Deep Vein Thrombosis

1. DEEP VEIN THROMBOSIS
PRESENTER:-
Ms. Anshu
M.Sc. Nursing
KGMU College of Nursing

2. INTRODUCTION
• Deep vein thrombosis (DVT) and pulmonary
embolism (PE) collectively make up the
condition known as venous thromboembolism
(VTE).

3. What Is Deep Vein
Thrombosis ?

4. DEFINITION
• Deep vein thrombosis is the formation of a
blood clot in one of the deep veins of the
body, usually in the leg.

5. IT IS LIKE ICEBERG DISEASE
• Symptomatic deep vein thrombosis is"tip of
the iceberg"

6. EPIDEMIOLOGY
• Venous ThromboEmbolism related deaths
• 3,00,000/anum
• 7% diagnosed and treated
• 34% sudden pulmonary embolism
• 59% as undected

7. INCIDENCE
• An annual incidence of symptomatic Venous
ThromboEmbolism as 117 per 100,000
persons .
• Venous ThromboEmbolism in hospitalized
patients has increased from 0.8% to 1.3% over
a period of 20 years (reported in 2005).

8. Without prophylaxis the incidence of deep vein
thrombosis is about –
• 14% in gynaecological surgery
• 22% in neurosurgery
• 26% in abdominal surgery
• 45%-60% in patients undergoing hip and
knee surgeries.
• 15% to 40% Urologic surgery.

9. ETIOLOGY
Virchow's triad
Describes
three factors that are thought to contribute to
thrombosis

10. VIRCHOW TRIAD
More than 100 years ago, Rudolf Virchow
described a triad of factors of -

12. VENOUS STASIS
• prolonged bed rest (4 days or more)
• A cast on the leg
• Limb paralysis from stroke
• spinal cord injury
• extended travel in a vehicle
• Age (greater than 65 yrs)

13. HYPERCOAGULABILITY
• Surgery and trauma - 40% of all thrombo
embolic disease
• Malignancy
• increased estrogen
• Inherited disorders of coagulation -Deficiencies
of protein-S, protein-C, anti-thrombin III.
• Acquired disorders of coagulation- Nephrotic
syndrome, Anti-phospholipid antibodies

14. ENDOTHELIAL INJURY
• Trauma
• Surgery
• Pacing wires
• Dialysis access catheters
• Repetitive motion injury
• central venous catheters
Subclavian
Internal jugular lines
These lines cause of upper extremity DVT.

15. PATHOPHYSIOLOGY
Vessel trauma stimulates the clotting cascade.
Platelets aggregate at the site particularly when
venous stasis present
Platelets and fibrin form the initial clot
RBC are trapped in the fibrin meshwork

16. The thrombus propagates in the direction of the blood
flow.
Inflammation is triggered, causing tenderness,
swelling, and erythema.
Pieces of thrombus may break loose and travel
through circulation- emboli.
Fibroblasts eventually invade the thrombus,
scarring vein wall and destroying valves. Patency
may be restored valve damage is permanent,
affecting directional flow.

18. • Thrombophlebitis - a thrombus
accompanied by inflammation of the vein
(phlebitis).
• Phlebothrombosis - refers to a thrombus
with minimal inflammation.
• Dislodgment and migration of a thrombus
are known as thromboembolism. Which is
common in phlebothrombosis.

19. COMMON CLINICAL MANIFESTATIONS
• Calf pain or tenderness, or both
• Swelling with pitting oedema
• Increased skin temperature and fever
• Superficial venous dilatation
• Cyanosis can occur with severe obstruction

20. • Less frequent manifestations of venous
thrombosis include:-
• Phlegmasia alba dolens,
• Phlegmasia cerulea dolens, and
• Venous gangrene.
• These are clinical spectrum of the same
disorder.

21. PHLEGMASIA ALBA DOLENS
Thrombosis in only major deep venous channels
sparing collateral veins
Causing painful congestion and oedema of
leg, with lymphangitis
Which further increases
Oedema

22. PHLEGMASIA CERULEA DOLENS
Thrombosis extends to collateral veins.
congestions, massive fluid sequestration, edema

23. CLINICAL EXAMINATION
• Palpate distal pulses and evaluate capillary
refill to assess limb perfusion.
• Move and palpate all joints to detect acute
arthritis or other joint pathology.
• Neurologic evaluation may detect nerve root
irritation; sensory, motor, and reflex deficits
should be noted

24. • Homans sign: pain in the posterior calf or
knee with forced dorsiflexion of the foot.

25. • Moses sign
• Gentle squeezing of the lower part of the
calf from side to side.
• Lintons sign/Trendelenburg test
• After applying torniquet at saphenofemoral
junction patient made to walk , then limb is
elevated in supine position prominent
superficial veins will be observed.

26. Moses Sign also known as Bancroft's
sign

27. Procedure
• Patient should be awake and cooperative during a
Moses’ test.
• Patient should be prone during this examination.
• The patient should have her knee flexed 90
degrees.
• The examiner squeezes the patient’s calf and
observes patient for signs of discomfort and pain.

28. Interpretation:-
• Positive Moses’ Test
• There is positive Moses’ test when there is
• Short duration “deep” calf pain – this could
indicate lower extremity vascular insufficiency,
thrombophlebitis, arteriosclerosis obliterans.
• Persistent “achy” calf pain – gastrosoleus strain or
MFTPs.

29. DIAGNOSTIC STUDIES
• Clinical examination alone is able to confirm
only 20-30% of cases of DVT
• Blood Tests
The D-dimer
• Imaging Studies

30. IMAGING STUDIES
• Invasive
• venography,
• radiolabeled fibrinogen
• noninvasive
• ultrasound,
• plethysmography,
• MRI techniques

31. Venography
• VENOGRAM:
• POPLITEAL VEIN
THROMBOSIS

32. VENOGRAPHY
• It detects thrombi in both calf and thigh
• It can conclude and exclude the diagnosis of
DVT when other objective testings are not
conclusive.
Advantages
• It is useful if the patient has a high clinical
probability of thrombosis and a negative
ultrasound.
• It is also valuable in symptomatic patients with
a history of prior thrombosis in whom the
ultrasound is non-diagnostic.

33. DISADVANTAGE
• It can primary cause of DVT in 3% of patients
who undergo this diagnostic procedure.
• An invasive and expensive.
• Although Venography was once considered
the gold standard for diagnosis of DVT, today it
is more commonly used in research
environments and less frequently utilized in
clinical practice.

34. Nuclear Medicine Studies

35. NUCLEAR MEDICINE STUDIES
• Because the radioactive isotope
incorporates into a growing thrombus, this
test can distinguish new clot from an old clot.
• Nuclear medicine studies done with I125-
labeled fibrinogen .
• More commonly used in research.

36. PLETHYSMOGRAPHY
• Plethysmography measures change in lower
extremity volume in response to certain
stimuli.

37. Conti….
• Principle- Blood volume changes in the leg
lead to changes in electrical resistance.
• Venous return in the lower extremity is
occluded by inflation of a thigh cuff, and then
the cuff is released, resulting in a decrease in
calf blood volume. Any obstruction of the
proximal veins diminishes the volume change,
which is detected by measuring changes in
electrical resistance (impedance) over the calf.

38. ULTRASONOGRAPHY
• color-flow Duplex scanning is the imaging
test of choice for patients with suspected DVT
• inexpensive,
• noninvasive,
• widely available
• Ultrasound can also distinguish other causes
of leg swelling, such as tumor, popliteal
cyst,abscess, aneurysm, or hematoma.

39. MAGNETIC RESONANCE IMAGING
• It detects leg, pelvis, and pulmonary thrombi
and is 97% sensitive and 95% specific for DVT.
• It distinguishes a mature from an immature
clot.
• MRI is safe in all stages of pregnancy.
• Test may not be appropriate for patients
with pacemakers or other metallic implants, it
can be an effective diagnostic option for some
patients.

40. MANAGEMENT
The primary objectives of the treatment of DVT are
to -
prevent pulmonary embolism,
reduce morbidity, and
prevent or minimize the risk of developing the
postphlebitic syndrome.

41. GENERAL THERAPEUTIC MEASURES :
• Bed rest .
• Encourage the patient to perform gentle
foot & leg exercises every hour.
• Increase fluid intake upto 2 L/day unless
contraindicated.
• Avoid deep palpation .

42. SPECIFIC TREATMENT
• Anticoagulation
• Thrombolytic therapy for DVT
• Surgery for DVT
• Filters for DVT
• Compression stockings

43. • Initial treatment of DVT is with
lowmolecular-weight heparin or
unfractionated heparin for at least 5 days,
followed by warfarin (target INR, 2.0–3.0) for
at least 3 months.

44. ANTICOAGULATION
• Heparin prevents extension of the thrombus
• Heparin's anticoagulant effect is related
directly to its activation of antithrombin III.
• Antithrombin III, the body's primary
anticoagulant, inactivates thrombin and
inhibits the activity of activated factor X,
factor IX in the coagulation process.

45. DOSE
• IV bolus dose of 5,000 to 10,000 units
followed by an infusion of 1,000 units per
hour. Other method of initiating therapy is to
begin with
• Loading dose of 50-100 units/kg of heparin
followed by a constant infusion of 15-
25units/kg/hr.

46. LOW MOLECULAR WEIGHT
HEPARIN
• Selectively inhibit factor Xa .
• Superior bioavailability
• Superior or equivalent safety and efficacy
• Subcutaneous once- or twice-daily dosing
• No laboratory monitoring
• Less phlebotomy (no monitoring/no
intravenous line)
• Less thrombocytopenia

47. • The optimal regimen for the treatment of
DVT is anticoagulation with heparin or an
LMWH followed by full anticoagulation with
oral warfarin for 3-6 months
• Warfarin therapy is overlapped with heparin
for 4-5 days until the INR is therapeutically
elevated to between 2-3.

48. WARFARIN
• Interferes with hepatic synthesis of vitamin
K dependent coagulation factors
• Dose must be individualized and adjusted to
maintain INR between 2-3
• Oral dose of 2-10 mg/d

49. THROMBOLYTIC THERAPY FOR
DVT
Advantages include
• Prompt resolution of symptoms,
• Prevention of pulmonary embolism,
• Restoration of normal venous circulation,
• Preservation of venous valvular function,
• Prevention of postphlebitic syndrome.

50. DISADVANTAGE
• Thrombolytic therapy does not prevent
• clot propagation,
• rethrombosis, or
• subsequent embolization.
• Heparin therapy and oral anticoagulant
therapy always must followed after a course
of thrombolysis.

51. SURGERY FOR DVT
Indications:-
• when anticoagulant therapy is ineffective
• unsafe,
• contraindicated.
• The major surgical procedures for DVT are
clot removal and partial interruption of the
inferior vena cava to prevent pulmonary
embolism.

52. THROMBECTOMY
• This mechanical method of clot removal may
involve using using intraluminal catheter with
a balloon or other devices.
• Some of these spins to break the clot and
other uses oscillation to breakup the clot to
facilitate removal.

53. • A vena cava filter may be placed at the time of
thrombectomy; this filter traps large large
emboli & prevent pulmonary embolism.
• In patient with chronic iliac vein compression,
balloon angioplasty with stent placement may
successfully treat the patients.

54. • These pulmonary emboli removed at autopsy
look like casts of the deep veins of the leg
where they originated.

55. NURSING MANAGEMENT
• GOAL:-
• • To prevent DVT in high risk patient
• • To prevent existing thrombi from becoming
emboli and prevent new thrombi from
forming.
• • To monitor anticoagulant therapy.

56. Prevent DVT
• All clients prescribed bed rest should be
encouraged to move their legs because blood
stasis leads to clotting.
• Sequential compression devices (SCDs) should
be used for those clients expected to be
prescribed bed rest for longer than 24 hrs.
• SCDs are removed twice daily to inspect the
skin and allow perspiration to evaporate.

57. 2. Promote venous return
• Elevation of the legs above the level of heart
facilitates blood flow by force of gravity. The
increase of blood flow prevent venous stasis and
formation of new thrombi
• Elevate foot of the bed 6 inchs (trendelenburg’s
position), with a slight knee bend to prevent
popliteal pressure.
• Elastic bandage can be applied for 4-8 hrs daily.

58. • 3. Reduce discomfort
• Elevation of extremity and application of
warm packs usually reduce discomfort

59. • 4. Monitor anticoagulant therapy
• Blood sampling every 4-8 hrs for bleeding
time, PTT, INR & PT.
• Client should be observed for frank bleeding
in the urine, tarry o frank blood in the stool,
bleeding with brushing the teeth, easy
subcutaneous bruising, and frank pain.
• If invasive studies are necessary eg, ABG,
apply pressure for 30 min at puncture site.

60. • 5. Monitor for pulmonary embolism(PE)
• PE is acute and lithal complication of DVT.
• Tachypnea and anxiety are common
manifestation.
• Other manifestations are:-
• Cough without hemoptysis, diaphoresis,
dyspnea, crackles and wheezing.

61. NURSING CARE PLAN FOR DEEP VEIN
THROMBOSIS
• Nursing Assessment
• Assessment of a patient with deep vein
thrombosis include:
• Presenting signs and symptoms. If a patient
presents with signs and symptoms of DVT,
carry out an assessment of general medical
history and a physical examination to exclude
other causes.

62. Nursing Diagnosis
• • Ineffective tissue perfusion related to
interruption of venous blood flow.
• • Impaired comfort related to vascular
inflammation and irritation.
• • Deficient knowledge regarding
pathophysiology of condition related to lack of
information and misinterpretation.
• • Risk For Bleeding related to chronic use of
anticoagulant therapy.

63. 1. Ineffective tissue perfusion related
to interruption of venous blood flow.
• Desired Outcomes:-
• Client will maintain optimal peripheral tissue
perfusion in the affected extremity, as
evidenced by strong palpable pulses,
reduction in and/or absence of pain, warm,
and dry extremities, and adequate capillary
refill.

64. • Intervention:-
• 1) Assess for contributing factors:Central venous catheters,
Dehydration, History of varicosities, Immobility, Leg trauma and surgery,
Malignancy, Obesity, Oral contraceptive use, Pregnancy, Smoking, Venous
stasis
• 2) Most clients with DVT are asymptomatic. Knowledge of high-risk
situations helps in early detection.
• 3) Assess for the signs and symptoms of deep vein thrombosis (DVT).
• 4) Measure the circumference of the affected leg with a tape measure.
Deep vein thrombosis is suspected if there is a difference of >3 cm
between the extremities.
• 5) Maintain adequate hydration. Hydration prevents an increased
viscosity of blood, which contributes to venous stasis and clotting.
• 6) Encourage bedrest and keep the affected leg elevated (depending on
size and location of the clot) as indicated. Clients usually require bed rest
until symptoms are relieved. The affected leg should be elevated to a
position above the heart to decrease swelling.
• 7) Provide warm, moist heat to the affected site.Heat promotes
comfort and reduces inflammation.

65. • 8) Apply below-knee compression stockings as prescribed. Ensure that
the stockings are the correct size and are applied correctly.Compression
stockings enhance circulation by providing a graduated pressure on the
affected leg to help return the venous blood to the heart. Inaccurately
applied stockings can serve as a tourniquet and can promote clot
formation.
• 9) Administer analgesics as prescribed. Analgesics relieve pain and
promote comfort.
• 10) Administer anticoagulants as (heparin/warfarin [Coumadin]) as
prescribed. Treatment with anticoagulant is used primarily to prevent the
formation of new clots by decreasing the normal activity of the clotting
mechanism. Heparin IV or subcutaneous low-molecular-weight heparin is
started initially. Oral anticoagulant therapy (warfarin) will be initiated
while the client is still receiving heparin because the onset of action for
warfarin can be up to 72 hours. Heparin will be discontinued once the
warfarin reaches therapeutic levels.
• 11) With a massive DVT severely comprising tissue perfusion, anticipate
thrombolytic therapy.

66. 2.Impaired comfort related to vascular
inflammation and irritation.
• Desired Outcomes:-
• Client will report that pain or discomfort is
alleviated or controlled.

67. • Interventions:-
• 1) Assess degree and characteristics of discomfort and pain.
• 2) Investigate reports of sudden or sharp chest pain,
accompanied by dyspnea, tachycardia, and apprehension, or
development of a new pain with signs of another site of vascular
involvement. These signs and symptoms suggest the presence of
pulmonary embolism as a complication of DVT.
• 3) Monitor vital signs, noting increased temperature. Elevations
in heart rate may indicate increased discomfort or may occur in
response to fever and inflammatory process.
• 4) Maintain bed rest during the acute phase. Decreases
discomfort associated with muscle contraction and movement.
• 5) Encourage client to change position frequently. Reduces
muscle fatigue, helps minimize muscle spasm and maximizes
circulation to tissues.

68. • 6) Provide foot cradle. Cradle keeps the pressure of bedclothes
off the affected leg, thereby reducing pressure discomfort.
• 7) Elevate affected extremity. Encourages venous return to
facilitate circulation, reducing stasis and edema formation.
• 8) Apply a warm compress to the affected leg using a 2-hour-on,
2-hour-off schedule around the clock. Moist heat may be
applied to the affected region to relieve pain and improve
circulation through vasodilation.
• 9) Administer medications, as indicated:Opioid and nonopioid
analgesics,Relieves pain and decreases muscle tension.
• 10) Antipyretics (Acetaminophen). It reduces fever and
inflammation.

69. 3. Deficient knowledge regarding
pathophysiology of condition related
to lack of information and
misinterpretation.
• Desired Outcomes
• Client and/or significant others will verbalize
understanding of the disease, treatment, and
prevention.

70. • Interventions:-
1) Assess the client’s understanding of the causes, treatment, and prevention
plan for deep vein thrombosis.
2) For clients with DVT, instruct in the following signs of pulmonary
embolus:Restlessness, Shortness of breath, Sudden chest pain, Tachycardia,
Tachypnea.
3) Instruct the client to take medications as indicated, explaining their actions,
dosages, and side effects.
4) Inform the client of the need for regular laboratory testing while on oral
anticoagulation.
5) Discuss and give the client a list of signs and symptoms of excessive
anticoagulation.
6) Provide teaching regarding the safety measures while on anticoagulant
therapy such as the use of an electric razor, the use of a soft toothbrush.
7) Instruct the client to avoid rubbing or massaging the calf.
8) Instruct the client in the correct application of compression stockings.

71. REFRENCES
• Black M. J, Hawks J H. Medical Surgical
Nursing. 8th edition. Vol-2. Reed Elsevier.
1331-1335
• https://medisavvy.com/moses-test/
• https://en.wikipedia.org/wiki/Trendelenburg_
test