Wendy Ebner and Nora Gray 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’s Recognize 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