Nursing Care Plan (NCP) for Thrombophlebitis / Deep Vein Thrombosis (DVT)

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Lesson Objective for Thrombophlebitis/Deep Vein Thrombosis (DVT) Nursing Care Plan:

Upon completion of this nursing care plan for Thrombophlebitis/Deep Vein Thrombosis (DVT), nursing students will be able to:

  • Understand the Pathophysiology:
    • Develop a comprehensive understanding of the pathophysiology of thrombophlebitis/DVT, including the formation, risk factors, and potential complications of blood clots within deep veins.
  • Recognize Clinical Manifestations:
    • Recognize and differentiate the clinical manifestations of thrombophlebitis/DVT, including localized pain, swelling, erythema, and potential systemic complications such as pulmonary embolism.
  • Implement Preventive Measures:
    • Acquire proficiency in implementing preventive measures to reduce the risk of thrombophlebitis/DVT, including early ambulation, compression stockings, and pharmacological prophylaxis in high-risk populations.
  • Provide Thrombosis Management:
    • Develop skills in managing thrombophlebitis/DVT, including the administration of anticoagulant therapy, monitoring laboratory values, and collaborating with the healthcare team to prevent clot extension and recurrence.
  • Educate Patients on Self-Care:
    • Educate individuals on self-care practices, signs of thrombophlebitis/DVT, and the importance of adherence to prescribed medications. Empower patients to recognize and report symptoms promptly.

Pathophysiology of Thrombophlebitis/Deep Vein Thrombosis (DVT):

  • Blood Clot Formation:
    • Thrombophlebitis/DVT involves the formation of blood clots (thrombi) within deep veins, commonly in the lower extremities. These clots may obstruct blood flow and pose the risk of embolization.
  • Endothelial Injury or Dysfunction:
    • The process often begins with endothelial injury or dysfunction, which may result from trauma, surgery, inflammation, or other factors. Damaged endothelial surfaces can initiate the clotting cascade.
  • Stasis of Blood Flow:
    • Stasis of blood flow, often associated with prolonged immobility, contributes to the development of clots. Reduced circulation allows blood to pool, creating an environment favorable for clot formation.
  • Hypercoagulability:
    • Conditions that increase blood coagulability, such as genetic predispositions, certain medications, and underlying medical conditions, contribute to the hypercoagulable state, increasing the likelihood of thrombosis.
  • Clot Extension and Embolization:
    • If left untreated, the clot may extend within the deep veins, posing the risk of embolization. Clots can dislodge and travel to the lungs, causing a pulmonary embolism, a serious and potentially life-threatening complication.

Etiology of Thrombophlebitis/Deep Vein Thrombosis (DVT):

  • Prolonged Immobility:
    • Prolonged periods of immobility, such as bed rest or long flights, contribute to stasis of blood flow, increasing the risk of clot formation within deep veins.
  • Surgery and Trauma:
    • Surgical procedures, particularly those involving the lower extremities or pelvis, and trauma, which can cause endothelial injury, are significant risk factors for the development of thrombophlebitis/DVT.
  • Hypercoagulable States:
    • Conditions that increase blood coagulability, such as inherited thrombophilias (e.g., Factor V Leiden mutation), antiphospholipid syndrome, and certain malignancies, contribute to the development of blood clots.
  • Medical Conditions:
    • Underlying medical conditions, including heart failure, inflammatory disorders (e.g., vasculitis), and conditions affecting blood vessels, can predispose individuals to thrombophlebitis/DVT.
  • Use of Hormonal Contraceptives:
    • The use of hormonal contraceptives, including birth control pills, hormone replacement therapy, and pregnancy, increases the risk of thrombophlebitis/DVT due to hormonal effects on blood coagulation.

Desired Outcomes for Thrombophlebitis/Deep Vein Thrombosis (DVT) Nursing Care Plan:

  • Prevention of Clot Extension:
    • Implement measures to prevent the extension of blood clots within deep veins, reducing the risk of complications such as pulmonary embolism.
  • Pain and Swelling Management:
    • Alleviate pain and swelling associated with thrombophlebitis/DVT through appropriate interventions, promoting patient comfort and mobility.
  • Prevention of Recurrence:
    • Minimize the risk of recurrence by implementing long-term preventive measures, including anticoagulant therapy, lifestyle modifications, and addressing underlying risk factors.
  • Patient Education and Empowerment:
    • Educate patients on self-care practices, signs and symptoms of thrombophlebitis/DVT, and the importance of adherence to prescribed medications. Empower patients to actively participate in their care.
  • Early Recognition of Complications:
    • Ensure early recognition of potential complications, such as pulmonary embolism, and initiate prompt interventions to prevent adverse outcomes.

Thrombophlebitis / Deep Vein Thrombosis (DVT) Nursing Care Plan

 

Subjective Data:

  • Unilateral findings on affected extremity:
  • Painful
  • Numbness
  • Tingling
  • Symptoms of Embolism
    • Lungs → Pulmonary Embolism (PE)
      • Anxiety
      • Shortness of Breath (SOB)
      • Chest Pain (CP)
    • Heart → Myocardial Infarction (MI)
      • Chest Pain (CP)
    • Brain → Stroke
      • Facial asymmetry
      • Confusion
      • One-sided deficit

Objective Data:

  • Unilateral findings on affected extremity:
  • Warmth
  • Redness
  • Swelling (firm)
  • Decreased peripheral pulse
  • Positive D-Dimer
  • Evidence of Clot on Ultrasound
  • Decreased oxygen saturation (for PE or MI)
  • Change in neurological status (for stroke or severe complications)
  • Possible Positive Homan’s Sign (pain with dorsiflexion of the foot) *caution – this maneuver may dislodge the clot*

*Note – the evidence shows that Homan’s Sign is an unreliable and nonspecific finding. It is only present in 33% of those with a DVT and should not be used as standard practice in isolation.

 

Nursing Assessment for Thrombophlebitis/Deep Vein Thrombosis (DVT):

 

  • Clinical History:
    • Obtain a detailed clinical history, including recent surgeries, trauma, prolonged periods of immobility, hormonal contraceptive use, and any personal or family history of clotting disorders.
  • Symptom Assessment:
    • Assess for symptoms of thrombophlebitis/DVT, including localized pain, swelling, erythema, and warmth in the affected extremity. Inquire about any changes in skin color or the presence of prominent superficial veins.
  • Risk Factor Evaluation:
    • Evaluate risk factors contributing to thrombophlebitis/DVT, such as obesity, smoking, advanced age, pregnancy, and underlying medical conditions. Identify factors that may exacerbate the risk.
  • Physical Examination:
    • Perform a thorough physical examination, focusing on the affected extremity. Assess for edema, tenderness, and differences in calf circumference. Palpate for cord-like structures, indicating the presence of deep vein thrombosis.
  • Neurovascular Assessment:
    • Conduct a neurovascular assessment, checking for changes in sensation, motor function, and peripheral pulses. Assess capillary refill and skin temperature to detect any compromise in blood circulation.
  • Laboratory and Imaging Studies:
    • Order appropriate laboratory studies, including D-dimer tests and imaging studies such as ultrasound, to confirm the diagnosis and determine the extent of thrombophlebitis/DVT.
  • Pulmonary Assessment:
    • Monitor for signs of pulmonary embolism, such as dyspnea, chest pain, and hemoptysis. Assess respiratory rate, and oxygen saturation, and auscultate for abnormal breath sounds.
  • Patient Education:
    • Educate the patient on the importance of adherence to prescribed anticoagulant therapy, lifestyle modifications, and the recognition of signs and symptoms requiring prompt medical attention. Provide written materials for reference.

Nursing Interventions and Rationales

  • Administer anti-coagulants as ordered
    • Heparin per IV drip or SQ is administered in the acute phase to prevent the worsening of clots or the development of new clotsEnoxaparin (Lovenox) or fondaparinux {Arixtra) SQ is administered SQ to treat or prevent blood clots. These are typically used in the inpatient setting but can be used at home.
    • Oral anti-coagulants, such as warfarin (Coumadin), rivaroxaban (Xarelto), and apixaban (Eliquis) are used as long-term therapy to prevent blood clots
  • Monitor anticoagulation labs
    • For a patient on heparin, frequent monitoring of aPTT levels is required to determine therapeutic dosing.
    • For a patient on warfarin, routine monitoring of the PT/INR levels is required to determine therapeutic dosing.
    • Routinely monitor platelet level to evaluate patient’s risk for bleedin
  • Encourage ambulation / Compression socks / SCDs (Prevention)
  The sooner you get a patient moving the less likely they are to form any more blood clots. Compression socks and SCDs encourage blood flow back to the heart and prevent blood stasis.*Caution – as soon as the patient has a confirmed DVT, all three of these should be held until an IVC filter can be placed
  • Educate about avoiding vitamin K (both supplements as well as food)
  Vitamin K works to help increase clotting, this is the opposite of what we are trying to do for this patient. The only time Vitamin K is used therapeutically is if the patient is bleeding out, in which case the treatment may be vitamin K with Fresh Frozen Plasma (FFP). Vitamin K is also the antidote for Coumadin (warfarin)
  • Continuous monitoring:
    • 3 or 5 lead cardiac monitoring
    • Pulse oximetry monitoring
  This monitors for changes in the heart and allows for quick intervention if the clot moves and is stuck in the heart. This monitors for changes in oxygenation if the clot moves to the lungs.
  • Bleeding/fall precautions because of anticoagulant therapy

  This isn’t just for in the hospital, it is also for when the patient goes home. The patient is at a major risk for bleeding out, thus educating about s/sx of internal bleeding as well as educating about fall precautions is vital.

  • GI bleeding: Dark, tarry stool (Upper GI bleed) OR bright red bloody stools (lower GI bleed)
  • Epistaxis: Nosebleeds are obvious, however, inform the patient that if they bleed through nasal packing for longer than 15 minutes they should go to the ER. Also, if they feel dizzy, faint, or are losing color in their face they should go to the ER.
  • Cuts that don’t stop bleeding: if the cut has had pressure applied for longer than 15 minutes and the gauze is being soaked through the patient should go to the ER.
  • Brain bleeds: Have patients and the people who are around them look for S/Sx such as confusion, facial droop, and one-sided weakness.

Evaluation for Thrombophlebitis/Deep Vein Thrombosis (DVT) Care Management:

 

  • Resolution of Symptoms:
    • Evaluate the resolution or improvement of symptoms associated with thrombophlebitis/DVT, including pain, swelling, and erythema. Assess the overall comfort and mobility of the patient.
  • Laboratory and Imaging Confirmation:
    • Confirm the resolution of thrombophlebitis/DVT through laboratory studies and imaging, comparing current results to baseline assessments. Ensure there is no extension of the clot or recurrence.
  • Effectiveness of Anticoagulant Therapy:
    • Monitor the effectiveness of anticoagulant therapy by assessing laboratory values, including international normalized ratio (INR), prothrombin time (PT), and activated partial thromboplastin time (aPTT). Adjust medication dosage as needed.
  • Prevention of Complications:
    • Assess for the prevention of complications, particularly pulmonary embolism. Ensure that preventive measures and interventions have been effective in minimizing the risk of adverse events.
  • Patient Adherence and Education Retention:
    • Evaluate patient adherence to prescribed medications and lifestyle modifications. Assess the retention and application of patient education on self-care practices and the recognition of signs requiring medical attention.
  • Long-Term Prevention Strategies:
    • Collaborate with the healthcare team to develop and evaluate long-term prevention strategies, including ongoing anticoagulant therapy, lifestyle modifications, and addressing underlying risk factors.


References

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Transcript

Hey everyone, we’re going to be talking about DVT, or deep vein thrombosis, and how to put this into a nursing care plan. First for our care plan, we have to collect our information. That’s our first step, our assessment pieces and gathering all our data. 

 

Our subjective data, which is that data that we get from the patient, so the assessment pieces that they give us, or things that they’re experiencing. So, for having a DVT, this patient might come to us with some information that they are having pain, some numbness, tingling in their extremity, because they have a blood clot, and Mayer, so blood flow is all messed up, maybe if it’s gotten worse and they are experiencing a PE, they could be having the shortness of breath and anxiety, or worse, they could be having a stroke from the DVT, so they might start to show some stroke symptoms. They might be experiencing some of that themselves, like the facial asymmetry, confusion, that one-sided deficit. 

 

So the objective data, or the things that the nurse observes, data collected by labs, things like that. So, for this patient with our DVT, you’re going to have the unilateral findings of the affected extremity. We might assess some warmth, redness right to that extremity as that blood flow is getting backed up, swelling, ,decreased peripheral pulses on that one side, and then how about a positive D-dimer on the lab showing us that there is a high likelihood that there’s a blood clot. 

 

Now, we have to analyze this information that we’ve collected, and this is going to help us to diagnose and prioritize. So what is the problem here? For this patient, we have a blood clot and we’ve noted there to be a swollen red calf. Let’s say for our hypothetical patient, what needs to be improved? Well, blood flow, right, and perfusion and then also just prevention, right? We want to prevent further complications.

 

These would be the things that we’ll get to, the things that we can do to help prevent further complications from happening, and then what is our priority? So, our priority is to fix the perfusion that is being blocked from that blood clot, and we can do things like anticoagulants to help fix that perfusion. 

 

Now we have to ask ourselves how, so this will be our plan, implementation, and evaluation. So, how did we know it was a problem? Well, this is where whatever data that you have on your patient, you’re going to link that data. We’ll link the data together, all those assessment findings, link it together. So we have a blockage. We see that there’s a clot, visualize a clot on a doppler, whatever it may be, but link all that data together, and that’s how we knew it was a problem. How are we going to address it? So for this client, we can give some medication to thin the blood, right? So our anticoagulate like heparin, things like that. How would I know it gets better? Well, if the blood clot is not worsening, we’re not growing a bigger clot, it hasn’t been released into the bloodstream, no new blood clots form, circulation improves and that perfusion improves. 

 

Now, we’re going to translate. This is where we come up with our high-level nursing concepts. There can be so many different ones to pick from. For this patient with DVT, we have perfusion, like we’ve mentioned, and some patient education that we can pull together for our problems and priorities. 

 

Let’s get into our transcribing. This is where you’re going to put all the pieces together for your care plan. We have perfusion, clotting, and patient education. First let’s look at our perfusion. Our signs and symptoms are subjective and objective data here okay, that’s what we’re putting in this column. So perfusion, we know it’s a problem because there’s swelling in the calf and redness. That’s noted, then how are we going to intervene? What are we going to do to fix this? 

We can give some anticoagulants. I don’t know why that’s so hard to say today, and this is going to be as prescribed or as ordered, right, because we are not just going to the Pyxis, the medstation and pulling some heparin, and we are giving it as ordered.

 

Then our rationale. So why, why is this intervention going to be helpful or why should it be helpful? Well, it’s going to thin the blood and help our perfusion. Our expected outcome. So the blood is thin and our perfusion improves. That’s what we expect to see. Alright, let’s look at clotting. So clotting, let’s say on this hypothetical patient, we have doppler confirmation that there is a clot. So what can we do? 

 

Our intervention? So for this, it’s also going to be our anticoagulants as ordered and that’s going to help reduce or prevent further clots from forming, and then surgery. Now, we’re not surgeons, we’re not performing the surgery. We are the prep people. So, we can help prep the patient for surgery. Maybe they need to have one of the filters placed, whatever it is to get rid of that clot or catch that clot, prevent it from dislodging, that the providers have decided to do, so that can help with our clotting problem. 

 

And then why? So, prophylaxis for the anti-coagulants, we’re preventing further clots from forming, we’re preventing the growth of this one clot that we have, and then surgery, just to remove that clot, catch it, or keep it from moving through the bloodstream and causing bigger problems. 

 

So, for our expected outcome, we’re going to have no additional blood clots and the clot will be dissolved or removed. 

 

So patient education. So let’s say that with our hypothetical patient, our data collected shows that this patient is a smoker, and they have some diet concerns that we can talk about. How are we going to intervene? Well, smoking cessation, right, that will help, diet, a low cholesterol diet, and the rationale behind this, is it’s going to stop the narrowing of those vessels, right? So you have your vessel and we’re not getting narrower, and improve plaque buildup there on the sides where then a clot is getting in there, and we are not having good circulation through the system. 

 

In our expected outcomes, with patient education, we expect that the patient will verbalize or demonstrate an understanding of this education. 

 

Alright guys, let’s look at our key points and review. So you’re collecting information, that’s your data, that’s your subjective and objective data. Then we’re going to analyze, and that’s how we diagnose and prioritize. We ask our how questions and that’s how we’re going to plan, implement and evaluate what we’re doing. Translating, so that’s just coming up with those concise terms, those concepts, and then we’re going to transcribe. So whatever form you prefer just to get your care plan on paper. 

 

I hope that was helpful to learn about our deep vein thrombosis and how to put that in a care plan. Check out all the care plan lessons that we have for you and the videos attached to them. We love you guys. Now, go out and be your best selves today and as always, happy nursing!

 

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