DVT Overview and Management

Hey everyone, it's Sarah with RegisteredNurseRN.com and today we're going to talk about deep vein thrombosis, also called DVT. And as always, whenever you get done watching this YouTube video, you can access the free quiz that will test you on this content. So let's get started. A deep vein thrombosis is the formation of a clot within a deep vein. And a DVT is a type of VTE, So you may see that term. VTE stands for venous thromboembolism. Another type of VTE is called a pulmonary embolism. This is where the deep vein thrombosis has broke off within that vein, has entered into circulation, went to the heart, and eventually ended up into the lungs. That's where it can get really dangerous. Now, what veins are most susceptible to a deep vein thrombosis formation? Well, we're talking mainly about the veins that are found in the pelvic area, the lower leg and the hip. So these veins include the perineal, the posterior tibial, the popliteal and the superficial femoral. And here in a moment, we're going to talk about Firco's triad. And as a nursing student, you want to be familiar with this triad because it details the three factors that really put a patient at risk for developing a blood clot deep within these veins. So whenever a patient gets a DVT, they're most likely going to occur in these lower extremities. However, they can occur in the upper extremities. But if they occur in these lower extremities, there's a higher risk of those clots actually breaking off, going into circulation, and becoming a pulmonary embolism. So here with our little illustration, we have a blood clot in the deep. vein. Now we're not talking about arteries, we're talking about veins. So what does our venous system do? It takes blood that's unoxygenated and delivers it back to the heart. So it's pushing blood back to the heart. Now if this clot breaks off, it's going to go with the flow. So where's it going to go? It's going to go to the heart. A lot of times they will go leave the lower extremities, They'll go up through the inferior vena cava, enter in. to the right side of the heart. And as we learned in our blood flow video, everything really starts on that right side of the heart. So the clot can go into the right side, then it can travel up through the pulmonary artery, which is taking that unoxygenated blood and getting it to the lungs because the lungs are supposed to oxygenate that blood and then pump it to the left side. And then it's going to enter into the arterial system and provide our body with all that nice where it's oxygen. But if that clot makes it that far and hits that pulmonary artery, then it can enter into pulmonary circulation and lead to that pulmonary embolism. And this is what makes a deep vein thrombosis so dangerous because whenever that clot gets into that lung, that can cause the patient major issues. Now let's talk about fear coast triad. And just as the name says, the word triad means a set of three. So again, And we're talking about... three main factors that can lead to blood clot formation within the vein vessel. And it's important to note that anyone can develop a blood clot, especially if they have these risk factors that we're going to go over. So here in this picture on the left, you can see an illustration of how a blood clot is starting to form. So in picture one, we have a clot starting to form and blood clots like to form within that cusp of the valve of the vein. And then in picture two, that blood clot is starting to get larger. And then in picture three, it has broke off. And again, these blood clots in the vein, they're just going to go with the flow. So where are they going to go? They're going to go to the heart because that's where the vein's blood travels. So to help us remember those three factors of Fierco's triad, let's remember the word she. S stands for stasis of venous circulation. H is for hypercoagulability. And then E is for endothelial damage. And if you have any of those risk factors presenting, it can lead to a deep vein thrombosis, which is illustrated here in this patient's leg. Notice that this leg on the bottom is very red. It's very swollen, especially compared to the leg that is laying right beside of it. Here in a moment, we're going to talk about all those signs and symptoms of a possible DVT. Now let's dive a little bit deeper and let's talk about stasis of venous blood. What would cause the blood in the venous system to just become static or stagnant and not really move? Well, first let's talk about the blood. The blood has to flow back to the heart via the veins. And it does this with the assistance of... Healthy vein valves and the muscles within the extremity, especially in your legs like your calf muscles, help squeeze blood down from those lower extremities and back to the heart. So if the vein valves are damaged or the muscles aren't working or they're not being used, and what's some conditions where you think that the muscles wouldn't be used? Well, if a patient's immobilized, if they're paralyzed, they're really not using those muscles to help squeeze that blood. So that blood just hanging out and being stagnant. But whatever the cause is, the blood isn't going to go back very well and it's not going to flow very well. And blood clots can develop because when blood hangs out together for a while, it starts to congeal. It starts sticking together. because it has platelets in it. So what are some conditions that can cause stasis of blood flow? A big one, as I've already pointed out, is a patient being immobilized or if a patient has varicose veins. We talked about this in our video about peripheral vascular disease. Also a patient who's had surgery, especially those joint replacement surgeries like hip or knee. Also people who have traveled for long hours without moving their extremities, they can develop a blood clot. Any type of obstruction that's presenting in the body, like whenever a person, a woman is in pregnancy, that really that last trimester, obesity, heart failure, especially patients who have left ventricular dysfunction, and atrial fibrillation. Next is hypercoagulability. And just as the name says, hyper means increased or high. In coag, we're talking about the coagulation of the blood where it can form into a clot. So we're talking about a person. whose blood has a high risk of clotting. Now usually this is due to some type of disease process that is in that patient causing their blood to do that but it can happen due to other reasons and this list right here is not an exhausted list but it just highlights some of the main causes. So a patient who has cancer is at risk for this. Severe illnesses like sepsis and we talked about this in our septic shock for why this occurs because you have all those endotoxins releasing this and it's really going to throw off how our blood is being able to clot. Dehydration, the usage of estrogen like birth control pills, heparin-induced thrombocytopenia, and that postpartum period after a woman has a baby. And the last part of our triad is endothelial damage. And think of this, anything that damages that vein vessel. This can be where it directly damages the vessel or indirectly does. But regardless, whenever that vessel becomes damaged, it stimulates the platelets in the body. and starts that coagulation process because the platelets get there and they're like, oh, we have damage. We don't want excessive bleeding to occur. So we're going to play our role and stop it. But whenever they come, they also make other things happen, which can cause a blood clot to form. So think of anything that damages that lining of that vein vessel that can lead to a blood clot. So some things that can do this are like IV drug usage, where a person is injecting drugs into to their vein. It can lead to a blood clot. I have seen this a lot of times in younger patients who inject drugs. They will get a blood clot, so that can really happen. Also, venipuncture. Some other things are like indwelling device in the patient's body, like a central line catheter, IV line, or heart valve. Medications that are really hard on those veins can damage the lining inside the vein or of course any type of trauma or or injury to that vessel, like with surgery or just some type of major trauma that has happened to them. Now to help you truly visualize a blood clot forming within the vessel and what substances you have on board which are really leading to that, let's look at this illustration. Because regardless of the cause, as Fearco's triad laid out for us, what's happening in a nutshell is that platelets are starting to collect at the edges of the vessel, again usually within the cut. of the veins valve and this will help create a seal to stop the bleeding but the body needs to further seal it. So chemicals are released called clotting factors and clotting factors cause fibrin to be created and I want you to remember fibrin because whenever we're talking about d-dimer, fibrin, fibrinogen, all of that we're really talking about these substances. So fibrin is what's really going to cause our big problem. fibrin is a strand-like mesh and it's going to cause white blood cells, red blood cells, and platelets to stick together within that vein. And as you can see here, you have that fibrin illustrated in that yellow and it's just a big clump. aka a clot within that vessel. So we've looked at how a patient can develop a blood clot within the vein. Now let's talk about the signs and symptoms of how a patient may present if they do have a DVT. Well, some hallmark signs and symptoms is that the skin surrounding the area of wherever that clot is located is usually going to be very red. It's also going to be swollen and very warm. And one thing you want to do is you want to look at that other extremity. If their lower leg is showing these signs and symptoms look at the other leg is it a swollen is it as red if not it's unilateral you want to think hmm this could possibly be a dbt and let's look at this picture here this is the picture that i showed you earlier but it's really enlarged as you can see the leg towards the bottom is very red i bet if we touch that it would be very warm and it's swollen and look at the leg right beside of him. It's not swollen. It's not red. So this patient patient here does have a deep vein thrombosis. Now another sign and symptom that you may hear about while you're studying DBTs is homin sign. A homin sign is not a reliable indicator that a patient does indeed have a DBT because it's associated with a lot of false positives. However, for your exams, you want to know how to elicit a homin sign and what a positive homin sign would be. So to elicit one, what you're going to do is you'd have the page. patient extend their leg out and then you're going to manually dorsiflex the foot. So you're going to push it this way so you'll push it towards the shin of the leg and if the patient has pain that is considered a positive Haman sign. Now let's talk about your role as the nurse for a patient who has a DVT or is at risk for developing one. So let's say your patient is presenting with those signs and symptoms that we talked about earlier that they may have a clot within that vein. Well most likely the physician is going to order an ultrasound. The ultrasound will ultrasound that extremity and check and see if we do have a blood clot within that vein. They can also order a D-dimer and a D-dimer is a blood test where you will go and remove blood from the vein, put it in a vial, send it to the lab and the lab will run that blood. And what it's going to look for is it's going to assess the blood for fibrin degradation fragment. And this is a protein fragment that hang out in the blood when a clot has presented and started to break down. So that tells us hey there's a clot and it's starting to break down because we have this fragment protein presenting in the blood. However there's some things you need to know about the D-dimer. The D-dimer can diagnose blood clots and DIC disseminated intravascular coagulation. However it does not tell us where that clot is located so the physician will have to further investigate that. and it can sometimes give us false positive results. So necessarily if your patient does have a positive D-dimer it doesn't 100% mean that they have a clot because some disease processes can cause a positive D-dimer like liver disease, myocardial infarction, heart surgery and so forth. So you always want to further investigate that if your patient does have a positive D-dimer. Now, what is a normal D-dimer result? Well, whenever you're looking at at the results of your patient's D-domer, you need to see how your lab that's giving you the results reports the cutoff, say, for that D-domer. Because some labs will report the cutoff in D-domer units, DDU, while some labs will report it in fibrinogen equivalent units, FEU. So always look at that. But they're equivalent to each other. So if your lab reports an FEU, a negative D-domer would be less than 500 nanograms per milliliter. If your lab reports in DDU, it would be less than 250 nanograms per milliliter. So anything greater than these values would be considered a positive D-Dimer. Now let's talk about our role as a nurse for a patient who doesn't necessarily have a deep vein thrombosis, but they're at high risk for developing it because we've assessed our patient and we've seen some of those risk factors that they have from Firco's triads. So what can we do? Well, prevention. As a nurse, we play a huge role with preventing a deep vein thrombosis in our patient because the steps that we can take in helping prevent a blood clot are very, very simple and we can prevent a really long-term problem for our patient. So some things we can do is that a physician can order pneumatic compression devices like SCDs. These are sequential compression devices. They wrap around the leg. W and they inflate and deflate and help move blood flow similar to walking and some things you want to remember about these is that they need to be fitted properly and your patient needs to wear them at the right time some things I've seen with these is that the patient will have them on their legs but they won't be plugged into the wall or the unit won't be on so they're not necessarily working. So always make sure they're plugged in and that they're working and ask the patient are these inflating and deflating on your legs? Do you feel this? and you want to make sure that your patient wears them all times while they're in bed or while they're sitting. They can take them off while they're up walking but other than that they need to have these on and working and we want to make sure that we change these regularly. We look at the skin because if you've ever worked with these they can get really smelly and sweaty underneath so we need to make sure that they're nice and clean so we can prevent infection. Now if your patient has a blood clot in the extremity you would not not want to put one of these devices on that extremity because it could dislodge the clot and we don't want to cause a pulmonary embolism. So keep those things in mind. Also for patients who are able, we want them up and ambulating several times a day. We want them up and out of bed, especially with all meals. And we want to teach them leg exercises that they can do with their legs and their feet. They want to do this several times every hour while they're awake to keep that blood moving. And we want to apply compression stockings depending on whatever the physician order. This is a set amount of compression that can be delivered to the extremity that will help prevent blood clot formation. And per physician order a lot of times prophylactic anticoagulation is ordered usually anoxaparin which is lovinox. It's an injection that goes in the sub-q tissue of the abdomen patients don't like these but you want to teach your patient why they're having this. A lot of times after a patient has a joint replacement surgery, they will get this to help prevent blood clots since there's a high risk of blood clot development. And teach them while they're having this and watch your patient's risk for bleeding because they're at risk for bleeding because of this anticoagulation. Now let's wrap up this lecture and let's talk about our role as a nurse for a patient who actually has a deep vein thrombosis. And to remember our role, we're going to remember the word deep. deep clot. D is for don't massage or rub the affected extremity. So if your patient has a blood clot, you don't want to go and massage it and rub it because some patients are going to have pain. Like their calf can really tense up if that's where the clot is located and the patient may even want to rub or massage the area, but you want to teach them not to because this could dislodge the clot and lead to that pulmonary embolism. E is for elevate affected extremity above heart level. This is going to help promote blood return and decrease that swelling. The next E is for ensure bed rest. When your patient has an active blood clot, at first we want them to be in bed resting. We don't want them up moving around because we don't want the clot to become dislodged. P is for pharmacological measures and there's many things that we can do for a patient who has a blood clot. A big thing is through anticoagulants. Now, one thing I want you to remember about anticoagulants is that they do not break up an existing clot, but helps prevent the clot from getting bigger and new clots from forming. And some anticoagulants that we're going to concentrate on are indirect thrombin inhibitors, such as heparin, and vitamin K antagonists, such as warfarin. This is where exams really love to ask you about the anticoagulation for DVTs. So let's talk about indirect thrombin inhibitors, specifically heparin. Heparin works by enhancing the activity of antithrombin 3 which will inhibit thrombin and the conversion of fibrinogen to fibrin. And remember fibrin was that mesh, that strand that went and attracted everything else together like those white blood cells, red blood cells and made everything clump together and caused that clot. So heparin is going to help really prevent that. And some concepts you want to remember about heparin for exams is that heparin works fast. It can be given IV or sub-Q, and it's weight-based. So depending on how much your patient weighs will depend on how many units you give them. So as a nurse, it's very important that you have a current weight on your patient. And whenever a patient is taking heparin, you're going to be monitoring a certain lab result, and you want to commit this lab result to memory. You're going to be monitoring an APTT. We call it a PTT. And this stands for activated partial thromboplastin time. And it. And in order for a patient to be therapeutic, on heparin, meaning the heparin is actually going to work to prevent blood clot formation, is that they need to be one and a half to two and a half times the normal range. So let's say that their PTT result is greater than 80 seconds. How would you interpret that? Well, that means that they're at risk for bleeding. So you need to contact the doctor who will probably order the dose to be decreased. They're on continuous. IV heparin, you may need to turn the drip off for a specific amount of time, decrease the dose. And let's say that their PTT was less than 60 seconds. How would you interpret that? Well, the patient's not therapeutic. So there are risks for clots developing and you may need to increase their dosage of heparin of whatever they're getting per protocol or whatever the physician says. Now, some things you want to remember is that heparin can be used in combination with warfare. which we're talking about here in a moment until the INR for warfarin is therapeutic and then the heparin will be discontinued so keep that in mind. Now what is the antidote for heparin? It is protamine sulfate. Now let's talk about the other category of anticoagulant called vitamin K antagonist specifically warfarin also called coumadin. Warfarin works to inhibit clotting factors from using vitamin K. They can't get to the vitamin K, they can't do their job. job, hence make a clot. So some concepts to remember about warfarin is that it has a slow onset. So that is why the patient may have to take it for about three to five days to actually become therapeutic. It's only given orally. And we're going to monitor a specific lab result with this. We're going to monitor the PTINR. PT stands for prothrombin time and INR stands for international normalized ratio. We're really looking at that INR. And for a patient to be therapeutic on Coumadin for where it can work to prevent blood clots, a therapeutic INR is about two to three. So let's say the INR is greater than three. How would you interpret that as a nurse? There's a risk for bleeding. If it's less than two, the drug's not working great. There are risk for clots. And an antidote for warfarin would be vitamin K. Some other pharmacological medications that can be used in deep vein thrombosis is thrombolytics and just as this name says it's going to lysis that clot so it's going to bust that clot up remember anticoagulants didn't do that but thrombolytics do and this can be a catheter directed where a clot busting agent is given to that clot and we're talking about like tpa now what you want to remember with thrombolytics is there's a high risk of bleeding. So monitor your your patient for that. And another thing that can be used to treat blood clots, it's not necessarily a pharmacological medication, but I wanted to place it under this category, is an IVC filter. This is placed in the inferior vena cava. And as you can see, you can actually see one in a patient in this picture on the left where the red arrow is pointing. It's a small metal device that's place in the inferior vena cava. And what it's going to do is it's going to prevent blood clots from entering into the heart and lungs because remember I showed you earlier on the board how blood clot can leave that vein and travel up to that inferior vena cava get in the heart and then eventually get into the lungs but this filter can help prevent that and this is sometimes placed in patients who can't take anticoagulants then see for compresses these need to be warm and moist and they can be applied to the affected extremity this is going to help with pain that the patient may have and circulation. L is for leg circumference measurement and we're talking about measuring the calf. So to do that as a nurse you can measure about 10 centimeters or about four inches below the tibial tuberosity and if you feel on your kneecap and then you go a little bit below it you can feel that prominence area that is where your tibial tuberosity is located and we're looking for a three centimeter circumference measurement or more more in that calf compared to that non-affected calf. Then O, for observe for signs and symptoms of a pulmonary embolism. We've learned that that is a risk definitely with those deep vein thrombosis located in the lower extremities. So what could tell you that your patient may have a pulmonary embolism? Well, they have sudden shortness of breath or coughing. They have decreased oxygen saturation. They have a fast heart rate. They have chest pain. pain. They feel very anxious, a lot of anxiety, sweating. That could point to that this patient may have a pulmonary embolism. And lastly, T for tight compression stockings. This can be thigh or knee high in length. Whatever the physician orders, they'll order the type that you need to apply to the patient. And what these will do is help promote blood flow and decrease swelling. You want to make sure that they are changed regularly and show the patient how to apply them. And compression stockings may pervade your prevent PTS, which is post-thrombotic syndrome, which happens sometimes after a patient has a blood clot in the vein because the vein valves and walls become damaged due to that clot in that vein. And there's this reflex of blood where it doesn't flow back the way it should in that right direction to the heart. Okay, so that wraps up this review over deep vein thrombosis. And don't forget to access the free quiz.

And a DVT is a type of VTE, So you may see that term. VTE stands for venous thromboembolism. Another type of VTE is called a pulmonary embolism.

This is where the deep vein thrombosis has broke off within that vein, has entered into circulation, went to the heart, and eventually ended up into the lungs. That's where it can get really dangerous. Now, what veins are most susceptible to a deep vein thrombosis formation? Well, we're talking mainly about the veins that are found in the pelvic area, the lower leg and the hip.

So these veins include the perineal, the posterior tibial, the popliteal and the superficial femoral. And here in a moment, we're going to talk about Firco's triad. And as a nursing student, you want to be familiar with this triad because it details the three factors that really put a patient at risk for developing a blood clot deep within these veins.

So whenever a patient gets a DVT, they're most likely going to occur in these lower extremities. However, they can occur in the upper extremities. But if they occur in these lower extremities, there's a higher risk of those clots actually breaking off, going into circulation, and becoming a pulmonary embolism.

So here with our little illustration, we have a blood clot in the deep. vein. Now we're not talking about arteries, we're talking about veins.

So what does our venous system do? It takes blood that's unoxygenated and delivers it back to the heart. So it's pushing blood back to the heart.

Now if this clot breaks off, it's going to go with the flow. So where's it going to go? It's going to go to the heart. A lot of times they will go leave the lower extremities, They'll go up through the inferior vena cava, enter in.

to the right side of the heart. And as we learned in our blood flow video, everything really starts on that right side of the heart. So the clot can go into the right side, then it can travel up through the pulmonary artery, which is taking that unoxygenated blood and getting it to the lungs because the lungs are supposed to oxygenate that blood and then pump it to the left side. And then it's going to enter into the arterial system and provide our body with all that nice where it's oxygen. But if that clot makes it that far and hits that pulmonary artery, then it can enter into pulmonary circulation and lead to that pulmonary embolism.

And this is what makes a deep vein thrombosis so dangerous because whenever that clot gets into that lung, that can cause the patient major issues. Now let's talk about fear coast triad. And just as the name says, the word triad means a set of three. So again, And we're talking about...

three main factors that can lead to blood clot formation within the vein vessel. And it's important to note that anyone can develop a blood clot, especially if they have these risk factors that we're going to go over. So here in this picture on the left, you can see an illustration of how a blood clot is starting to form.

So in picture one, we have a clot starting to form and blood clots like to form within that cusp of the valve of the vein. And then in picture two, that blood clot is starting to get larger. And then in picture three, it has broke off. And again, these blood clots in the vein, they're just going to go with the flow.

So where are they going to go? They're going to go to the heart because that's where the vein's blood travels. So to help us remember those three factors of Fierco's triad, let's remember the word she.

S stands for stasis of venous circulation. H is for hypercoagulability. And then E is for endothelial damage.

And if you have any of those risk factors presenting, it can lead to a deep vein thrombosis, which is illustrated here in this patient's leg. Notice that this leg on the bottom is very red. It's very swollen, especially compared to the leg that is laying right beside of it.

Here in a moment, we're going to talk about all those signs and symptoms of a possible DVT. Now let's dive a little bit deeper and let's talk about stasis of venous blood. What would cause the blood in the venous system to just become static or stagnant and not really move?

Well, first let's talk about the blood. The blood has to flow back to the heart via the veins. And it does this with the assistance of... Healthy vein valves and the muscles within the extremity, especially in your legs like your calf muscles, help squeeze blood down from those lower extremities and back to the heart. So if the vein valves are damaged or the muscles aren't working or they're not being used, and what's some conditions where you think that the muscles wouldn't be used?

Well, if a patient's immobilized, if they're paralyzed, they're really not using those muscles to help squeeze that blood. So that blood just hanging out and being stagnant. But whatever the cause is, the blood isn't going to go back very well and it's not going to flow very well.

And blood clots can develop because when blood hangs out together for a while, it starts to congeal. It starts sticking together. because it has platelets in it. So what are some conditions that can cause stasis of blood flow?

A big one, as I've already pointed out, is a patient being immobilized or if a patient has varicose veins. We talked about this in our video about peripheral vascular disease. Also a patient who's had surgery, especially those joint replacement surgeries like hip or knee. Also people who have traveled for long hours without moving their extremities, they can develop a blood clot. Any type of obstruction that's presenting in the body, like whenever a person, a woman is in pregnancy, that really that last trimester, obesity, heart failure, especially patients who have left ventricular dysfunction, and atrial fibrillation.

Next is hypercoagulability. And just as the name says, hyper means increased or high. In coag, we're talking about the coagulation of the blood where it can form into a clot.

So we're talking about a person. whose blood has a high risk of clotting. Now usually this is due to some type of disease process that is in that patient causing their blood to do that but it can happen due to other reasons and this list right here is not an exhausted list but it just highlights some of the main causes. So a patient who has cancer is at risk for this.

Severe illnesses like sepsis and we talked about this in our septic shock for why this occurs because you have all those endotoxins releasing this and it's really going to throw off how our blood is being able to clot. Dehydration, the usage of estrogen like birth control pills, heparin-induced thrombocytopenia, and that postpartum period after a woman has a baby. And the last part of our triad is endothelial damage. And think of this, anything that damages that vein vessel.

This can be where it directly damages the vessel or indirectly does. But regardless, whenever that vessel becomes damaged, it stimulates the platelets in the body. and starts that coagulation process because the platelets get there and they're like, oh, we have damage. We don't want excessive bleeding to occur.

So we're going to play our role and stop it. But whenever they come, they also make other things happen, which can cause a blood clot to form. So think of anything that damages that lining of that vein vessel that can lead to a blood clot. So some things that can do this are like IV drug usage, where a person is injecting drugs into to their vein.

It can lead to a blood clot. I have seen this a lot of times in younger patients who inject drugs. They will get a blood clot, so that can really happen.

Also, venipuncture. Some other things are like indwelling device in the patient's body, like a central line catheter, IV line, or heart valve. Medications that are really hard on those veins can damage the lining inside the vein or of course any type of trauma or or injury to that vessel, like with surgery or just some type of major trauma that has happened to them. Now to help you truly visualize a blood clot forming within the vessel and what substances you have on board which are really leading to that, let's look at this illustration. Because regardless of the cause, as Fearco's triad laid out for us, what's happening in a nutshell is that platelets are starting to collect at the edges of the vessel, again usually within the cut.

of the veins valve and this will help create a seal to stop the bleeding but the body needs to further seal it. So chemicals are released called clotting factors and clotting factors cause fibrin to be created and I want you to remember fibrin because whenever we're talking about d-dimer, fibrin, fibrinogen, all of that we're really talking about these substances. So fibrin is what's really going to cause our big problem.

fibrin is a strand-like mesh and it's going to cause white blood cells, red blood cells, and platelets to stick together within that vein. And as you can see here, you have that fibrin illustrated in that yellow and it's just a big clump. aka a clot within that vessel.

So we've looked at how a patient can develop a blood clot within the vein. Now let's talk about the signs and symptoms of how a patient may present if they do have a DVT. Well, some hallmark signs and symptoms is that the skin surrounding the area of wherever that clot is located is usually going to be very red.

It's also going to be swollen and very warm. And one thing you want to do is you want to look at that other extremity. If their lower leg is showing these signs and symptoms look at the other leg is it a swollen is it as red if not it's unilateral you want to think hmm this could possibly be a dbt and let's look at this picture here this is the picture that i showed you earlier but it's really enlarged as you can see the leg towards the bottom is very red i bet if we touch that it would be very warm and it's swollen and look at the leg right beside of him. It's not swollen.

It's not red. So this patient patient here does have a deep vein thrombosis. Now another sign and symptom that you may hear about while you're studying DBTs is homin sign. A homin sign is not a reliable indicator that a patient does indeed have a DBT because it's associated with a lot of false positives.

However, for your exams, you want to know how to elicit a homin sign and what a positive homin sign would be. So to elicit one, what you're going to do is you'd have the page. patient extend their leg out and then you're going to manually dorsiflex the foot. So you're going to push it this way so you'll push it towards the shin of the leg and if the patient has pain that is considered a positive Haman sign. Now let's talk about your role as the nurse for a patient who has a DVT or is at risk for developing one.

So let's say your patient is presenting with those signs and symptoms that we talked about earlier that they may have a clot within that vein. Well most likely the physician is going to order an ultrasound. The ultrasound will ultrasound that extremity and check and see if we do have a blood clot within that vein.

They can also order a D-dimer and a D-dimer is a blood test where you will go and remove blood from the vein, put it in a vial, send it to the lab and the lab will run that blood. And what it's going to look for is it's going to assess the blood for fibrin degradation fragment. And this is a protein fragment that hang out in the blood when a clot has presented and started to break down.

So that tells us hey there's a clot and it's starting to break down because we have this fragment protein presenting in the blood. However there's some things you need to know about the D-dimer. The D-dimer can diagnose blood clots and DIC disseminated intravascular coagulation. However it does not tell us where that clot is located so the physician will have to further investigate that. and it can sometimes give us false positive results.

So necessarily if your patient does have a positive D-dimer it doesn't 100% mean that they have a clot because some disease processes can cause a positive D-dimer like liver disease, myocardial infarction, heart surgery and so forth. So you always want to further investigate that if your patient does have a positive D-dimer. Now, what is a normal D-dimer result? Well, whenever you're looking at at the results of your patient's D-domer, you need to see how your lab that's giving you the results reports the cutoff, say, for that D-domer.

Because some labs will report the cutoff in D-domer units, DDU, while some labs will report it in fibrinogen equivalent units, FEU. So always look at that. But they're equivalent to each other.

So if your lab reports an FEU, a negative D-domer would be less than 500 nanograms per milliliter. If your lab reports in DDU, it would be less than 250 nanograms per milliliter. So anything greater than these values would be considered a positive D-Dimer. Now let's talk about our role as a nurse for a patient who doesn't necessarily have a deep vein thrombosis, but they're at high risk for developing it because we've assessed our patient and we've seen some of those risk factors that they have from Firco's triads.

So what can we do? Well, prevention. As a nurse, we play a huge role with preventing a deep vein thrombosis in our patient because the steps that we can take in helping prevent a blood clot are very, very simple and we can prevent a really long-term problem for our patient.

So some things we can do is that a physician can order pneumatic compression devices like SCDs. These are sequential compression devices. They wrap around the leg. W and they inflate and deflate and help move blood flow similar to walking and some things you want to remember about these is that they need to be fitted properly and your patient needs to wear them at the right time some things I've seen with these is that the patient will have them on their legs but they won't be plugged into the wall or the unit won't be on so they're not necessarily working.

So always make sure they're plugged in and that they're working and ask the patient are these inflating and deflating on your legs? Do you feel this? and you want to make sure that your patient wears them all times while they're in bed or while they're sitting. They can take them off while they're up walking but other than that they need to have these on and working and we want to make sure that we change these regularly. We look at the skin because if you've ever worked with these they can get really smelly and sweaty underneath so we need to make sure that they're nice and clean so we can prevent infection.

Now if your patient has a blood clot in the extremity you would not not want to put one of these devices on that extremity because it could dislodge the clot and we don't want to cause a pulmonary embolism. So keep those things in mind. Also for patients who are able, we want them up and ambulating several times a day. We want them up and out of bed, especially with all meals.

And we want to teach them leg exercises that they can do with their legs and their feet. They want to do this several times every hour while they're awake to keep that blood moving. And we want to apply compression stockings depending on whatever the physician order.

This is a set amount of compression that can be delivered to the extremity that will help prevent blood clot formation. And per physician order a lot of times prophylactic anticoagulation is ordered usually anoxaparin which is lovinox. It's an injection that goes in the sub-q tissue of the abdomen patients don't like these but you want to teach your patient why they're having this.

A lot of times after a patient has a joint replacement surgery, they will get this to help prevent blood clots since there's a high risk of blood clot development. And teach them while they're having this and watch your patient's risk for bleeding because they're at risk for bleeding because of this anticoagulation. Now let's wrap up this lecture and let's talk about our role as a nurse for a patient who actually has a deep vein thrombosis. And to remember our role, we're going to remember the word deep.

deep clot. D is for don't massage or rub the affected extremity. So if your patient has a blood clot, you don't want to go and massage it and rub it because some patients are going to have pain. Like their calf can really tense up if that's where the clot is located and the patient may even want to rub or massage the area, but you want to teach them not to because this could dislodge the clot and lead to that pulmonary embolism. E is for elevate affected extremity above heart level.

This is going to help promote blood return and decrease that swelling. The next E is for ensure bed rest. When your patient has an active blood clot, at first we want them to be in bed resting. We don't want them up moving around because we don't want the clot to become dislodged.

P is for pharmacological measures and there's many things that we can do for a patient who has a blood clot. A big thing is through anticoagulants. Now, one thing I want you to remember about anticoagulants is that they do not break up an existing clot, but helps prevent the clot from getting bigger and new clots from forming.

And some anticoagulants that we're going to concentrate on are indirect thrombin inhibitors, such as heparin, and vitamin K antagonists, such as warfarin. This is where exams really love to ask you about the anticoagulation for DVTs. So let's talk about indirect thrombin inhibitors, specifically heparin. Heparin works by enhancing the activity of antithrombin 3 which will inhibit thrombin and the conversion of fibrinogen to fibrin.

And remember fibrin was that mesh, that strand that went and attracted everything else together like those white blood cells, red blood cells and made everything clump together and caused that clot. So heparin is going to help really prevent that. And some concepts you want to remember about heparin for exams is that heparin works fast.

It can be given IV or sub-Q, and it's weight-based. So depending on how much your patient weighs will depend on how many units you give them. So as a nurse, it's very important that you have a current weight on your patient. And whenever a patient is taking heparin, you're going to be monitoring a certain lab result, and you want to commit this lab result to memory. You're going to be monitoring an APTT.

We call it a PTT. And this stands for activated partial thromboplastin time. And it. And in order for a patient to be therapeutic, on heparin, meaning the heparin is actually going to work to prevent blood clot formation, is that they need to be one and a half to two and a half times the normal range. So let's say that their PTT result is greater than 80 seconds.

How would you interpret that? Well, that means that they're at risk for bleeding. So you need to contact the doctor who will probably order the dose to be decreased.

They're on continuous. IV heparin, you may need to turn the drip off for a specific amount of time, decrease the dose. And let's say that their PTT was less than 60 seconds.

How would you interpret that? Well, the patient's not therapeutic. So there are risks for clots developing and you may need to increase their dosage of heparin of whatever they're getting per protocol or whatever the physician says. Now, some things you want to remember is that heparin can be used in combination with warfare. which we're talking about here in a moment until the INR for warfarin is therapeutic and then the heparin will be discontinued so keep that in mind.

Now what is the antidote for heparin? It is protamine sulfate. Now let's talk about the other category of anticoagulant called vitamin K antagonist specifically warfarin also called coumadin.

Warfarin works to inhibit clotting factors from using vitamin K. They can't get to the vitamin K, they can't do their job. job, hence make a clot.

So some concepts to remember about warfarin is that it has a slow onset. So that is why the patient may have to take it for about three to five days to actually become therapeutic. It's only given orally.

And we're going to monitor a specific lab result with this. We're going to monitor the PTINR. PT stands for prothrombin time and INR stands for international normalized ratio.

We're really looking at that INR. And for a patient to be therapeutic on Coumadin for where it can work to prevent blood clots, a therapeutic INR is about two to three. So let's say the INR is greater than three.

How would you interpret that as a nurse? There's a risk for bleeding. If it's less than two, the drug's not working great. There are risk for clots.

And an antidote for warfarin would be vitamin K. Some other pharmacological medications that can be used in deep vein thrombosis is thrombolytics and just as this name says it's going to lysis that clot so it's going to bust that clot up remember anticoagulants didn't do that but thrombolytics do and this can be a catheter directed where a clot busting agent is given to that clot and we're talking about like tpa now what you want to remember with thrombolytics is there's a high risk of bleeding. So monitor your your patient for that.

And another thing that can be used to treat blood clots, it's not necessarily a pharmacological medication, but I wanted to place it under this category, is an IVC filter. This is placed in the inferior vena cava. And as you can see, you can actually see one in a patient in this picture on the left where the red arrow is pointing.

It's a small metal device that's place in the inferior vena cava. And what it's going to do is it's going to prevent blood clots from entering into the heart and lungs because remember I showed you earlier on the board how blood clot can leave that vein and travel up to that inferior vena cava get in the heart and then eventually get into the lungs but this filter can help prevent that and this is sometimes placed in patients who can't take anticoagulants then see for compresses these need to be warm and moist and they can be applied to the affected extremity this is going to help with pain that the patient may have and circulation. L is for leg circumference measurement and we're talking about measuring the calf. So to do that as a nurse you can measure about 10 centimeters or about four inches below the tibial tuberosity and if you feel on your kneecap and then you go a little bit below it you can feel that prominence area that is where your tibial tuberosity is located and we're looking for a three centimeter circumference measurement or more more in that calf compared to that non-affected calf. Then O, for observe for signs and symptoms of a pulmonary embolism.

We've learned that that is a risk definitely with those deep vein thrombosis located in the lower extremities. So what could tell you that your patient may have a pulmonary embolism? Well, they have sudden shortness of breath or coughing.

They have decreased oxygen saturation. They have a fast heart rate. They have chest pain.

pain. They feel very anxious, a lot of anxiety, sweating. That could point to that this patient may have a pulmonary embolism. And lastly, T for tight compression stockings. This can be thigh or knee high in length.

Whatever the physician orders, they'll order the type that you need to apply to the patient. And what these will do is help promote blood flow and decrease swelling. You want to make sure that they are changed regularly and show the patient how to apply them.

And compression stockings may pervade your prevent PTS, which is post-thrombotic syndrome, which happens sometimes after a patient has a blood clot in the vein because the vein valves and walls become damaged due to that clot in that vein. And there's this reflex of blood where it doesn't flow back the way it should in that right direction to the heart. Okay, so that wraps up this review over deep vein thrombosis. And don't forget to access the free quiz.

Transcript for:DVT Overview and Management

Transcript for:
DVT Overview and Management