DVT (Deep Vein Thrombosis)

Disorder involving a thrombus (blood clot) in a deep vein, most commonly the iliac and femoral veins.

Patho-Localized platelet aggregation and fibrin entrap RBCs, WBCs and more platelets to form a thrombus (frequently in the valve cusps of veins where venous stasis occurs). May lead to an emboli.


Video found here.




Video found here.

Assessment:

Subjective Data:
*Pain/Tenderness in calf or groin

Objective Data:
*Warmth
*Edema
*Extremities measurements
*+ Homan's -->controversial

Diagnosic Studies: Ultrasound, D-dimer, CT


Nursing Diagnosis:
Ineffective peripheral tissue perfusion

Goals:
*PREVENTION!!!
*Adequate blood flow to extremities
*No pulmonary embolism (PE)

Interventions:
*Affected leg circumference
*Doppler
*Bed Rest (Do NOT massage extremity)
*Elevate Leg
*Warm moist packs
*Compression stockings
*Anticoagulants - COUMADIN & HEPARIN
*DO NOT WALK ON LEG!!
*Monitor for S/S of PE (SOB, chest pain)

Patient Teaching:
*Need for frequent f/u with blood tests
*Side effects of drugs-blood in urine or stool, unusual bleeding, severe h/a or stomach pain, weakness, dizziness, change in LOC, cold blue or painful feet.
*Avoid trauma or injury that may cause bleeding
*Avoid NSAIDS and alcohol
*Avoid Vitamin K
*Contact EMS immediately if CP, SOB, palpitations or feeling of passing out is experienced.