INTRODUCTION:

Deep vein thrombosis is a part of a condition called venous thromboembolism. Deep vein thrombosis can
cause leg pain or swelling, but may occur without any symptoms. Deep vein thrombosis is a serious
condition because blood clots in the veins can break loose, travel through the bloodstream, and obstruct the
lungs, blocking blood flow.

DEFINITION:
 Deep vein thrombosis occurs when a blood clot (thrombus) forms in one or more of the deep veins in
the body, usually in the legs.
 Venous thromboembolism (VTE) encompasses deep venous thrombosis (DVT) and pulmonary
embolism (PE) and causes cardiovascular death and disability.
 In the United States, the Surgeon General estimates there are 100,000 to 180,000 deaths annually from
PE and has declared that PE is the most common preventable cause of death among hospitalized
patients.

EPIDEMIOLOGY:
 Venous Thromboembolism related deaths 3,00,000/anum
 7% diagnosed and treated
 34% sudden pulmonary embolism
 59% as undected

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).

ETIOLOGY:
Starts in lower extremity calf vein

progressing proximally to involves

popliteal, femoral, iliac system

VIRCHOW TRIAD:
More than 100 years ago, rudolf virchow described three triad factors of deep vein thrombosis.

Venous stasis

Hypercoagulable state Endothelial damage

a) VENOUS STASIS:
 Surgery, trauma, immobility, paresis
 Increasing age
 Pregnancy and postpartum
 Heart or respiratory failure
 Obesity

b) HYPERCOAGULABILITY OF BLOOD:
The effect of hypercoagulability on thrombosis is favoured by advancing age, smoking, use of oral
contraceptives and obesity. Hypercoagulability may occur by the following changes in the composition of
blood:
i) Increase in coagulation factors e.g. fibrinogen, prothrombin, factor VIIa, VIIIa and Xa.
ii) Increase in platelet count and their adhesiveness.
iii) Decreased levels of coagulation inhibitors e.g. antithrombin III

c) ENDOTHELIAL INJURY:
 Trauma
 Surgery
 Invasive procedure may distrupt venous integrity
 Iatrogenic cause of venous thrombosis like CVC cause upper limb DVT.

PATHOPHYSIOLOGY:
Reduced blood flow :Venous stasis occurs when blood flow is reduced, when veins are dilated, and when
skeletal muscle contraction is reduced.

Damage: Damage to the intimal lining of blood vessels creates a site for clot formation.

Phlebitis: Formation of a thrombus frequently accompanies phlebitis, which is an inflammation of the vein
walls.

Platelet aggregates Venous thrombi are aggregates of platelets attached to the vein wall that have a tail-like
Appendage containing fibrin, white blood cells, and many red blood cells.

Tail The “tail” can grow or can propagate in the direction of the blood flow as successive layers of the
thrombus form

Fragmentation Fragmentation of the thrombus can occur spontaneously as it dissolves naturally, or it can
occur with an elevated venous pressure.

Recanalization After an acute episode of DVT, Recanalization or reestablishment of the lumen of the vessel
typically occurs.

CLINICAL MANIFESTATION:
 Edema:
With obstruction of the deep veins comes edema and swelling of the extremity because the out flow
of venous blood is inhibited.

 Tenderness:
Tenderness, which usually occurs later, is produced by inflammation of the vein wall and can be
detected by gently palpating the affected extremity.

 Pulmonary embolus:
In some cases, signs and symptoms of a pulmonary embolus are the first indication of DVT.

 Phlegmasia cerulea dolens:

Also called massive iliofemoral venous thrombosis, the entire extremity becomes massively swollen,
tense, painful , and cool to the touch.

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.
 Lintons sign: After applying torniquet at saphenofemoral junction patient made to walk , then limb is
elevated in supine posation prominent superficial veins will be observed.
 Homans sign: pain in the posterior calf or knee with forced dorsiflexion of the foot.
 Moses sign : Gentle squeezing of the lower part of the calf from side to side.
 Neuhofs sign: Thickening and deep tenderness elicited while palpating deep in calf muscles.

INTERPRETATION:

High probability: ≥ 3 (Prevalence of DVT - 53%)

Moderate probability: 1-2 (Prevalence of DVT - 17%)
Low probability: ≤ 0 (Prevalence of DVT - 5%)

DIAGNOSTIC STUDIES:
 Clinical examination alone is able to confirm only 20-30% of cases of DVT
 Blood Tests The D-dimer
 Imaging Studies
D-DIMER:
 It specific degradation product of cross-linked fibrin.
 Because concurrent production and breakdown of clot characterize thrombosis, patients with
thromboembolic disease have elevated levels of D-dimer.
Three major approaches for measuring D-dimer
 ELISA
 latex agglutination
 blood agglutination test

MEDICAL MANAGEMENT:
The objectives for treatment of DVT are to prevent thrombus from growing and fragmenting,
Recurrent thromboemboli, and post thrombotic syndrome.
Endovascular management: Endovascular management is necessary for dvt when anticoagulant or
thrombolytic therapy is contraindicated, the danger of pulmonary Embolism is extreme, or venous drainage
is so severely compromised that permanent damage to the extremity is likely.
Vena cava filter: A vena cava filter may be placed at the time of thromboectomy; this filter traps late emboli
and prevents pulmonary emboli.

EMERGENCY DEPARTMANT CARE:

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.

GENERAL THERAPEUTICMEASURES:
 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.

SPECIFIC TREATMENT:
 Anticoagulation
 Thrombolytic therapy for DVT
 Surgery for DVT
 Filters for DVT
 Compression stockings

PHARMACOLOGIC THERAPY:
ANTICOAGULATION:
Heparin prevents extension of the thrombus
It is a heterogeneous mixture of polysaccharide fragments with varying molecular weights but with similar
biological activity.

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 15-25 units/kg/hr.

SIDE EFFECTS:
 Bleeding
 Osteoporosis
 Thrombocytopenia
 Skins lesions- papules, necrosis

CONTRAINDICATIONS:
 Bleeding disorders,
 Severe hypertension,
 threatened abortion, piles,
 large malignancies, tuberculosis
 Ocular surgery and neurosurgery,
 Chronic alcoholics, cirrhosis, renal failure

LOW MOLECULAR WEIGHTHEPARIN:

 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
 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:
 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
 caution in active tuberculosis or diabetes; patients with protein C or S deficiency are at risk of
developing skin necrosis

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.
These pulmonary emboli removed at autopsy look like casts of the deep veins of the leg where they
originated.
 THROMBECTOMY.
 CATHETER-DIRECTED THROMBOLYSIS
 FIRST-GENERATION PCDT
 NEW: SINGLE-SESSION PCDT Power Pulse Isolated Thrombolysis
 FILTERS FOR DVT

NURSING MANAGEMENT:
Assessment of a patient with deep vein thrombosis includes:
 physical examination
 Well’s diagnostic algorithm, Because of the unreliability of clinical features, Well’s diagnostic
algorithm has been validated whereby patients are classified as having a high, intermediate, or low
probability of developing DVT.
NURSING DIAGNOSIS:
1. Ineffective tissue perfusion related to interruption of venous blood flow.
2. Impaired comfort related to vascular inflammation and irritation.
3. Risk for impaired physical mobility related to discomfort and safety precautions.
4. Deficient knowledge regarding Pathophysiology of condition related to lack of information and
misinterpretation.
NURSING INTERVENTION:
The major nursing interventions that the nurse should observe are:
1. Provide comfort: Elevation of the affected extremity, graduated compression stockings, warm
application, and ambulation are adjuncts to the therapy that can remove or reduce discomfort.
2. Compression therapy: Graduated compression stockings reduce the caliber of the superficial veins in the
leg and increase flow in the deep veins; external compression devices and wraps are short stretch elastic
wraps that are applied from the toes to the knees in a 50% spiral overlap; intermittent pneumatic
compression devices increase blood velocity beyond that produced by the stockings.
3. Positioning and exercise: When patient is on bed rest, the feet and lower legs should be elevated
periodically above the level of the heart and active and passive leg exercises should be performed to
increase venous flow.

HOME CARE AND FOLLOW UP:

The nurse must also promote discharge and home care to the patient.
 Drug education: The nurse should teach about the prescribed anticoagulant, its purpose, and the need to
take the correct amount at the specific times prescribed.
 Blood tests: The patient should be aware that periodic blood tests are necessary to determine if a change
in medication or dosage is required.
 Avoid alcohol: A person who refuses to discontinue the use of alcohol should not receive
anticoagulants because chronic alcohol intake decreases their effectiveness.
 Activity: Explain the importance of elevating the legs and exercising adequately.

SUMMARY:
Deep vein thrombosis (DVT) occurs when a blood clot (thrombus) forms in one or more of the deep veins in
your body, usually in your legs. Deep vein thrombosis can cause leg pain or swelling but also can occur with
no symptoms. You can get DVT if you have certain medical conditions that affect how your blood clots.
CONCLUSION:
Deep vein thrombosis (DVT) is a serious condition that occurs when a blood clot forms in a vein located
deep inside your body. A blood clot is a clump of blood that's turned to a solid state. Deep vein blood clots
typically form in your thigh or lower leg, but they can also develop in other areas of your body.

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page no842-845.
 M. black, joyce. Medical Surgical Nursing. New delhi; Elsevier publication, 8th edition, vol. volume–2,
pp- 1331-1335.
 Davidson’s. Principles and practice of medicine. London; Elsevier publication, 21th edition, pp- 717-
720.

 Rana nurse practitioner in critical care Follow, pankaj. (n.d.). Deep vein thrombosis (DVT). SlideShare.
https://www.slideshare.net/pankajrana87/deep-vein-thrombosis-dvt-127703104.

 Patil Follow, A. (n.d.). Dvt. SlideShare. https://www.slideshare.net/cshekharg/dvt.

 Deep vein thrombosis. Physiopedia. (n.d.). https://www.physio-pedia.com/Deep_Vein_Thrombosis.