DEEP VEIN

THROMBOSIS
 OBJECTIVES

At the end of this presentation students should be

able to
• Define Deep Vein Thrombosis
• State the incidence of Deep Vein Thrombosis
• List the aetiology and risk factors of DVT
• Describe the pathophysiology of DVT
• List the clinical manifestations of DVT
• State the diagnostic assessment of DVT
• Discuss the medical, surgical and nursing
management
 DEFINITION

• DVT occurs when a blood clot forms in a

deep vein.
• It most commonly happens in the deep
veins of the lower leg (calf), and can spread
up to the deep veins in the thigh.
• Rarely, it can develop in other deep veins,
for example in the arm
•
 INCIDENCE

• DVT occur in about 1 per 1000 persons per

year.
• Approximately 350,000 to 600,000
Americans each year suffer from DVT and 1
in every 100 people who develops DVT
dies.
• More common in people over the age of 80
(up to one in 500).
•
 AETIOLOGY
IMMOBILITY: this causes blood flow in the veins to
be slow. Slow flowing blood is more likely to clot
HYPERCOAGULABILITY (coagulation of blood
faster than usual)
TRAUMA to the vein: increases the risk of a blood
clot forming
 RISK FACTORS
• Sitting for long periods of time, such as when
driving or flying
• Prolonged bed rest, during a long hospital stay, or
paralysis (from spinal cord injury)
(causes calf muscles not to contract, slows blood
circulation thus forming clots)
• Inheriting a blood-clotting disorder
• Injury or surgery (can slow blood flow thus
increasing the risk of blood clots)
• Pregnancy (increases the pressure in the veins in
the pelvis and legs)
 RISK FACTORS
• Cancer (some cancers increase clotting factors
along with some forms of cancer treatment
increase the risk of blood clots)
• Heart failure (affects the pumping mechanism of
the heart increases the chance that blood will pool
and clot)
• Smoking (affects blood clotting and circulation)
• Birth control pills or hormone replacement
therapy (increase the blood's ability to clot)
• A history of deep vein thrombosis or pulmonary
embolism.
 RISK FACTORS
• A family history of DVT or PE.
• Being overweight or obese (increases the
pressure in the veins in your pelvis and legs)
• Increasing age (people older than 40)
• Polycythemia (increased number of red blood
cells)
 PATHOPHYSIOLOGY
VIRCHOW’S TRIAD
• Stasis of blood
• Vessel damage
• Increased blood coagulability

Vessel trauma stimulates the clotting cascade.

• Platelets aggregate at the site particularly when
venous stasis present
• Platelets and fibrin form the initial clot
 PATHOPHYSIOLOGY cont’d
• RBC are trapped in the fibrin meshwork
• The thrombus propagates in the direction of the
blood flow
• Inflammation is triggered, causing tenderness,
swelling, and erythema
• Pieces of thrombus may break loose and travel
through circulation- emboli
• Fibroblasts eventually invade the thrombus,
scarring vein wall and destroying valves.
• Although the patency may be restored valve
damage is permanent, affecting directional flow
PATHOPHYSIOLOGY
 Clinical Manifestations

• Tenderness in the calf (this is one of the

most important signs)
• Swelling of the leg
• Increased warmth of the leg
• Redness in the leg
• Bluish skin discoloration
• Discomfort when the foot is pulled upward
 Diagnostic Assessment
• Venous duplex / color duplex ultrasound-
this non-invasive test allows for visualization
of the thrombus. Most effective in the
detection of thrombus in the lower extremities.

• Impedance plethysmography – measures

changes in calf volume corresponding to
changes in blood volume brought about by
temporary venous occlusion with a high-
pneumatic cuff.
 Diagnostic Assessment cont’d
• Radioactive fibrinogen - is administered
intravenously. Images are taken through
nuclear scanning at 12-24 hours, the
radioactive fibrinogen will be concentrated
at the area of clot formation.

• Venography- intravenous injection of a

radiocontrast agent. The vascular tree is
visualized and obstruction is identified.
 Diagnostic Assessment cont’d

• Coagulation profiles- partial thrombin time,

international normalized ratio, circulating
fibrin, monometer complexes, fibrinopeptide
A, serum fibrin, D-dimer, antithrombin III
levels.
 MANAGEMENT
The goals of DVT treatment are:
 to stop blood clot from getting any bigger
 to prevent the clot from breaking loose
and causing a PE
 to prevent DVT from occurring again.

• Deep vein thrombosis treatment options

include: Blood thinners, Clot busters,
Filters & Compression Stockings
 MANAGEMENT
MEDICATIO
NS
 Blood thinners (anticoagulants) such as
HEPARIN and WARFARIN
decrease blood's ability to clot
prevent clots from getting bigger
reduce the risk of additional clots.

• Typically, heparin injections are given for a

few days. Treatment may be followed with
warfarin (orally) for 3 mths or longer.
 MANAGEMENT
• The use of heparin and
warfarin must be closely
monitored as they can
increased risk of bleeding.
• To monitor the effects of
blood thinners, blood tests
are done to check how long
it takes the blood to clot.
• Pregnant women should
not take warfarin.
 MANAGEMENT
 Clotbusters (thrombolytics) such as tissue
plasminogen activator (tPA) or Steptokinase are
given by IV to break up blood clots.
These drugs can cause serious bleeding and are
used only in life-threatening situations.

 Filters (umbrellas)are used when medications

cannot be taken to thin the blood, it may be
inserted into the vena cava and prevents emboli
from lodging in the lungs.
MEDICAL MANAGEMENT
 MEDICAL MANAGEMENT

• Rest: in DVT and limited mobilization is

required to prevent dislodgement of clot
leading to pulmonary embolism.
• Elevation of the affected part: this is to
promote adequate venous return and
prevent stasis.
 MANAGEMENT
 Compression
stockings
helps prevent swelling
associated with DVT by
applying pressure thus
reduce the chances that
the blood will pool and
clot .

The stockings are worn

on the leg from the foot
to the level of the knee
and should be worn for
at least a year if
possible.
 SURGICAL MANAGEMENT
• Deep vein thrombosis is usually treated with
conservative measures and anticoagulant. In
some cases however surgery may be required
to remove thrombus.
• Venous thrombectomy: done when thrombi
lodge into femoral vein and their removal is
necessary.
• When DVT is recurrent and anticoagulant
therapy is contraindicated a Greenfield filter or
a venal caval filter may be inserted into the
inferior vena cava to trap the clots.
 Surgical management

• Ligation or external clips: if filters are not

effective in preventing pulmonary emboli or
becomes blocked ligation is done or an
external clip (Adam DeWeese clip) may be
inserted on the inferior vena cava. This can
be done by means of an abdominal
laparatomy
 NURSING MANAGEMENT
ASSESSMENT
Health history:
• C/o calf pain, duration characteristics and the effect
of walking on the pain
• Hx of venous thrombosis or other clotting disorders
• Current medication
Physical examination:
• Inspect affected extremity for redness and edema
• Palpate for tenderness, warmth and cordlike
structures
• Body temperature
 NURSING MANAGEMENT
Rest comfort and activity:
Altered comfort pain: r/t inflammatory process 20 DVT
as evidenced by patients verbalization
INTERVENTIONS
• Assess pain location, characteristic and level. For
baseline data and to plan appropriate nursing
interventions
• Monitor for increasing pain, location or
characteristics and report to the physician promptly
– increasing pain may indicate extension if
thrombosis sudden chest pain may indicate
pulmonary embolism
 NURSING MANAGEMENT
• Apply warm moist heat to the affected extremity at
least four times daily. Moist heat penetrate tissues
to a greater depth. Warmth promotes vasodilation
which reduces resistance within the affected
vessels, reducing pain.
• Elevate the affected limb about 150 to 200above
the level of the heart. To promote venous return
which reduces edema thus reducing pain
• Maintain bed rest as ordered. Using muscles
during walking exacerbate the inflammatory
process and increases edema which increases
venous compression and pain
 NURSING MANAGEMENT

• Administer NSAID’s for leg pain as ordered eg.

Voltaren. To inhibit prostaglandin synthesis by
decreasing enzyme needed for biosynthesis, thus
decreasing pain.
• Encourage diversional activities such as watching
television or guided imagery. To augment
analgesics and improve pain tolerance.
 NURSING MANAGEMENT
Oxygen
Ineffective tissue perfusion: peripheral r/t obstruction
of blood flow and vessel spasm 20 DVT aeb cyanosis
of affected extremity
• Assess skin of the affected leg which includes skin
integrity and colour. Reassess every 8 hrs. To
rapidly detect early signs and plan for appropriate
nursing intervention.
• Monitor peripheral pulses and capillary refill time at
least every 4 hrs, and report changes immediately.
Weak or absent pulses and impaired capillary refill
may indicate extension of the thrombus.
 NURSING MANAGEMENT

levate extremities at all times, keeping knees

slightly flexed and legs above the level of the heart.
To promote venous return and reduce peripheral
edema

ncourage patient to wear an antiembolic stocking.

To exert pressure on the extremity and promote
venous return

emove antiembolic stocking for 30-60 mins during

daily hygienic. To assess the underlying tissue and
 NURSING MANAGEMENT

nsure adequate hydration by increasing oral fluids. To

prevent dehydration as increased blood viscosity and
decreased cardiac output contribute to thrombus formation

se egg crate mattress on the bed as needed. To

distribute weight evenly, preventing excess pressure on the
affected tissues

ncourage frequent position changes, at least every 2

hrs. This reduce pressure on bony prominences and
edematous tissues, reducing the risk of tissue breakdown.
 NURSING MANAGEMENT
SAFETY AND SECURITY
Risk for Complication: Pulmonary Embolism r/t
dislodgement of thrombus 2 to DVT
• Assess vital signs esp. respiration and pulse. To
detect early signs of complication for early
intervention.
• Promote bed rest and limited mobilization. To
prevent dislodgement of clots.
• Encourage the use of support stocking. To prevent
stasis of blood, hence reducing clot formation.
• Administer thrombolytic agents, eg. Streptokinase.
To dissolve clots and decrease the risk of PE
 NURSING MANAGEMENT

• Administer antispasmodic agents ie.

Baclofen. To prevent vascular spasm that
may dislodge clot and cause PE.
• Prepare patient for surgical insertion of
filters, if indicated. Filters are placed in the
inferior vena cava to trap clot so they do not
enter the lungs causing PE.
 NURSING MANAGEMENT
Safety and security
Risk for complication: haemorrhage r/t
anticoagulant therapy
• Assess for evidence of bleeding such
as petechiae, bruising, bleeding gums
etc. For baseline and to plan
appropriate nursing interventions
 NURSING MANAGEMENT

onitor lab results such as INR, APTT, Hb and

haematocrit levels. Report values outside the
desired range. Value within normal rage
prevent further clot development while a fall
may indicate undetected bleeding.

onitor vital signs q4h. Rapid weak thready

pulse and low blood pressure may be
 NURSING MANAGEMENT

eep Protamine sulfate available. To treat excessive

bleeding

ncourage patient to use an electric razor for shaving

and a soft tooth brush for brushing teeth. To decrease
the risk of bruising and bleeding

void invasive procedures as much as possible such

as rectal temperature, vaginal douches or tampons,
urinary catheterization. Parenteral injections etc. Invasive
procedure can cause tissue trauma and bleeding
 PREVENTION

xercise the legs regularly – take a brisk 30-minute

walk every day

aintain a weight that's appropriate for your height

void sitting or lying in bed for long periods of time

without moving the legs

lthough the added risk of developing a DVT caused

by traveling appears to be low, it can be reduced
even further by exercising the legs at least once every
hour during long-distance travel
 PREVENTION

• Keep the legs uncrossed

• Keep hydrated by drinking normally (urine should
be no darker than a pale yellow). Avoid alcohol to
prevent dehydration
• Wear graduated compression stockings. This is
particularly important for travelers who have other
risk factors for DVT
 COMPLICATIONS

The primary complication to be concerned

with is a Pulmonary embolism.
It occurs when an artery in your lung becomes
blocked by a blood clot (thrombus) that
travels to your lungs from another part of
your body, usually your leg
COMPLICATIONS
 COMPLICATIONS

Postphlebitic syndrome also called post-

thrombotic syndrome.
• Occurs in 15% of patients DVT.
• It presents with leg edema, pain, nocturnal
cramping, venous claudication, skin
pigmentation, dermatitis and ulceration
(usually on the medial aspect of the lower
leg)
 REFERENCE

• http://www.webmd.com/heart-disease/tc/deep-vein-thrombosis-what-
increases-your-risk

• http://www.webmd.com/heart-disease/tc/deep-vein-thrombosis-topic-
overview

• http://www.mayoclinic.com/health/deep-vein-thrombosis/DS01005

• http://en.wikipedia.org/wiki/Deep_vein_thrombosis

• http://www.medicinenet.com/deep_vein_thrombosis/article.htm