Question

Deep Vein Thrombosis

Patient Profile

D.R. is a 74-year-old obese Hispanic woman who is in the third postoperative day after an open reduction internal fixation (ORIF) for repair of a left femoral neck fracture after a fall at home.

Subjective Data

• States pain in her left hip is a 4 to 5 on a 1-to-10 scale
• States pain in her left calf area is a 3 on a 1-to-10 scale

Objective Data

Physical Examination

• Vital signs: BP 140/68, pulse 64, temperature 98.7°F, respirations 20
• Oxygen saturation 93% on room air
• Lungs clear all lobes
• Bowel sounds are present in all 4 quadrants
• Apical pulse: 64, irregular
• Alert and oriented to person, place, and time
• Skin warm to touch bilateral lower extremities, slight erythema left lower extremity
• No edema right lower extremity, 2+ left lower extremity
• Pedal pulses 2+ right lower extremity, 1+ left lower extremity
• Calf circumference: right, 8 cm; left, 10 cm
• Left hip wound has staples; no signs or symptoms of infection
• Last bowel movement was four days ago

Interprofessional Care

Medication Administration Record

• Morphine sulfate 2 mg IVP every two hours as needed for pain scale 6 to 10

• Lisinopril 20 mg PO daily
• Bisacodyl 10 mg PO daily

Discussion Questions

1. What do you suspect is occurring with D.R.? What data were used to make this determination?

2. What are the priority nursing interventions at this time?

3. Using SBAR, what would you report to the provider?

4. What diagnostic studies would be used to determine the existence, location, and extent of a DVT?

5. What risk factors for development of a DVT does D. R. have?

6. What measures can be taken to prevent a DVT in an at-risk patient?

SAMPLE VENOUS THROMBOEMBOLISM PROTOCOL AND ORDER SET

Low Risk	Moderate Risk	High Risk
Ambulatory patient without additional VTE risk factors or expected length of stay <2 days Minor surgery in patient without additional VTE risk factors (same day surgery or operating room time <30 min) Early ambulation*	Patients who are not in either the low- or high-risk group (see VTE risk factor table below) Select one pharmacologic* option: Enoxaparin† 40 mg SC q24hr UFH 5000 units SC q8 hr UFH 5000 units SQ q12hr (use only if wt <50 kg or >75 yrs) or No pharmacologic prophylaxis because of contraindication ________________________ (see table below) No pharmacologic prophylaxis because it is optional in this special population (gynecologic surgery) Sequential compression device aka SCDs (Optional for these patients if they are on pharmacologic prophylaxis, mandatory if not) SCDs to Both lower extremities Right leg only Left leg only Patient intolerant or has skin lesions on both legs, do not use SCDs	Elective hip or knee arthroplasty Acute spinal cord injury with paresis Multiple major trauma Abdominal or pelvic surgery for cancer Select one pharmacologic* option: Enoxaparin* 40 mg SC q24hr Enoxaparin* 30 mg SQ q12hr (knee replacement) Warfarin _______ mg PO daily, target INR 2-3; hold INR >3 or UFH 5,000 units SQ q8hr (only if creatinine clearance is <30, SCr >2, and warfarin is not an option) No pharmacologic prophylaxis because of contraindication _______________________ (see table below) and SCDs to Both lower extremities Right leg only Left leg only Patient intolerant or has skin lesions on both legs, do not use SCDs

Source: Agency for Healthcare Research and Quality: Appendix B: sample venous thromboembolism protocol/order set: Preventing Hospital-Acquired Venous Thromboembolism, 2014. Retrieved from http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/vtguideapb.html.

Case Study Progression

D.R. is diagnosed with a deep vein thrombosis (DVT) in the left lower extremity.

7. What treatment do you anticipate for D.R.?

8. What is the most serious complication of a DVT, and how would you monitor D.R. for this complication?

Answer 1

1) Treatment of Deep vein thrombosis (DVT) :-

The main aim of the treatment is to prevent the increase in the size of the blood clot and it's further movement to other sites in the body.

Medical treatment :-

• Anticoagulants like Heparin, etc to decrease the chances of further clot formation.
• Blood thinners to keep the size of the clot small.
• Thrombolytic drugs to dissolve the existing blood clots like Anistreplase, Reteplase, etc.

Surgical treatment :-

It is very rare. It is required in those who have developed recurrent blood clots while on anticoagulants or who cannot take blood thinners. The main aim is to place an inferior vena cava filter to prevent future clots from embolizing to the lungs.

Self care :-

• Stretching of legs and feet while sitting.
• Avoiding tight clothes and shocks.
• Regular exercises.
• Wearing compression stockings.

2) The most serious complication of a DVT is Pulmonary Embolism. It is caused when blood clots breaks off from the veins and reaches the lungs through blood stream.

Monitoring of D.R.for this complication :

We should look for following clinical features:

• Difficulty in breathing.
• Chest pain.
• Shortness of breath.
• Coughing.
• Pain and swelling in legs.

​​​​​​​​​​​​​​