DEEP VEIN THROMBOSIS (DVT)

WHAT IS DEEP VEIN THROMBOSIS?It is the development of thrombi in the great in the deep veins of the extremities or pelvis.DVT is potentially life-threatening because it may lead to pulmonary embolism.

PATHOPHYSIOLOGYVirchows TriadStasis of bloodVessel damageIncreased blood coagulabilityHypercoagulable state or subclavian vein compression at the thoracic outlet.Endothelial injury due to central venous catheters, pacemakers, or injection drug use.Vessel trauma stimulates the clotting cascadePlatelets aggregate at the site particularly when venous stasis present

PATHOPHYSIOLOGYPlatelets and fibrin form the initial clotRBC are trapped in the fibrin meshworkThe thrombus propagates in the direction of the blood flowInflammation is triggered ,TendernessSwellingErythemaFIBROSISChronic venous insufficiency Postphlebitic syndrome Enlarging clot may occlude the vessel lumen partially or totally and may detach and lodge elsewhere in the systemic circulationPulmonary Embolism

CAUSESIt is caused by Virchows triad Vessel wall injury (e.g. cigarette smoking) Venous stasis (e.g. prolonged bed rest) hypercoagulability of the blood (e.g. use of contraceptive pills, dehydration, hyperglycemia)* note: For a DVT to occur, at least two among the triad should be presented by the patient. (Nursing Crib)

Clinical Manifestations of DVTUsually non specific. The exception is Phlegmasia cerula dolens.Deep VeinsWith obstruction of the deep vein comes edema and swelling of the extremity because the outflow of venous blood is inhibited. signs and symptoms of a pulmonary embolus are the first indication of DVT.Superficial VeinsThrombosis of superficial veins produces pain or tenderness, redness and warmth in the involved area. The risk of the superficial venous thrombi becoming dislodged or fragmenting into emboli is very low because most of them dissolve spontaneously

Clinical Manifestations of DVTCalf pain (+ Homans sign)

* Response: Pain in the calf with this maneuver may be consistent with the diagnosis of deep venous thrombosis.

Clinical Manifestations of DVTTendernessPalpable induration (redness) along the course of veinEdema

DIAGNOSISpossibly a positive Homans sign (Duplex Doppler Ultrasonography and impedance plethysmographyPlethysmography and/or Phlebography

COLLABORATIVE MANAGEMENTMedical ManagementPharmacologic TreatmentAnticoagulants - Used in clients with venous and arterial disorders that put them at high risk for clot formationHeparin it inhibits the action of thrombin; conversion of fibrinogen to fibrin does not occur and the formation of a fibrin clot is prevented.Coumadin inhibits hepatic synthesis of Vitamin K, thus affecting the clotting factors II, VII, IX and X.

COLLABORATIVE MANAGEMENTMedical ManagementPharmacologic TreatmentThrombolytics - It disintegrates blood clot (thrombus)Unlike heparins, catheter directed thrombolytic therapy lyses and dissolves thrombi in atleast 50 % of cases.Advantage: It includes less long-term damage to the venous valves and a reduced incidence of postthrombic syndrome and chronic venous insufficiency.Disadvantage: Thrombolytic therapy results in a threefold greater incidence of bleeding than heparin. If bleeding occurs and cannot be stopped, the thrombolytic agent is discontinued.

COLLABORATIVE MANAGEMENTSurgical ManagementThromboembolectomyGreenfield vena cave filter and umbrella filter

NURSING MANAGEMENT

MANAGEMENTRATIONALE(for patients taking up anticoagulants) Assess and Monitor anticoagulant therapyMonitor and manage potential complications such as Bleeding, Thrombocytopenia and Drug interactionsBleeding - Since the principal complication of anticoagulant therapy is spontaneous bleeding.

Thrombocytopenia Monitor platelet count because a complication of heparin therapy may include Heparin induce Thrombocytopenia.

Drug Interaction Oral anticoagulants interact with many other medications and herbal and nutritional supplements, close monitoring of the patients medication schedule is necessary

NURSING MANAGEMENT

MANAGEMENTRATIONALEMaintain tissue perfusion.*Check pulse distal to the site of the thrombosis.*Elevate legs*The nurse should also instruct the client that walking is better than standing or sitting for long periods. *Monitor calf pain.

To assess for circulatory blockage

To promote venous return and to prevent edemaTo prevent venous stasis.

Presence of calf pain indicates thrombophlebitis.

NURSING MANAGEMENT

MANAGEMENTRATIONALEProvide comfort.Apply warm, moist packs to the affected extremity.Encourage the client to walk once anticoagulation therapy has been initiated. Administration of analgesic agents.

To reduce the discomfort associated with DVT.To prevent venous stasis.For pain relief

******