1. Deep Venous Thrombosis/ Thrombophlebitis By Dr. Hanan Said Ali

2. Learning Objectives  Define deep venous thrombosis.  Mention aetiology of deep venous thrombosis.  Identify Pathophysiology of deep venous thrombosis.  Enumerates clinical manifestations of deep venous thrombosis.  List Complication.  Describe the treatment & nursing care for client with deep venous thrombosis.

3. Deep Venous Thrombosis/Thrombophlebitis  The most common venous disorder, results from incompetent valves in the veins and obstruction of venous return to the heart usually results in a thrombus.  The formation of thrombus(clot) in association with inflammation of the veins is called “Thrombophlebitis”

4. Deep Venous Thrombosis/Thrombophlebitis Aetiology Venous thrombosis typically results from at least one element of Virchow triad:  Venous stasis  Damage to the endothelial lining of the vein  Hypercoagulopathy. Risk factors for deep vein thrombosis  Advanced age-the elderly typically have a number of risk factors.

5. Deep Venous Thrombosis/Thrombophlebitis Risk factors for deep vein thrombosis Cont.  Gender-DVT occurs more often in women.  Positive history of thromboses.  Immobility/ stasis  Surgery, bed rest, paralysis, fractured hip.  Prolonged sitting.  Obesity and pregnancy.

6. Deep Venous Thrombosis/Thrombophlebitis Risk factors for deep vein thrombosis Cont.  Increased viscosity  Dehydration, fever and malnutrition.  Sever anaemia  Intimal damage.  Central and peripheral IV catheter, pacemaker  IV drug abuse.  Trauma  Fractures (pelvis and long bones)  Burns

7. Deep Venous Thrombosis/Thrombophlebitis Risk factors for deep vein thrombosis Cont.  Associated conditions/ disorders.  Malignancy.  Varicose veins.  Inherited coagulation disorder.  Haemolytic anaemia  Use of oral contraceptives (oestrogen content)  Chronic lung and heart disease (CHF, cereb.vascu.)  Cigarette smoking.  Venous cannulation or catheterization

8. Deep Venous Thrombosis/Thrombophlebitis Pathophysiology  Thrombi develop from platelets, fibrin, and both red and white cells.  They typically form in areas where the blood flow is slow or turbulent.  Muscle spasm and changes in the intravascular pressure can cause the developing thrombus to dislodge and move towards the heart and lung.

9. Deep Venous Thrombosis/Thrombophlebitis Pathophysiology  The lungs are rich in heparin and plasmin activators and can effectively dissolve some thrombi.  However, if the thrombus is not successfully dissolved, it can lodge in an artery and obstruct perfusion to the lung segment causing problems.

10. Deep Venous Thrombosis/Thrombophlebitis Clinical Manifestation It varies according to the size and location of the thrombus and adequacy of collateral circulation. Superficial Thrombophlebitis  A palpable firm, subcutaneous cord-like vein.  The area surrounding the vein may be tender to the touch, reddened, and warm.  Temperature elevation, oedema

11. Deep Venous Thrombosis/Thrombophlebitis Clinical Manifestation Deep Thrombophlebitis May have no symptoms or have :  Unilateral leg oedema, pain, warm skin and temperature greater than 38c.  Homan's sign, pain on dorsiflexon of the foot when the leg is raised is a classic but unreliable sign because it is not specific for DVT.

12. Deep Venous Thrombosis/Thrombophlebitis Clinical Manifestation Deep Thrombophlebitis  If the inferior vena cava involved, the lower extremities may be oedematous and cyanotic.  If the superior vena cava involved, the upper extremities, neck, back and face may be oedematous and cyanotic.  If the calf is involved, tenderness pres ent.

13. Deep Venous Thrombosis/Thrombophlebitis Complication  Pulmonary embolism  Chronic venous insufficiency and phlegmasia ceruleadolens. Management Diagnosis  Chest x-ray  APTT(activated partial thromboplastin time)  PT(prothrombin time)  Venogram, lung scan and pulmonary angiogram.

14. Deep Venous Thrombosis/Thrombophlebitis Treatment Complete bed rest for 5 to 7 days. Local heat to extremity when inflammation is acute. Fit the client carefully for graduated compression stockings and teach correct use. Taught the client the action, dosage and side effects of anticoagulant.

15. Deep Venous Thrombosis/Thrombophlebitis Eat dark green and yellow leafy vegetables moderately because these are rich in vitamin K which can counteract the effect of Coumadin (warfran) Advice the client to bleeding precaution and need for ongoing laboratory follow-up.

16. Deep Venous Thrombosis/Thrombophlebitis Treatment Cont. The conservative treatment includes:  Continuous IV heparin.  Bed rest with bathroom privileges.  Elevation of legs above the heart level.  Anticoagulant therapy and heparin, warfarin.  Elastic compression stockings.

17. Deep Venous Thrombosis/Thrombophlebitis Treatment Cont. The conservative treatment includes Cont.:  Measurement and charting of size of both thighs and calves every morning  Mild oral analgesics such as aspirin and codiene.  NSAIDS

18. Deep Venous Thrombosis/Thrombophlebitis Surgical Procedure if indicated include:  Intracaval filter insertion.  Venous Thrombectomy. The primary option is transvenous filtration Device placed in the vena cava to trap emboli before they reach the heart and pulmonary vessels.

19. Deep Venous Thrombosis/Thrombophlebitis Nursing care of the client with a venacaval filter  Assess venipuncture site for signs of bleeding or infection.  Immobilize the extremity after the procedure.  Assess peripheral pulses, temperature, colour and sensation in affected extremity.  Assess for pain and presence of positive Homan's sign.

20. Deep Venous Thrombosis/Thrombophlebitis Nursing care of the client with a venacaval filter  Assess respiratory status and monitor pulse oximetry or blood gases.  Position in partial or high- fowler's position.  Implement bleeding precaution and associated safety measures if systemic anticoagulation is to be continued.

21. Deep Venous Thrombosis/Thrombophlebitis Nursing care of the client with a venacaval filter  Teach the client to monitor for signs of infection at insertion site.  Signs of systemic bleeding (e.g. Blood in stool, urine, gums, nosebleed easy bruises.  Pulmonary embolism- swelling and warmth in extremity, sudden chest pain, dyspnea, tachypnoea, restlessness.

22. Thank You