Matters of the Heart - DVT
Alright, guys, we are starting the vascular content of our Matters of the heart series. Vascular components can being like the red headed step child of the Cardiac world, because people, even some nurses, don’t always think of vascular issues in direct link with heart issues. IDK why that’s the case, there can be no pump without the plumbing…..
But of course, you beautiful and intelligent individuals know that. So let’s get to what we need to know about a common vessel and vasculature issue, Deep Vein Thrombosis, also known as DVT.
What is a DVT?
According to the office of the Surgeon General, a DVT occurs when a thrombus (a singular blood clot) or thrombi (more than one blood clot) occludes one the larger (“deeper”) veins, most often in the pelvis or lower extremities (in calf muscles). The blood clot occluding leads to inflammation in and around that vein.
When a DVT occurs in the lower extremities, it often only happens in one extremity or the other, but it’s not impossible for them to happen in both lower extremities, I’ve seen it a few times in my practice.
Remember DVT is Not the Same as an Embolus, though a DVT can cause an Embolism. Note the difference in the graphic below
What does a DVT look like?
(Source)
Note: You will sometimes see the word thrombophlebitis used in harmony with DVT, they are even listed in the same section in most of my nursing textbooks. However, many don’t clearly differentiate between the two condition. Thrombophlebitis = A Blood Clot and inflammation of the vascular vessel in a smaller and more superficial (or closer to the skin) vein. Remember DVT = blood clot and inflammation in deeper and large veins. For more information on the differences and similarities between the 2 conditions, the Columbia University Department of Surgery has some good information.
Why do people get DVT?
That’s a good question. Here are some common risk factors:
Immobility - Particularly prolonged periods of immobility or bedrest. This is why our nurse managers are always on us about mobilizing our patients.
Obesity
Being over age 60.
Having a surgical procedure done.
Heart Failure.
Blunt physical trauma to an extremity.
Having a condition that increases the coagulability or your blood, such as diabetes mellitus or a clotting disorder.
Having a personal or significant family history of DVT and blood clots.
Recent broken bones.
Hormonal changes - Such as from hormonal therapies or pregnancy. Yes even birth control ladies.
Signs and symptoms of DVT
Fever and Chills
Malaise
Severe pain
Unilateral, or one-sided, swelling of the impacted extremity
Cyanosis (blue or sometimes grayish tinting) of the impacted extremity, below the blockage
Positive Homan’s sign (Acute Calf Muscle Tenderness or pain with dorsiflexion of impacted extremity), when lower extremities are the impacted site
It should be noted that Homan’s sign is useful when used in harmony with other diagnostic techniques. Some research shows that the Homan’s sign can be inconsistent and has been noted to be the symptom in about ⅓ of those diagnosed with DVT
Tenderness of the impacted extremity
Warmth to the site of impacted extremity
Redness to impacted extremity
What can nurses do for DVT?
The biggest take away for you nurses and future nurses out there should be the fact that DVTs can become life-threatening quickly, particularly if the clot (or clot fragment) dislodges goes on to become lodged in one of the (often smaller) vessels in the lungs or (less common) in the heart. Thus a DVT can quickly become an emergent Pulmonary Embolism (PE) or Heart Attack (Myocardial Infarction).
Educate your patients who are being discharged or who are in the inpatient setting to call 911 if they experience acute shortness of breath, chest pain, or bloody sputum when they cough, as these can be signs of a dislodged clot in the lungs and/or heart.
If your patient is started on anticoagulants or sent home on them, educate them what to expect, such as ease of bruising and being more susceptible to feeling cold (for some people). Also tell them when they should seek the help of a medical provider, such as uncontrolled bleeding, blood in their stool (or that dark and tarry and especially foul-smelling stool).
In many cases, patients will not be mandated to be on bed rest when they have a DVT, though the provider may specify no vigorous activity and exercise while in the acute phase of having a DVT.
Elevating the extremity can help alleviate pain.
Note: Venous clots don't typically migrate to coronary arteries or to the brain, but that’s not a hard and fast rule.
Other helpful nursing interventions include….
Perform regular and routine VS, at least every for hours is common in many healthcare settings, follow your institution's policy and utilize your nursing judgment.
Monitor Respiratory status and perform regular respiratory assessments.
Monitor Cardiovascular status and perform regular heart and vascular assessments, including capillary refill and peripheral pulse checks in impacted extremities.
Avoid firmly manipulating or palpating impacted extremities.
Use warm water soaks, intermittently, to help with tenderness and inflammation.
How to prevent a DVT
Early ambulation after surgery.
Taking anticoagulant medications as prescribed.
Use the VTE protocol and use antithrombotic devices such as Compression Stockings and pneumatic Sequential Compression Devices (SCDs).
Avoid prolonged immobility, where possible.
Even with patients with limited mobility, they can help themselves by intermittently doing pedal pushes while in bed or sitting.
Tests and Treatments for DVT
Did you know that not necessarily all cases of DVT will be treated overnight in the hospital? Some cases of DVT can be treated in the outpatient setting, take a look at this information from the American academy of family physicians.
Expected and common Laboratory Tests
PT/INR - Remember the target for these patients will be different from the normal and expected values since patients with a DVT will be on anticoagulant therapy.
D-Dimer (testing hypercoagulable state)
Expected and common Radiological Test and Exams
MRI of Extremity or thoracic cavity, to assess for PE.
Chest X-ray (CXR) - Especially for those with high risk for PE development.
Pharmacological Preventative and Treatment Options
DVT patient will need more than an aspirin… let’s make this clear….
A Low Molecular Weight Heparin Product, I almost exclusively see Lovenox (Enoxaparin)
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Can be given in subcutaneous form or Intravenously as a continuous IV infusion or drip (gtt).
Thrombolytic agents such as t-PA - known as “clot busters”. Typically only used in more severe or serious cases.
Anticoagulant therapy
Analgesics for treatment of pain and inflammation
NSAIDS Like Ibuprofen and Naproxen
Surgical, Procedural, and mechanical treatment and prevention
Surgery is not commonly needed in the majority of the cases I’ve seen in my practice.
Sources
Columbia University department of Surgery
Pathophysiology of Nursing Demystified
Diseases and Disorders, A Nursing Therapeutics Manual