Deep Vein Thrombosis

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Venous Thrombosis: The formation of a thrombus (clot) in association with inflammation of the vein.
Two Classifications Superficial Thrombophlebitis Deep Vein Thrombosis (DVT): Superficial Thrombophlebitis
-inflammation of a vein
-occurs in about 65 percent of patients receiving IV therapy
Two Classifications cont. Deep Vein Thrombosis (DVT): -Disorder involving a thrombus in a deep vein, most commonly the iliac and femoral veins
-Occurs in 5% of all Med-Surg patients
Deep Vein Thrombosis Etiology: Vichrow's Triad
-Venous Stasis
-Damaged Endothelium
-Hypercoagulability
Venous Stasis (pooling of blood): -Occurs when valves are dysfunctional or the muscles of the extremities are inactive
-*Causes: bed rest, immobility, obesity, CHF, AF, pregnancy (30% increase in blood volume during pregnancy), and post partum
Damaged Endothelium: -Occurs as a result of trauma or external pressure on the vessel itself
-Everytime a venipuncture is performed
*causes: IV agents irritating to veins-antibiotics, K+, chemo, or hypertonic solutions; burns, DM, pooling blood, sepsis (bacteria damage endothelium of vessel wall), IV drug abuse
Hypercoagulability: -Occurs as the result of hematologic disorders
*Causes: Polycythemia (increased RBC's), severe anemia, oral contraceptives, smoking, and various malignancies (breast, brain, pancreas, GI tract), sepsis
Pathophysiology Thrombus=clot: -A change in blood flow, vessel wall, and coagulability of blood leading RBC's, WBC's, platelets, and fibrin to adhere and form a thrombus.
-This frequently occurs at valve custps of veins where venous stasis allows accumulation of blood clots
Pathophysiology (cont): -If a thrombus only partially occludes the vein, the thrombus becomes covered by endothelial cells and the thrombotic process stops.
-If it does not detach, it undergoes lysis or becomes firmly organized and adherent within 5 to 7 days
Clinical Manifestations: -Pain or heaviness of the limb
-Edema, Redness (dark red)
-+Homan's Sign (10% of patients)
-Malaise, fever, and chills
Diagnostic Tests: *Non Invasive Doppler - determines venous flow
*Duplex Scan - combination of ultrasound and doppler; determines flow, location and extent of thrombus
*Venogram - x-ray with contrast-determines location and extent of thrombus and development of collateral circulation (most definitive test)
Laboratory Values: PT (Prothrombin Time), PTT (Partial Thromboplastin Time), INR (International Normalized Ratio), Bleeding Time
*Increase - more prone to bleeding, decreased risk for clots
*Decrease - polycythemia, increased risk for clots
**Also need to consider the platelet count
Treatment: Medical
-Bed rest
-Elevation (decreases swelling)
-Warm Compresses (promotes venous return)
**Anticoagulation (will not dissolve clot)
-Heparin
-Lovenox
-Coumadin
Anticoagulation: Goal: Prevent enlargement of the clot, development of new thrombus, and embolization.
**Anticoagulation does not dissolve the clot. Lysis of the clot happens through the bodies intrinsic fibrinolytic system.
IV Heparin: -Class-fast/short acting anticoagulant
-Potentiates the inhibitory effect of antithrombin on factor Xa and thrombin (major clotting factors)
-Inhibits thrombin and prevents conversion of fibrinogen to fibrin
**Antidote - Protamine Sulfate (given IV)
IV Heparin (cont) Acute DVT: -Treatment of a large DVT requires continuous IV heparin for 5-7 days. oral anticoagulation for 3-6 months
*Heparin must be continued until the patient is therapeutic on Coumadin*
-Heparin is administered as an IV bolus, followed by a continuous drip-wt based in units/hr
**Must be on an infusion pump**
-Monitor PTT 6 hours after starting - and every 6 hours after a change in dose
-Normal PTT 24-36 seconds
*Therapeutic PTT is 1.5-2X normal (*Heparin Protocol*)
Prophylactic Heparin: -Prevention of DVT
-Heparin SC
Given deep SC into the fatty layer of the abdomen, 2 inches away from the umbilicus, rotate sites, do not aspirate, hold skin fold during injection, do not rub
*Dose - 5,000 units SC Q 8-12 hours
*No monitoring of PTT
Lovenox SC (Low molecular weight heparin): -Classification: low molecular weight heparin
-Action: potentiates the inhibitory effect of antithrombin on Factor Xa and thrombin
-No PTT monitoring
-Do not expel air bubble
-First line therapy for prevention and treatment of small DVT
-Prevention Dose - 30-80mg/day SC (weight based)
-Small uncomplicated DVT can be treated outpatient with Lovenox 1mg/kg Q 12 hours
-Patient is given Coumadin concurrently-Lovenox is discontinued when patient is therapeutic on Coumadin
*Antidote: Protamine Sulfate
Coumadin: -Classification - Anticoagulant/long acting
-Action - Interferes with hepatic synthesis of vitamin K (four clotting factors require vitamin K for their synthesis)
-Prevention of thrombus formation
-Recurrent DVT's require lifelong anticoagulation
**Antidote: Vitamin K
Coumadin (cont): -Peak effects take several days to a week
-Starting dose 10-15mg/day po daily
-Monitor INR
-INR = International Normalized Ratio
-Normal INR 0.75-1.25 seconds
-Therapeutic INR 2-3 seconds
**Continue heparin until INR is therapeutic
-If discontinued can take >3days for INR to return to normal
**Must know INR before you give Coumadin**
Adverse Effects of Anticoagulants: -Heparin Induced thrombocytopenia (HIT)
-Black tarry stools or blood in stools
-Hematemesis or hemoptysis
-Hematuria
-Epitaxis
-Petechiae and bleeding of lips and gums
-Heavy menstrual bleeding
-Handout Table 37-12
**Treat significant bleeding with FFP, Plts, and PRBCS
Medications that interact with oral anticoagulants: -See Table 37-11 in Lewis page 932
***Caution with ASA and NSAIDS with heparin and lovenox
Surgical: Venous Thrombectomy
-remove DVT through incision in vein
Vena Cava Interruption Devices (IVC Filters)
Venous Thrombectomy: -Removal of DVT through an incision in the vein
-Done to prevent PE or decrease the risk of chronic venous insufficiency
Vena Cava Interruption Devices/Intracaval Filter Devices: -Greenfield or Simon-Nitinol filters
-Inserted percutaneously through superficial femoral or internal jugular veins
-Filter is opened and the spokes penetrate the vessel walls
-This permits filtration of clots without interruption of blood flow
Complications of DVT: -Pulmonary Embolism
-Chronic Venous Insufficiency (CVI)
-Phlegmasis Cerulea Dolens
Painful blue swollen foot
Chronic Venous Insufficiency (CVI): -Results from valvular destruction allowing retrograde flow of venous blood
-Persistent edema, increased pigmentation, secondary varicosities, ulceration, cyanosis of the limb in the dependent position
Phlegmasia Cerulea Dolens (Swollen Blue Painful Leg): -Rare, may develop with severe lower extremity DVT
-Causes sudden massive swelling and intense cyanosis of the extremity
-Gangrene occurs due to arterial occlusion secondary to venous obstruction
Core Components and Competencies of Nursing Practice: 1. Care Manager
2. Care Provider
3. Clinical Decision Maker
4. Collaborator
5. Communicator
6. Learner
7. Professional Behaviors
8. Teacher
Nursing Process: Assessment: Physiological Integrity
Risk Factors for DVT--Table 37-7 Lewis page 928
Analysis/Diagnosis: Actual: Acute pain related to venous inflammation and venous congestion
Risk For:
-Altered peripheral tissue perfusion related to impaired venous return.
-Impaired skin integrity related to immobility and edema.
-Ineffective management of therapeutic regime related to insufficient knowledge of prevention of treatment
Analysis/Diagnosis (cont): Potential Complications (PC):
-Bleeding related to anticoagulation therapy
-Pulmonary emboli related to embolization of thrombus and immobility.
-Chronic leg edema related to venous congestion.
-Chronic stasis ulcers related to venous congestion.
Plan/Outcomes: -Relief of pain
-Decreased edema
-Absence of skin ulceration
-Absence of complications from anticoagulation therapy
-Absence of pulmonary emboli
Implementation: Prevention: -Adequate hydration (increases blood volume)
-Early ambulation/OOB three times a day
-Exercises: ROM
change position every 2 hours
Dorsiflex feet every 2 hours
Rotate ankles every 2 hours
-Intermittent Compression Devices
-Elastic Compression Stockings
-Anticoagulation
Implementation: Acute: -Bed rest with limb elevation
-Decrease risks of immobility TCDB
-Anticoagulants
-Warm packs for comfort and inflammation
-Analgesics
-Anti-inflammatories (caution with NSAIDS)
-No ICDS on leg with +DVT
-Teds only when patient resumes ambulation
Implementation: Post Hospital: -Prevention
-Medical Alert Bracelet: on Coumadin
-Bleeding Precautions - Table 37-12 Lewis
-Drug Interactions - Table 37-11 Lewis
-Anticoagulation teaching guide - Table 37-14 Lewis
-Follow up lab studies for INR
-Maintain a consistent level of vitamin K rich foods-broccoli, spinach, kale, greens
-Smoking cessation
-Nutrition/Weight Control
-Stop oral contraceptives/hormonal therapy
-Avoid/limit alcohol
Herbs: -Can interfere with clotting in various ways
-A common mechanism is to inhibit platelet aggregation
***garlic, ginger, ginkgo, ginseng, goldenseal, feverfew, chamomile, angelica, bilberry, and evening primrose
Current Trends & Research: -Lovenox as first line therapy for prevention and treatment of small DVT's
-Three times a day dosing of SC Heparin for prophylaxis instead of twice a day
-Arixta SC once daily for treatment of DVT (synthetic drug as effective as lovenox)
-Home self-monitoring of INR
Thrombocytopenia: An abnormal decrease in the number of platelets
Hematemesis: The vomiting of blood
Hemoptysis: The coughing up of blood
Hematuria: Blood in the urine
Epistaxis: Nosebleed
Petechiae: Small, purplish, hemorrhagic spots on the skin that appear in patients with platelet deficiencies (thrombocytopenias) and in many febrile illnesses.
Phlegmasis Cerulea Dolens: A complication of Deep Vein Thrombosis of the iliofemoral veins, in which the entire limb distal to the clot becomes swollen, purple, and painful.

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