venous thromboembolism: consensus, controversies, and

challenges.• Hematology. 286-292. Accessed July 8, 2010, from• http://asheducationbook.hematologylibrary.org/cgi/content/full/2009/1/286#T1• Skinner, N., & Moran, R. (2008). Case Management Adherence Guidelines Version 1.0 Deep Vein Thrombosis

(DVT). Case Management Society of American: Aston, PA. Retrieved July 12, 1010 from http://www.cmsa.org/portals/0/pdf/CMAG_DVT.pdf

• The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism. (2008). Retrieved July 8, 2010, from http://svnnet.org/uploads/File/08SGReport.pdf

• Van Wicklin, S., Ward, K., & Cantrell, S. (2006). Home study program. Implementing a research utilization plan for prevention of deep vein thrombosis. AORN Journal, 83(6), 1351. Retrieved from CINAHL with Full Text database

• Summary of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy• CHEST 2004; 126:163S-696S. Retrieved July 12, 2010 from

http://health.usi.edu/summaryoftheseventhaccpconference.pdf