Risk for DVT – Nursing Diagnosis For Pulmonary Embolism

Introduction

Deep vein thrombosis is a blood clot that occurs in the body’s deep veins, most commonly in the legs but also in the arms and upper extremities. A pulmonary embolism can occur when blood clots become dislodged.

The blood clot in the vessel is referred to as a thrombus; as it dislodges and begins to flow through the bloodstream, it is referred to as an embolus. Consider an embolus to be a moving thrombus! An embolus can be anything that travels through the bloodstream (air emboli, fat emboli, and even foreign body emboli).

Thrombophlebitis is a dangerous condition in which the veins become inflamed, causing blood clots or thrombosis, which can obstruct the normal flow of blood through the vessels.

Venous thrombophlebitis is a type of thrombophlebitis that affects the lower limbs or superficial veins such as the basilic, greater saphenous, and cephalic veins. It is usually not life-threatening.

This blog post discusses about deep vein thrombosis, the risk for DVT nursing diagnosis, care plans and interventions with elaborate examples .As you follow along, remember that our qualified writers are always ready to help in any of your nursing assignments. All you need to do is place an order with us!

Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

Deep Vein Thrombosis

Risk for DVT - Nursing Diagnosis For Pulmonary Embolism
Risk for DVT - Nursing Diagnosis For Pulmonary Embolism 5

A deep vein thrombosis (DVT) is a medical disorder in which a blood clot forms in a vein deep within the body. Clots in the lower leg, thigh, or pelvis are most common, but they can also occur in the arm.

It’s crucial to understand DVT since it can strike anyone and result in significant disease, paralysis, and, in some circumstances, death. The good news is that DVT can be prevented and treated if caught early.

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Types of Thrombosis

Arterial and venous thrombosis are the two most common kinds of thrombosis.

Arterial thrombosis

A thrombus forms in an artery in this case. Arteries are blood vessels that transport oxygenated blood from the heart to various body parts.

Depending on the size of the thrombus and the artery in which it originates, cases of arterial thrombosis can be modest or severe. A thrombus in a blood vessel supplying blood to the brain can induce a stroke, while a thrombus in a blood vessel supplying blood to the heart can cause a heart attack.

Venous thrombosis

A thrombus forms in a vein in this case. 

Blood clots in the veins are called venous thromboembolism (VTE). The two subtypes are deep vein thrombosis (DVT) and pulmonary embolism(PE).

A thrombus, or clot, forms in a deep vein, generally in the arm, leg, or pelvis, causing DVT. PE happens when a piece of a DVT breaks off and travels through the bloodstream to the lungs, obstructing a pulmonary blood artery.

Causes of Deep Vein Thrombosis

Although the actual origin of deep vein thrombosis is unknown, some variables can make it worse.

Trauma that is experienced directly. The veins can be damaged by direct trauma to the vessels, such as a fracture or dislocation, illnesses of the veins, and chemical irritation of the veins by medications and solutions.

Blood coagulability. Increased blood coagulability is particularly common in people who have abruptly stopped their anticoagulant medicines.

Oral contraceptives. The usage of oral contraceptives causes hypercoagulability.

Pregnancy. Normal pregnancy causes an increase in clotting factors, which may not return to baseline for up to 8 weeks after delivery, increasing the risk of thrombosis.

Repetitive motions. Repetitive motions can irritate the vascular wall, leading to inflammation and thrombosis.

DVT-Related Risk Factors

A DVT can affect almost everyone. Certain variables, however, can enhance the likelihood of developing this illness. If you have more than one of these factors simultaneously, your chances increase even more.

Everyone is in danger. Several factors can increase this risk.

These risks include: 

  1. Injury to a vein, often caused by:
  2. Fractures
  3. Severe muscle injury
  4. Major surgery (mainly involving the abdomen, pelvis, hip, or legs).
  5. Slow blood flow is commonly caused by:
  6. Being confined to bed (for example, due to a medical condition or following surgery);
  7. Limited movement (e.g., a cast on a leg to help heal an injured bone);
  8. Sitting for a long time, especially with crossed legs; or
  9. Paralysis.
  10. Increased estrogen, often caused by:
  11. Birth control pills
  12. Hormone replacement treatment is sometimes utilized after menopause
  13. Pregnancy or up to three months following delivery.
  14. Some chronic medical conditions, such as:
  15. Heart disease is a severe condition.
  16. Lung disease is a condition that affects people.
  17. The disease and its treatment
  18. Crohn’s disease (also known as ulcerative colitis) is an inflammatory bowel disease.

Other risk factors for DVT include:

  1. DVT or PE symptoms in the past
  2. DVT or PE in the family history
  3. Age (risk increases as age increases)
  4. Obesity
  5. A catheter is a tube inserted into a vein in the heart.
  6. Clotting problems that are passed on in the family

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Symptoms of DVT

According to the Centers for Disease Control and Prevention (CDC), only approximately half of those who have DVT experience symptoms.

  1. Swelling in your foot, ankle, or leg, usually on one side, is a common indication of DVT.
  2. Cramping in the affected leg, which commonly starts in the calf
  3. Severe and inexplicable foot and ankle pain
  4. A patch of skin that is noticeably warmer than the skin around it.
  5. Depending on skin tone, the skin over the affected area becomes pale, reddish, or bluish in hue.

The symptoms of an upper extremity DVT, or a blood clot in the arm, maybe absent. If they do, the following are some of the most prevalent symptoms:

  1. Neck ache
  2. Shoulder ache
  3. Swelling in the arm or hand is a common ailment.
  4. Skin with a blue or darker tint
  5. An ache in the forearm that travels up the arm
  6. A hand stumbling block.

It’s possible that people don’t realize they have DVT until they’ve had emergency treatment for a pulmonary embolism (blood clot in the lung).

When a DVT clot travels from the arm or leg to the lungs, it can cause a pulmonary embolism. When a pulmonary artery becomes clogged, it is a life-threatening condition requiring immediate medical attention.

Pathophysiology

Although the specific etiology of deep vein thrombosis is unknown, some pathways are thought to play a role in its progression.

Reduced blood flow. Blood flow is reduced, veins are dilated, and skeletal muscle contraction is reduced, resulting in venous stasis.

Damage. Damage to the intimal lining of blood vessels provides a clot-forming environment.

Phlebitis. Phlebitis, or inflammation of the vein walls, is commonly accompanied by the formation of a thrombus.

Aggregates of platelets. Venous thrombi are platelet aggregates with a tail-like appendage containing fibrin, white blood cells, and a large number of red blood cells adhered to the venous wall.

Tail. As successive layers of the thrombus from the tail which can extend or propagate in the direction of blood flow.

Fragmentation. Fragmentation of the thrombus can happen naturally when it dissolves, or it can happen due to high venous pressure.

Recanalization. Recanalization or reestablishment of the vascular lumen is common after an acute episode of DVT.

Complications of DVT

DVT complications can include:

Pulmonary embolism (PE) – is a life-threatening complication that can occur due to DVT. It happens when a blood clot (thrombus) travels to your lung from another area of your body, generally your leg, and blocks a blood vessel in your lung.

If you have signs and symptoms of PE, you should get medical care right once. With a PE, you may have shortness of breath, chest pain while inhaling or coughing, rapid breathing, quick pulse, feeling faint or fainting, and coughing up blood. 

Postphlebitic syndrome – is a condition that occurs after a blood transfusion. Damage to your veins caused by a blood clot restricts blood flow in the afflicted areas, resulting in leg pain and swelling, as well as skin discoloration and ulcers.

Complications of treatment Blood thinners used to treat DVTs can cause complications. Blood thinners can cause bleeding (hemorrhage), which is a dangerously adverse effect. When using such medications, it’s critical to get regular blood testing.

Diagnosis of DVT

D-Dimer blood test: This test measures the byproducts that occur when clots degrade. If it’s higher than usual, it could indicate the presence of a clot.

Ultrasound

Venography: This test involves injecting contrast dye into a vein and seeing it on an X-ray—the clot forms at the point where the dye flow is disrupted.

CT or MRI: These tests may be used to diagnose a clot, but I’ve never seen it. We typically use less intensive tests first, but these may be used in some situations.

Treatment

DVT is a life-threatening medical disorder. 

If you think you’re having DVT symptoms, call your doctor or go to the nearest emergency room right once. 

Your symptoms can be examined by a medical professional.

The goal of DVT treatment is to keep the clot from spreading. 

Treatment may also help you avoid a pulmonary embolism and reduce your chances of getting additional clots.

Medication

  • Heparin
  • Warfarin (coumadin)
  • Enoxaparin (lovenox)
  • Fondaparinux (arixtra)

Blood-thinning drugs make it more difficult for your blood to clot. They also keep existing clots as tiny as possible, lowering the risk of developing new ones.

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Nursing Care Plans for DVT

The nursing care plan for DVT in the leg may include:

  1. Information relating to the treatment, the disease condition, and how to prevent it
  2. Monitoring and assessing anticoagulant therapy
  3. Offering comfort measures
  4. Providing information about the positioning of the body
  5. Encourage exercise
  6. Maintaining sufficient tissue perfusion
  7. Information relating to the prevention of complications

Nursing Care Plans for DVT Based on the Diagnosis

Nursing Care Plan 1: Impaired Gas Exchange

 Carbon dioxide is removed from the alveolar-capillary membrane. The evidence of sufficient oxygenation and ventilation by ABGs that are within the patient’s normal range is one of the desired outcomes of this nursing care plan. The client demonstrates or reports the absence or remission of respiratory distress symptoms.

Nursing Care Plan 2: Ineffective Peripheral Tissue Perfusion

 This involves a decrease in oxygen, which causes a malfunction at the capillary level, preventing the tissues from receiving appropriate nourishment. Clients should maintain optimal tissue perfusion in the afflicted ends as one of the desired outcomes. A decrease in or elimination of pain, strong and steady palpable pulses, dry and warm extremities, and adequate capillary refill are all signs of this. The patient typically does not develop pulmonary embolism, as evidenced by normal heart rate and breathing, the absence of chest discomfort, and dyspnoea.

Nursing Care Plan 3: Acute Pain

Acute pain results from a potential or actual tissue injury or damage, creating unpleasant sensory and emotional sensations. The slow or rapid development of intensity, mild or severe, with a predicted finish in less than six months. The client will display the desired consequence of regulated or lessened discomfort or pain. He’ll have a laid-back demeanor and be able to rest, sleep, or indulge in a pleasurable pastime. The patient will employ linguistic techniques that will give him relief.

Nursing Care Plan 4: Deficient Knowledge

A lack of cognitive information about a specific issue or the absence of any cognitive information on a specific topic. The patient will demonstrate a thorough awareness of the treatment, ailment, and precautions.

The risk of bleeding – Bleeding can reduce blood volume in the body, putting your health at risk. Maintaining a therapeutic amount of anticoagulant in the blood, as measured by PT (prothrombin time), INR (international normalized ratio), and PTT (partial thromboplastin time) within an acceptable range, are desirable results.

Nursing Interventions for DVT

  1. Assist in providing comfort. Elevation of the affected extremity, progressive compression stockings, warm application, and ambulation are all options for alleviating or reducing discomfort during therapy.
  2. Compression therapy is a type of treatment that involves applying pressure to external compression devices. Short-stretch elastic wraps are applied in a 50 percent spiral overlap between the toes and knees. Intermittent pneumatic compression devices increase blood velocity beyond that produced by the stockings.
  3. Compression therapy entails wearing progressive compression stockings to lower the size of the leg’s superficial veins while increasing blood flow to the deep veins. External compression devices and wraps are short-stretch elastic wraps put in a 50 percent spiral overlap from the toes to the knees. Intermittent pneumatic compression devices

boost blood flow above and beyond that of stockings.

  • Exercise and positioning – When a patient is on bed rest, the feet and lower legs should be regularly raised above the heart level, and active and passive leg exercises should be done to improve venous flow.

Summary

Thrombosis occurs when a blood clot forms inside a blood vessel and impedes blood flow. There are two main types of thrombosis: arterial thrombosis, in which a blood clot blocks an artery, and venous thrombosis, in which a blood clot blocks a vein.

The lack of blood and oxygen to the portion of the body that the blocked vessel usually serves causes thrombosis symptoms. Anyone who develops signs of a blood clot should seek medical help right away. Early intervention lowers the risk of significant consequences and improves the prognosis.

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References

Related FAQs

1. What is DVT and how dangerous is it?

DVT, or deep vein thrombosis, is a serious and potentially life-threatening condition. It’s estimated to affect nearly one million people each year in the U.S., according to the Center for Disease Control and Prevention (CDC).

2. What does DVT stand for?

Deep vein thrombosis (DVTDeep vein thrombosis is a clot in a deep vein, usually in the leg. DVT sometimes affects the arm or other veins. Pulmonary embolism (PE) A pulmonary embolism occurs when a DVT clot breaks free from a vein wall, travels to the lungs and then blocks some or all of the blood supply. Blood clots originating in the thigh are more likely to break off and travel to the lungs than blood clots in the lower leg or other parts of the body.

3. Why can DVT be so dangerous?

Pulmonary embolism is the most serious threat of deep vein thrombosis (DVT), but DVT can also lead to heart failure, skin ulcers, and more. When blood clots, it’s the body’s way of preventing excessive blood loss. Most of the time, blood clots dissolve on their own.

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