Download DVT Protocol

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 lifethreatening 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
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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 reoccurring.
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
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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
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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