Deep Vein thrombosis.pptx

Deep Vein Thrombosis
Parbati Dahal
MN
Adult Health Nursing
1
Parbati Dahal, MN, CMC

Anatomy of Venous system
• Arteries are the blood vessels that carry oxygen-rich
blood from the heart to all other parts of the body.
Veins return the oxygen-depleted blood back to the
heart. There are two types of veins in the body:
• Superficial veins lie just below the skin's surface
• Deep veins are located deep within the muscles
Parbati Dahal, MN, CMC 2

Introduction
Related Terminology:
• Venous thrombosis: involves the formation of a thrombus
in association with inflammation of the vein. It is most
common disorder of vein and is classified either superficial
vein thrombosis or deep vein thrombosis.
• Superficial vein thrombosis (SVT): is the formation of a
thrombus in a superficial vein usually the greater or lesser
saphenous vein.
6

Deep vein thrombosis (DVT)
It is a disorder involving a thrombus in a deep vein,
most commonly the iliac and femoral vein.
Venous thromboembolism (VTE):
It is the preferred terminology and represents the
spectrum of pathology from DVT to pulmonary
embolism(PE).
7

Introduction of DVT
• Deep vein thrombosis (DVT) is a blood clot that
forms in a vein deep in the body.
• Blood clots occur when blood thickens and clumps
together.
• Most deep vein blood clots occur in the lower leg or
thigh. They also can occur in other parts of the
body.
8

Introduction Cont’d…
• It is also called as phlebothrombosis.
• A blood clot in a deep vein can break off and travel
through the bloodstream.
• The loose clot is called an embolus.
• It can travel to an artery in the lungs and block
blood flow. This condition is called pulmonary
embolism.
9

Epidemiology
In United States
• Deep venous thrombosis (DVT) and thromboembolism
remain a common cause of morbidity and mortality in
bedridden or hospitalized patients, as well as generally
healthy individuals.
• Existing data that probably underestimate the true
incidence of DVT suggest that about 80 cases per 100,000
population occur annually.
10

Epidemiology Cont’d…
• Approximately 1 person in 20 develops a DVT in
the course of his or her lifetime.
• About 600,000 hospitalizations per year occur for
DVT in the United States.
11

Epidemiology Cont’d…
Age distribution
• In elderly persons the incidence is increased four-fold.
• Deep venous thrombosis usually affects individuals
older than 40 years.
Sex:
• The male-to-female ratio is 1.2:1, indicating that males
have a higher risk of DVT than females (Patel, 2019).
12

Etiology / Risk factors
• Three main factors contribute to the development
of DVT:
• These represent the Virchow triad
13

Risk factor
Venous stasis
• Advanced age
• Immobilization longer than 3 days
• Previous DVT
• Chronic heart failure
• Stroke
• Acute myocardial infarction (AMI)
• Congestive heart failure (CHF)
• Sepsis
14

Risk factor Cont’d…
Hypercoagulability of blood
• Polycythemia rubra vera
• Thrombocytosis
• Inherited disorders of coagulation/fibrinolysis
• Protein C deficiency
• Protein S deficiency
• Antithrombin III deficiency
• Heparin-induced thrombocytopenia (HIT)
15

Risk factor Cont’d…
Endothelial Damage
• Major surgery in previous 4 weeks
• CNS/spinal cord injury
• Burns
• Lower extremity fractures
• History of previous venous thromboembolism
• IV drug abuse
• Trauma
16

Pathophysiology
Virchow's triad: A major theory delineating the
pathogenesis of venous thromboembolism (VTE), often
called Virchow's triad, proposes that VTE occurs as a
result of:
• Alterations in blood flow (i.e., stasis)
• Vascular endothelial injury
• Alterations in the constituents of the blood (i.e.,
inherited or acquired hypercoagulable state)
18

Pathophysiology
Virchow's triadTriad
• Platelets aggretes (especially at vein valve cups)
• Clotting factors stimulated to produce fibrin
• Fibrin entraps RBC, WBC and platelets and begins to adhere to
vein wall
Endothelial damage
• Release of clotting factors
• Activation of platelets
Blood hypercoagulability
• Imbalance in clotting
mechanism
• Increase in fibrin
production
Venous Stasis
• Dysfunctional vein valves
• Inactive extremity muscle
• Change in unidirectional
blood flow
Thrombus formation
Clinical manifestation
• Unilateral leg edema, pain and erythema
• Chronic venous insufficiency
• Embolism of thrombotic fragments 19

Sign and Symptoms
• Asymptomatic
• Fever –earliest symptoms
• Swelling of leg or long vein
in the leg (70% of patient)
• Leg pain occurs in 50% of
patients, but this is entirely
nonspecific. Pain can occur on
dorsiflexion of the foot
(positive Homan’s sign).
20

Sign and Symptoms Cont’d…
• Mose’s sign: Gentle
squeezing of lower part of
the calf muscle from side to
side is painful. Gentleness is
important otherwise it may
dislodge a thrombus to form
an embolus.
21

• Neuhof’s sign: Thickening and deep tenderness
elicited while palpating deep calf muscles.
• Linton’s sign: After applying tourniquet at
saphenofemoral junction, patient is made to walk
and without removing the tourniquet, limb is
elevated which shows persisting prominent
superficial veins will be observed in DVT.
22

• Tenderness occurs in 75% of
patients but is also found in
50% of patients without
objectively confirmed DVT.
• Red discolored skin on the leg
• Leg cramps (especially at
night and/or in the calf)
25

Warning sign of DVT
1. Swelling
2. Gradual onset of pain
3. Redness
4. Warmth to the touch
5. Worsening leg pain when bending the foot
6. Leg cramps, especially at night, and often starting in
the calf
7. Bluish or whitish discoloration of skin
26

Diagnosis
History taking
• Pain (50% of patients)
• Redness
• Swelling (70% of patients)
Physical Examination
• Limb edema may be unilateral or bilateral if the thrombus is extending to
pelvic veins
• Red and hot skin, with dilated veins
• Tenderness
• Pain on dorsiflexion of the foot (the Homans sign) 27

Diagnosis cont’d…
• Duplex ultrasonography: is an imaging test that uses
sound waves to look at the flow of blood in the veins. It
can detect blockages or blood clots in the deep veins. It
is the standard imaging test to diagnose DVT.
• D-dimer blood test: Fragment of fibrin formed as
result of fibrin degradation and clot lysis. Elevated
results suggest VTE.
• Normal Level- <250ng/ml
28

Assess clinical risk
Measure D – dimmer levels
D- dimer –ve
Risk low
D-dimer +ve D-dimer –ve
Risk high
Not
DVT/PE
Risk low
Treat • USG leg veins
• CT pulmonary
angiography
Confirm
diagnosis
Risk high
Parbati Dahal, MN, CMC 29

• Contrast venography: is a special type of X-ray where
contrast material (dye) is injected into a large vein so
that can visualize the deep veins in the leg and hip.
• It is the most accurate test for diagnosing blood clots
but it is an invasive procedure, Therefore this test has
been largely replaced by duplex ultrasonography, and it
is used only in certain patients.
30

• Magnetic resonance imaging (MRI) and CT scan
• Chest X-ray: Pulmonary edema
• Blood test: CBC,PT, INR, BT, CT
31

Management
The main goal of treating DVT are to:
• Stop the blood clot getting bigger
• Prevent the blood clot from breaking off and
moving to lungs (risking pulmonary embolism).
• Reduce the reoccurrence
33

Medical Management
Anticoagulation Therapy:
• Measures for preventing or reducing blood clotting
within the vascular system are indicated in patients with
thrombophlebitis, recurrent embolus formation, and
persistent leg edema from heart failure.
• They are also indicated in elderly patients with a hip
fracture that may result in lengthy immobilization.
34

Unfractionated Heparin:
• Unfractionated heparin (heparin) is administered subcutaneously to
prevent development of deep vein thrombosis, or by intermittent
intravenous infusion or continuous infusion for 5 to 7 days to
prevent the extension of a thrombus and the development of new
thrombi.
• Oral anticoagulants, such as warfarin (Coumadin), are
administered with heparin therapy.
• Medication dosage is regulated by monitoring the partial
thromboplastin time, the international normalized ratio (INR), and
the platelet count.
35

Low-Molecular-Weight Heparin
• Subcutaneous low-molecular weight heparin (LMWH) is an
effective treatment for some cases of deep vein thrombosis.
• It has a longer half-life than unfractionated heparin, so doses
can be given in one or two subcutaneous injections each day.
• Doses are adjusted according to weight. LMWH prevents the
extension of a thrombus and development of new thrombi and
is associated with fewer bleeding complications than
unfractionated heparin.
36

Medical Management Cont’d…
Thrombolytic Therapy:
• Unlike the heparins, thrombolytic (ﬁbrinolytic)
therapy causes the thrombus to lyse and dissolve in
50% of patients.
• Thrombolytic therapy (eg, tissue plasminogen
activator [t-PA, alteplase, Activase], reteplase [r-PA,
Retavase], tenecteplase [TNKase], staphylokinase,
urokinase, streptokinase) is given within the ﬁrst 3
days after acute thrombosis. 37

Management Cont’d…
Applying Elastic compression stockings
• Elastic compression stockings usually are prescribed
for patients with venous insufficiency.
• These stockings exert a sustained, evenly distributed
pressure over the entire surface of the calves, reducing
the caliber of the superﬁcial veins in the legs and
resulting in increased ﬂow in the deeper veins.
38

Cont’d…
Exercise:
• walking and calf exercise reduce venous stasis
because leg muscle contraction compress the veins
and pump blood up towards the heart.
40

Surgical Management
• Surgery is necessary for deep vein thrombosis when
anticoagulant or thrombolytic therapy is
contraindicated the danger of pulmonary embolism is
extreme, or the venous drainage is so severely
compromised that permanent damage to the extremity
will probably result.
41

• Vena cava Filter: The filter is
inserted inside the venacava.
The filter catches blood clots
before they travel to the lungs,
which prevents pulmonary
embolism. However, the filter
doesn’t stop new blood clots
from forming.
42

Thrombectomy/ Embolectomy
• In rare cases, a surgical procedure to remove the
clot may be necessary.
• Thrombectomy involves removal of the clot in a
patient with DVT.
• Embolectomy involves removal of the blockage in
the lungs caused by the clot in a patient with PE.
43

Assessment
History taking
Physical examination
Nursing Management
44

• Acute pain related to venous congestion, impaired venous
return and inflammation
• Ineffective health maintenance related to lack of
knowledge about disorder and its treatment
• Risk for impaired skin integrity related to altered
peripheral tissue perfusion
• Potential complication: bleeding related to anticoagulation
therapy
• Potential complication: PE related to embolization of
thrombus, dehydration and immobility
Nursing Diagnosis
45

Pain management
• Assess the patient’s pain, including location, quality and intensity,
respiratory rate, and level of conscious.
• Provide psychological support to the patient.
• Provide comfortable position.
• Administration analgesics as prescribed.
• Diversional Therapy and relaxation technique
• Reassess the pain to evaluate the effectiveness of interventions
Cont’d…
46

Emotional and psychological care
• Provide a safe environment for the expression of the ful
range of feeling.
• Encourage to identify and learn individual coping strengths.
• Provide accurate and complete information about disease
process.
• Acknowledge patient that this could be a fearful situation to
any one and others have expressed similar fears
Cont’d…
47

• Monitor the partial thromboplastin time, prothrombin
time, hemoglobin and hematocrit values, platelet
count, and ﬁbrinogen level.
• Close observation is also required to detect bleeding;
if bleeding occurs, it must be reported immediately
and anticoagulant therapy discontinued.
Minimize Risk of Bleeding
48

Cont’d…
• To prevent inadvertent infusion of large volumes of
heparin, which could cause hemorrhage, continuous
intravenous infusion by electronic infusion device is
the preferred method of administering unfractionated
heparin.
• Dosage calculations are based on the patient’s weight,
and any possible bleeding tendencies are detected by a
pretreatment clotting proﬁle
49

• If renal insufﬁciency exists, lower doses of heparin
are required.
• Periodic coagulation tests and hematocrit levels are
obtained.
• Heparin is in the effective, or therapeutic, range
when the partial thromboplastin time is 1.5 times
the control.
Cont’d…
50

• Oral anticoagulants, such as warfarin, are monitored
by the prothrombin time or INR. Because their effect
is delayed for 3 to 5 days, they are usually
administered with heparin until desired
anticoagulation has been achieved (ie, when the
prothrombin time is 1.5 to 2 times normal or the INR
is 2.0 to 3.0).
Contd…
51

Monitoring and managing potential complications
Bleeding
• The principal complication of anticoagulant therapy is
spontaneous bleeding anywhere in the body.
• Bleeding from the kidneys is detected by microscopic
examination of the urine and is often the ﬁrst sign of
anticoagulant toxicity from excessive dosage.
52

• Bruises, nosebleeds, and bleeding gums are also early
signs.
• To reverse the effects of heparin promptly, intravenous
injections of protamine sulfate may be administered.
• Reversing the effects of warfarin, a coumarin derivative, is
more difﬁcult, but effective measures that may be
prescribed include vitamin K and possibly transfusion of
fresh frozen plasma.
Cont’d…
53

Thrombocytopenia
• which may develop in patients who receive heparin for
more than 5 days or on re-administration after a brief
interruption of heparin therapy.
• Beginning warfarin concurrently with heparin can
provide a stable INR or prothrombin time by day 5 of
heparin treatment.
Cont’d…
54

• The use of LMWH is less frequently associated
with heparin induced thrombocytopenia.
• The thrombocytopenia is thought to result from an
immunologic mechanism that causes aggregation of
platelets.
Cont’d…
55

• This serious complication results in thromboembolic
manifestations, and the prognosis is extremely
guarded.
• Prevention of thrombocytopenia depends on regular
monitoring of platelet counts.
Cont’d…
56

• Early signs of thrombocytopenia are a falling
platelet count to less than 100,000/mL, a decrease.
• if thrombocytopenia does occur, platelet
aggregation studies are conducted, the heparin is
discontinued, and protamine sulfate is administered
to reverse heparin’s effects.
Cont’d…
57

Providing Comfort
• Bed rest, elevation of the affected extremity, elastic
compression stockings, and analgesics for pain relief
are adjuncts to therapy.
• They help to improve circulation and increase comfort.
• Depending on the extent and location of a venous
thrombosis, bed rest may be required for 5 to 7 days
after diagnosis.
58

• This is approximately the time necessary for the
thrombus to adhere to the vein wall, preventing
embolization.
• Warm, moist packs applied to the affected extremity
reduce the discomfort associated with deep vein
thrombosis, as do mild analgesics prescribed for pain
control.
Cont’d…
59

• When the patient begins to ambulate, elastic
compression stockings are used.
• Walking is better than standing or sitting for long
periods.
• Bed exercises, such as dorsiﬂexion of the foot, are
also recommended.
Cont’d…
60

Applying elastic compression stockings
• Elastic compression stockings usually are prescribed for
patients with venous insufficiency.
• These stockings exert a sustained, evenly distributed
pressure over the entire surface of the calves, reducing the
caliber of the superﬁcial veins in the legs and resulting in
increased ﬂow in the deeper veins.
• The stockings may be knee-high, thigh-high, or panty
hose.
61

• Thigh-high stockings are difﬁcult for the patient to
wear, because they have a tendency to roll down.
• The roll of the stocking further restricts blood ﬂow
rather than the stocking providing evenly distributed
pressure over the thigh.
Cont’d…
62

• When the stockings are off, the skin is inspected for
signs of irritation, and the calves are examined for
possible tenderness.
• Any skin changes or signs of tenderness are
reported. Stockings are contraindicated in patients
with severe pitting edema because they can produce
severe pitting at the knee.
Cont’d…
63

Complication
• Chronic venous occlusion
• Pulmonary emboli from dislodged thrombi
• Valvular destruction
oChronic venous insufﬁciency
oIncreased venous pressure
o Varicosities
o Venous ulcers

Complication Cont’d…
•Venous obstruction
oIncreased distal pressure
oFluid stasis
o Edema
oVenous gangrene
65

Prevention
• Lose weight if overweight or obese
• Avoid periods of prolonged immobility.
• Keep the legs elevated while sitting down or in bed.
• After surgery, get out of bed several times a day
during the recovery period, use compression devices
on the legs or elastic compression socks/stockings.
• Take regular dose of heparin or warfarin if prescribed
to prevent clot formation.
66

Prognosis
• Most cases of deep venous thrombosis (DVT) is occult and
usually resolves spontaneously without complication.
• The principal long-term morbidity from DVT is post
thrombotic syndrome (PTS), which complicates about a
quarter of cases of symptomatic proximal DVT; most cases
develop within 2 years afterward.
• Death from DVT is attributed to massive pulmonary
embolism (PE), which causes as many as 300,000 deaths
annually in the United States.
67

• Black, J. M. & Hawks, J. N. (2009). Medical-
surgical nursing (8th ed.). New Delhi: Elsevier
India Pvt. Ltd.
• Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., &
Bucher, L. (2015). Medical surgical nursing:
assessment and management of clinical problems
(2nd ed.). South Asia Edition, Vol 2. New Delhi:
Reed Elsevier India Pvt. Ltd
• Bhat, S. (2013). SRB’s Manual of surgery (4th ed.).
Jaypee brother medical publisher.
References
68

• Patel, K. (2019). Deep venous thrombosis (DVT).
Medescape. Retrieved from
https://emedicine.medscape.com/article/1911303-
overview#a6
• Smeltzer, S. C., Bare, B. G., Hinkle, J. L. &
Cheever, K. H. (2008). Brunner & suddarth’s
textbook of medical-surgical nursing (11th ed.). New
Delhi: Lippincott Williams & Wilkins , a Wolter
Kluwer business.
• Walker, B. R., Colledge, N. R., Ralston, S. H., &
Penman, I. D. (2014). Davidson's Principles &
Practice of Medicine (22nd ed.). China: Churchill
Livingstone Elsevier.
References
69

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