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308 Journal of Neuroscience Nursing

‘‘Tap and Twist’’: Preventing Deep Vein


Thrombosis in Neuroscience Patients Through
Foot and Ankle Range-of-Motion Exercises
Janet Palamone, Susan Brunovsky, Matt Groth, Linda Morris, Mary Kwasny

ABSTRACT
Neurosurgical patients tend to have the highest rate of deep vein thrombosis (DVT) rate among other
postsurgical patients. The methods and timing of DVT prevention and treatment continue to be debated
among neurointensivists. The greatest opportunity to intervene is early during the stay in the intensive
care unit. There are many factors, however, that can make this the most neglected time for aggressive
prevention measures. For large university teaching hospitals, the target of the University Health System
Consortium is to achieve an average DVT rate at or below half that of previous reported rates. The current
recommendations are effective only if there is compliance with these measures during the majority of the
patients’ hospitalization. Our hypothesis states that without changing any of the current measures to
prevent DVT, a structured program of foot and ankle range-of-motion (ROM) exercises will decrease the
incidence of DVT in the neuroscience intensive care patient population. This quasi-experimental study
was a quality improvement project examining 315 individuals over the age of 18 years, who were
admitted to the neurospine intensive care unit and who received a new program of foot exercises as a
method of DVT prevention. Data for the outcome measures were derived from bedside measurement
of lower extremity doppler, the percentage of time the exercises were performed, patient history, and
standard DVT prevention measures. Overall, there was no difference in DVT rates for those receiving the
foot ROM intervention during the study period in 2008Y2009 compared with the usual nursing practice
for the previous year. However, during the study period, those who developed DVT had a significantly
lower compliance rate with the ROM exercises (38.7%) than did those who did not develop DVT (58.4%;
p G .001). Therefore, foot and ankle ROM exercises may have a promising role in reducing the incidence
of DVT in neuroscience intensive care patients when there is diligent performance of the exercises.

O
ne of the most common complications afflict- disposing comorbidities prior to admission, significant
ing patients undergoing surgery is the pre- prolonged immobility during the acute stage of ill-
ventable condition of deep vein thrombosis ness, neurosurgical or procedural interventions that
(DVT), which results from venous stasis, vein injury, tend to be complex and require prolonged length of
and increased coagulation also know as Virchow’s triad stay, and increased inflammatory and infectious
(Burke, 2007). This triad is more prominent in the conditions. The use of higher risk pharmacological
neuroscience intensive care population because of pre- prophylactic interventions in the neurosurgical pa-
tient population may not always be appropriate.
Questions or comments about this article may be directed to Janet
Palamone, MSN APN CCRN CNRN, at jpalamon@nmh.org. She
is a practice manager at the NeuroSpine ICU at Northwestern Significance
Memorial Hospital, Chicago, IL. According to the Center for Disease Control and Pre-
Susan Brunovsky, BSN CNRN CCRN, is a staff nurse at the vention, DVT and pulmonary embolism (PE) are a
NeuroSpine Intensive Care Unit, Northwestern Memorial Hos- growing public health issue. Currently in the United
pital, Chicago, IL. States, 200,000Y400,000 people have DVT (Depart-
Matt Groth, BSN CCRN, is a staff nurse at the NeuroSpine Inten- ment of Health and Human Services, 2010). One third
sive Care Unit, Northwestern Memorial Hospital, Chicago, IL. of patients with DVT develop a chronic disabling con-
Linda Morris, PhD APN CCNS FCCM, is an advance practice dition known as post-thrombotic syndrome with symp-
nurse for the Respiratory Care Department, Northwestern Memorial toms of swelling, pain, discoloration, and scaling in the
Hospital, and assistant professor of clinical anesthesiology with
Feinberg School of Medicine, Northwestern University, Chicago, IL.
affected limb. Neurosurgical intensive care patients
are vulnerable to the development of DVT because
Mary Kwasny, ScN, is a statistician at the Department of Preven-
tative Medicine, Northwestern University, Chicago, IL.
they tend to have a higher degree of immobility due
to their neurological deficits, which can be com-
The authors declare no conflict of interest.
pounded by lengthy stays in the intensive care unit
Copyright B 2011 American Association of Neuroscience Nurses (ICU). In addition, the ICU milieu predisposed pa-
DOI: 10.1097/JNN.0b013e318234e9f2 tients to restricted mobility from such things as cables,

Copyright @ 2011 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Volume 43 & Number 6 & December 2011 309

IV lines, and drainage tubes. This immobility is


compounded by many situations that add to physical
deconditioning, such as frequent administration of
Potential thromboembolic events
sedative agents, poor nutritional intake, muscle atrophy pose a serious threat to neuroscience
from prolonged bed rest, or complex inflammatory
responses from the critical illness (Kress, 2009). In patients because of physical
addition, the increased risk of DVT associated with deconditioning and immobility, the
surgeries, trauma, and an array of acute and chronic
medical conditions often plagues the neuroscience use of sedative agents, poor intake,
patient population, and the consequences of immo-
bility add to this risk (Carlile et al., 2006; Danish et al.,
muscle atrophy from either bed rest or
2005; Gaber, 2007; Geerts et al., 2008; Graziano & disease processes themselves, and the
Charpie, 2001; Kress, 2009; Yang, 2005).
Methods of DVT prophylaxis include mechanical inflammatory responses to illness.
means (i.e., exercise, range of motion [ROM], com-
pression stockings, compression devices), pharma-
cological agents, or a combination of both (Gaber,
2007). At the time of this study, the mechanical pro- a DVT rate of 27 per 1,000 patients, the highest rate
phylactic measures in place to reduce DVT included among all the postsurgical patients (Figure 1). In
compression stockings and sequential compression de- quarters 3 and 4 of 2007, 48 patients were diagnosed
vices. Although we attempted to initiate early mobility with DVT in the NSICU. Twelve of these patients
measures, it was not recommended in all acute stages had DVT present prior to admission to the NSICU.
of the patient’s neurological disease, such as during There continues to be a debate among neuroin-
unstable periods. Nursing compliance with initiating tensivists related to the benefits and risks of more
mobility measures in the ICU varied based on level of aggressive methods for DVT prophylaxis. Mechan-
comfort and experience in moving critically ill patients ical methods of DVT prophylaxis continue to be the
or the notion that patients required evaluation by a avenue of choice and are clearly beneficial when
physical therapist before initiating mobility measures. appropriately applied. The greatest opportunity to
Early pharmacologic prophylaxis measures were of- intervene is while the patient is in the ICU; how-
ten contraindicated due to risk of intracranial bleeding ever, this tends to be the most neglected time for ag-
in neurospine ICU (NSICU) patients. gressive prevention measures because of competing
According to statistics compiled by the University priorities in a busy ICU. There are countless missed
Health System Consortium, DVT rates in all postsur- opportunities in daily practice to use many of the
gical patients at our university hospital was 28 per lower risk methods of prophylaxis. This observa-
1,000 patients at the beginning of September 2007. tion spearheaded the need for a simple but effective
The University Health System Consortium target was way of improving venous circulation in the moder-
12.5 per 1,000 patients, less than half of our rate. ately to severely high-risk patients commonly seen
During this same period, neurosurgical patients had in the NSICU.

FIGURE 1 Postsurgical Deep Vein Thrombosis and Pulmonary Embolism by Discharge


Specialty: September 2007, Prior to Study Intervention

Copyright @ 2011 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
310 Journal of Neuroscience Nursing

Literature Review large proportion of patients remained bedridden after


The risk of DVT affects nearly all hospitalized pa- discharge from the ICU. However, when aggressive
tients. There has been extensive literature com- physical therapy was initiated, there were improved
paring mechanical methods of DVT prevention, functional outcomes in these patients. Limiting pa-
especially exercise and early mobility, as well as tients to bed rest during their ICU stay is highly
other antithromboembolic guidelines for the pre- incongruent with normal human physiology (Vavra-
vention, management, and treatment of DVT (Agnelli, Hadzahmetovi, 2006). Pathophysiologic changes
2004; Arnold, Kahn, & Shrier, 2001; Carlile et al., occur in each body system during bed rest, and these
2006; Danish et al., 2005; Geerts et al., 2008; Kaplin, changes to the cardiovascular system are consider-
Czymy, Fung, Unsworth, & Hirsh, 2002; Timmerman, able. The complete bed rest common to most ICU
2007). Since 1986, the American College of Chest patients can shift 11% of the total blood volume away
Physicians (ACCP) has been reviewing published from the legs (Vollman, 2010). This not only affects
evidenced-based research and establishing guidelines autonomic tone and shifts fluid from the vascular
based on thrombotic therapies (Geerts et al., 2008). space but also creates microvascular dysfunction.
The ACCP 2008 guidelines recommended mechan- The devastating results of the impact of immobility
ical measures for their ease of use and minimal risk have been reported in the literature for decades. Sys-
temic examples of the complications associated with
for every hospitalized patient, including those who
immobility include atelectasis, pneumonia, PE, DVT,
may have contraindications to more aggressive mea-
orthostatic hypotension, constipation, ileus, urinary sta-
sures, such as neurosurgical and trauma patients. These
sis, hyperglycemia, insulin resistance, muscle atrophy,
methods are effective only when there is strict adher-
bone demineralization, contractures, decubitus ul-
ence to the guidelines during the entire duration of
cers, and depression (Agnelli, 2004; Arnold et al.,
hospitalization.
2001; Carlile et al., 2006; Department of Health and
Several studies examined foot and ankle move-
Human Services, 2010; Geerts et al., 2008; Graziano
ments and the effect on venous blood flow (Hitos,
& Charpie, 2001; Kehl-Pruett, 2006; Yang, 2005).
Cannon, Canon, Garth, & Feltcher, 2007; Kaplin
These risks increase in older people, who are the
et al., 2002; Sochart & Hardinge, 1999). Kaplin et al. most vulnerable. The occurrence of muscle atrophy
(2002) showed that there were increases in venous may begin with immobility but is multifactorial and
blood flow during electrical stimulation of the plan- includes proteolysis of muscle during inflammatory
tar muscle in one leg compared with flow seen in the disease states, a decrease in intensity of nerve im-
unstimulated leg. Sochart and Hardinge (1999) used pulses to the muscle, and significant fatiguing (Morris
venous doppler to demonstrate how venous blood & Herridge, 2007). Hopkins et al. (2007) found that
flow improved during foot and ankle exercises. They healthy individuals who were subjected to immobil-
demonstrated that venous blood flow was signifi- ity experienced a 1.3% to 3% loss in muscle strength
cantly increased if the subject was performing active per day, and overall postural muscle strength de-
foot and ankle movements compared with passive creased by 10% during 1 week of bed rest. Further-
movements. Recent attention in the media exploring more, they reviewed the inconsistency with physical
travel-related DVT with prolonged immobility on therapy practices in the ICUs, with an average of
airplanes, labeled ‘‘Economy Class Syndrome,’’ sup- only 17% of ICU patients receiving therapy. Kress
ported how foot and leg exercises can prevent DVT (2009) described severe deconditioning in ICU pa-
when sitting for long periods (Vavra-Hadzahmetovi, tients with critical illnesses, which led to profound
2006). The ACCP guidelines also addressed travel- functional impairment. In his review of clinical trials
related DVT during long flights and promoted active on early mobilization of ICU patients, he found that
calf muscle contraction exercises as a means to prevent not only was there a high percentage of patients who
DVT in flights longer than 8 hours (Geerts et al., 2008). were safe to ambulate while being ventilated, but
The impact of physical mobility on outcomes has also that functional outcomes improved with a de-
inundated the literature in the last decade (Arnold crease length of stay in the ICU. Incorporating mo-
et al., 2001; Bailey, Miller, & Clemmer, 2009; Bourdin bility measures during the ICU patient stay makes
et al., 2010; Hopkins & Spuhler, 2009; Hopkins, intuitive sense in reducing many complications like
Spuhler, & Thomsen, 2007; Kress, 2009; Morris & DVT; however, the milieu of the ICU has delayed
Herridge, 2007; Perme & Chandrashekar, 2009; progress toward this goal (Hopkins, Spuhler, &
Timmerman, 2007; Vollman, 2010; Yang, 2005). Thomsen, 2007). A cultural shift can occur if re-
Bailey et al. (2009) revealed that ICU patients with sources are accessible, if the tasks can be simplified or
no planned physical training were severely limited in made moreefficient, and if nurses focus their plan of
their physical conditioning and muscle strength. A care toward outcome-based initiatives to prevent DVT.

Copyright @ 2011 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Volume 43 & Number 6 & December 2011 311

Investigational Plan member performed these exercises passively 10 times


Study Design per hour. Verification of proper performance of the
This quasi-experimental study was a quality improve- prescribed intervention was assessed with a return
ment project between July 2008 and February 2009. demonstration. Exercises were done in conjunction
We created a new intervention and compared it with with hourly neurological assessments, so this did not
the standard care during the same period of the pre- create an additional disturbance in their daily rou-
vious year to limit any variation due to seasonal or tine. Nurses documented each hour if the exercises
fluctuations in the patient population. The sample size were performed actively or passively, or, if unable to
for this project was based on the average daily census perform, a rationale was provided. The diagnosis of
of 19.2 patients per day over a 6-month period. The DVT was made through bedside venous dopplers as
average length of stay in our patient population was a routine screening or when clinically indicated by
between 3 and 5 days. The new intervention was a pain, redness, or swelling of the affected extremity.
structured plan of active or passive foot and ankle ex- Data were reported as the number of patients ac-
ercises as a method of DVT prophylaxis in addition to quiring DVT during the study period. Data collec-
current standard of care. All neurology and neurosur- tion included all types of DVT prophylaxis in place
gery patients were assigned to the intervention group during the time of intervention, risk factors for DVT,
on admission to the NSICU. To increase the sample and if the exercises were active or passive. The cri-
size, we extended our study period by 2 months. terion for rejection of the null hypothesis was p G .05.
Comprehensive verbal and written instructions on
foot and ankle exercise were provided to all patients Results
and families included in the study. Patients unable Demographics
to complete active exercise had passive exercise per- From September 2008 to February 2009, a total of
formed by the nurse or family member. Nurses par- 551 patients received the foot and ankle ROM ex-
ticipated in a return demonstration to ensure reliability ercise per the study guidelines. The lower extremity
with ability to teach family members and proper ex- doppler (LED) examination was the standard mea-
ecution of the exercises. Nurses were also encouraged sure used to determine whether a patient had de-
to engage family members to participate by instruct- veloped DVT. A total of 230 patients were excluded
ing them on the exercise regimen. because LED was not ordered as part of their plan
of care. The final study group included 321 in-
Methods dividuals who had both foot and ankle ROM and
After institutional review board approval waived the LED (246 without DVT and 46 with DVT). Age
need for patient consent, all patients who were ad- and primary diagnosis showed no difference (inde-
mitted to the NSICU between July 2008 and February pendent t test p = .696 and Bonferroni adjustment
2009 were enrolled into the study. The comparison p = .096, respectively) in the development of DVT.
groups were patients admitted to the NSICU during Differences between men and women were not stud-
the same period of the previous year. All patients over ied. However, there was a cautionary finding for pa-
18 years of age were included in this study. Exclusion tients with traumatic brain injuries, who had a higher
criteria include those patients who were underage or tendency to develop DVT (unadjusted Wald p =
double amputees. .016). Any medical history of a high-risk diagnosis
All patients in the NSICU received sequential com- associated with vascular disease, with the exception
pression devices and compression stockings while of individuals with a smoking history, did not seem
immobile or on complete bed rest. Other methods to be related to the development of DVT in our
of DVT prophylaxis such as ROM exercises, early study. Those patients with a prior history of DVT did
ambulation, physical or occupational therapy, and not show an increased risk of developing a new-
pharmacological prophylaxis were decided on an onset DVT (Fisher’s exact test p = .060).
individual basis. The educational plan included
verbal and written instruction on how to perform Study Outcomes Related to Foot
dorsiflexion and plantar flexion (‘‘tap’’), followed ROM Exercises
by lateral and medial rotation of the feet (‘‘twist’’), The average compliance rate for the 551 patients who
10 times every hour. In addition to standard DVT had foot exercises recorded was 58.3% T 29.5% for
prophylaxis, all patients admitted to the NSICU dur- the right foot and 58.6% T 29.2% for the left foot,
ing the study period received the specific regimen of using a range of 0% to 100%. Interquartile range was
foot exercises. For patients who were unable to per- (37.1%, 84%) for the right foot and (37.4%, 84%)
form this task independently, the nurse or family for the left foot. Of the 315 patients who had the

Copyright @ 2011 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
312 Journal of Neuroscience Nursing

foot exercises and the LED, the mean compliance


FIGURE 3 Compliance With the Exercise
(right) was 59.5% T 26.5% for those without DVT
Regimen
and 36.1% T 29.3% for those who developed DVT.
This difference was significant ( p G .001). The
mean compliance (left) was 59.4% T 26.2% among
those who did not develop DVT and 41.3% T 28.2%
among those who developed DVT ( p G .001). There
were 15 individuals who did not participate in the
foot exercises at all (compliance = 0). Among those
who had at least some compliance, the mean percent-
age compliance on the right leg was 60.8 T 25.2 for
those without subsequent DVT (n = 263) and 44.9 T
25.8 among those who did develop DVT (n = 37).
Note. DVT = deep vein thrombosis.
This difference was significant ( p G .001). The mean
percentage compliance on the left leg was 60.3 T
25.4 for those without subsequent DVT (n = 265)
and 50.0 T 22.8 among those who did have DVT (n = compared with those who did not develop DVT
38). This difference was significant ( p = .019). Be- (compliance average = 58.4%; Figure 3).
cause the performance of the ROM exercises showed
statistical difference, the diligent performance of foot
and ankle ROM exercises has a promising role.
Discussion
The reasons for not performing foot exercises (re- Many researchers have shown that exercising the
sulting in a lower compliance) are listed in Figure 2. lower extremities can enhance blood flow in patients
The nursing discretion category could be further who experience prolonged immobility and could
broken down to include reasons such as patient sleep- contribute to DVT prevention (Kaplin et al., 2002;
ing, other duties requiring them to skip performing Kress, 2009; Sochart & Hardinge, 1999). The lit-
exercises, forgetting to perform, failure to document erature also demonstrates that bed rest has detrimen-
performance of exercises, and patient receiving phys- tal physiological effects on each body system and
places the patient at severe risk for complications
ical therapy/occupational therapy during that hour.
such as DVT and PE (Arnold et al., 2001; Bailey
There was an association in the development of DVT
et al., 2009; Bourdin et al., 2010; Hopkins &
between active, passive, or combination of ROM foot
Spuhler, 2009; Hopkins et al., 2007; Kress, 2009;
exercises ( p G .001), which supported active ROM as
Morris & Herridge, 2007; Perme & Chandrashekar,
the best method to prevent DVT. Overall, there was
2009; Timmerman, 2007; Vavra-Hadzahmetovi, 2006;
no difference in DVT rate before the foot ROM in-
Vollman, 2010). The reduction of DVT lies in the
tervention in 2007Y2008 compared with those receiv-
hands of ICU nurses through their knowledge and
ing the foot ROM intervention during the study ability to initiate and maintain preventative mobility
period in 2008Y2009. However, during the study measures throughout the patient’s ICU stay. Time
period, there was a statistically significant difference constraints, cultural barriers, and a patient’s insta-
( p G .001) between those who developed DVT being bility during the patient’s critical stage of his or her
less compliant with foot exercises (average 38.7%) illness make ROM and other early mobility mea-
sures a lower priority. The intent of this study was
to develop a simple and fast method of promoting
FIGURE 2 Rationale for Noncompliance circulation to the lower extremities that could easily
be incorporated into an ICU patient’s daily care. In
the NSICU, nurses incorporated the foot and ankle
ROM exercises into their hourly neuro assessments
much like our current practice of encouraging hourly
use of the incentive spirometer in this surgical patient
population. The study was designed to promote pa-
tient and family involvement through instructing them
in the importance of lower extremity exercises, the
risk factors of immobility, and the benefits of early
rehabilitation. It also was designed to assist family
Note. DVT = deep vein thrombosis; RN = registered nurse. members in taking an active role in helping promote

Copyright @ 2011 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Volume 43 & Number 6 & December 2011 313

wellness and to enable them to gain some control in everyone, as compliance rates could have been nurse
the ICU environment. The role of physical therapy dependent. High compliance with the exercises by
in the NSICU is variable and can be delayed when one nurse could have been offset by low compliance
patient stability is in question. Foot and ankle ROM of another.
exercises were meant to be an adjunct to current DVT An additional limitation was that we were unable
prophylaxis and a further bonus to early mobility to determine whether failure to document poten-
measures. These ROM exercises have been adver- tially contributed to the low compliance rates. We
tised in the media to prevent the Economy Class followed the premise that if the exercises were not
Syndrome and are now embraced by airline trav- documented, they were not being done. The reasons
elers (Vavra-Hadzahmetovi, 2006). We feel that in- for failure to document included the following: not
corporating these simple exercises should become initiating the form at time of admission, stopping
a part of daily practice and nursing education through- documentation when one form was completed for
out a patient’s hospital stay. the week rather than initiating a new form for ad-
ditional weeks, and missing documentation for an
entire shift by the nurse caring for the patient. Again,
Limitations the program depended on the accountability of each
This study had several limitations. First, exercises nurse to document performance of the exercises for
occurred only while the patient was in the ICU. Due success of the ROM program.
to the nature of care, critically ill neurology and Because we did not change the standard practice
neurosurgery patients often required frequent trips for screening patients for DVT, we were unable to
off the unit to the interventional radiology suite, ensure that all patients had LED done as part of their
computed tomography, or magnetic resonance im- ICU plan of care. We included only those patients
aging scans. These frequent trips resulted in many who had the LED done to make a direct conclusion
missed opportunities to provide exercises and were about the results. If all our subjects had LEDs, our
a contributing factor to the overall low compliance n would have been higher, contributing to more ro-
rates. In addition, we were unable to control for read- bust conclusions. Another limitation was not includ-
missions to the unit. These included patients who were ing length of stay in our study population as a risk
stable enough to be transferred out of the ICU but factor for developing DVT. Length of stay ranged
returned at some point later, with or without DVT. from 2 to 60 days, and this variability could have
Unless the patients were diagnosed with DVT while explained the overall failure to reduce DVT rates
they were in the ICU, we were unable to determine between the control and study groups.
at what point readmitted patients developed DVT.
We may have strengthened the results of our study Recommendations for Practice
if we had branched out to all the neurological areas
Because our study showed statistical significance in
beyond the ICU, so as to eliminate the need to con-
the patients who were more compliant with the foot
trol for readmissions to the ICU.
and ankle exercises, the following recommenda-
Another limitation was the low compliance rate
tions should be considered for nurses to incorporate
of the ROM exercises. Numerous factors contrib-
into their daily plan of care. The patient or nurse
uted to compliance with the exercises. The culture
should perform the minimum goal of 13 sets of ‘‘tap
of the ICU seems to place less value on ‘‘low-tech’’
and twist’’ exercises each day. In patients who require
interventions; therefore, ROM exercises may have
passive ROM, more frequent repetitions may be re-
been a lower priority. Many nurses feel that the ICU
quired. In addition, involving family members in the
is not the setting to begin early mobility initiatives
tap and twist exercises can increase compliance with
without patients first being evaluated by physical
performing the exercises with the added benefit of
therapy, providing a reason for deferring the exer-
helping families become more engaged with the pa-
cises. In addition, less experienced staff had some
tient’s care.
apprehension about the safety of moving patients with
more technical equipment, such as arterial line place-
ment in the foot. Time constraints became another lim- Summary
itation, as newer staff with less organizational skills Nurses play an important role in reducing the oc-
placed ROM exercises as a low priority in their busy currence of DVT, which has been supported in the
day. More experienced staff appeared to have a greater literature. Early mobilization has been shown to im-
understanding of the value of mobility and may have prove outcomes, and ROM exercises improve blood
made it more of a priority. The success of the program flow to the lower extremities. Although our study re-
depended on the commitment and accountability of vealed no difference in overall DVT rates, it did show

Copyright @ 2011 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
314 Journal of Neuroscience Nursing

that those who did not develop DVT were more Geerts, W., Heit, J. A., Clagett, G. P., Pineo, G. F., Colwell, C.,
compliant with the foot and ankle exercises. Active Anderson, F. A., & Wheeler, H. B. (2008). Prevention of
venous thromboembolism: American College of Chest Phy-
ROM proved to be the best method to decrease sicians’ evidence-based clinical practice guidelines (8th ed.).
one’s risk of DVT. Nurses are the key to incorpo- Chest, 133(6), 380SY453S.
rating these exercises into the daily plan of care for Graziano, J., & Charpie, J. (2001). Thrombosis in the intensive
their patients. Efforts to improve nursing compli- care unit: Etiology, diagnosis, management, and prevention
ance with this ROM exercise program should be the in adults and children. Cardiology in Review, 9(3), 173Y182.
focus of future studies to reach a more robust con- Hitos, K., Cannon, M., Canon, S., Garth, S., & Feltcher, J. P.
(2007). Effect of leg exercises on popliteal venous blood flow
clusion. With further study, foot and ankle ROM during prolonged immobility of seated subjects: Implications
exercises have a promising role in reducing DVT oc- for prevention of travel-related deep vein thrombosis. Journal
currences with diligent performance of the exercises of Thrombosis and Haemostasis, 5(9), 1890Y1895.
in critically ill patients. Hopkins, R., & Spuhler, V. (2009). Strategies for promoting early
activity in critically ill mechanically ventilated patients. AACN
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