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Nursing care plan ncp dvt deep vein thrombosis

Written by ncp nursing care plan on April 30th, 2011

Deep Vein Thrombosis
Venous thrombosis occurs when a thrombus forms in a superficial or deep vein. This condition is often called thrombophlebitis because of the associated inflammation in the involved vessel wall. The predisposing factors for venous thrombus formation are venous stasis, damage to the endothelium of the vein wall, and/or hypercoagulability. Conditions/factors associated with a high risk for venous thrombosis include surgery (especially orthopedic and abdominal surgery), immobility, advanced age, heart failure, certain malignancies, fractures or other injuries of the pelvis or lower extremities, varicose veins, pregnancy, obesity, estrogen and oral contraceptive use, sepsis, venous cannulation, administration of vessel irritants (e.g., hypertonic solutions, chemotherapeutic agents, high-dose antibiotics), history of deep vein thrombosis, and inherited coagulation abnormalities.

Deep vein thrombosis usually develops in a lower extremity; however, the incidence of subclavian venous thrombosis is rising because of the increased use of central venous catheters. Clinical manifestations of deep vein thrombosis are often not distinctive and, in many cases, the client is asymptomatic. Signs and symptoms that may be present include pain, tenderness, swelling, unusual warmth, and/or positive Homans’ sign in the involved extremity. The greatest danger associated with deep vein thrombosis is that the clot, or parts of it, will detach and cause embolic occlusion of a pulmonary vessel.

Persons with deep vein thrombosis are usually treated medically rather than surgically unless there is massive occlusion of a vessel and anticoagulation and thrombolytic therapy are contraindicated. With the increasing use of thrombolytic therapy, thrombectomies and embolectomies are rarely performed. Medical treatment varies depending on the location of the thrombus, the person’s risk for bleeding and history of previous thrombus, and whether a coagulation abnormality exists. Anticoagulant therapy is not universally used to treat calf vein thrombosis because the incidence of pulmonary embolism is low if there is no proximal vein involvement. However, there is a risk of extension of calf vein thrombi into a proximal venous segment if untreated, and because of this risk, many persons with calf vein thrombosis are treated with anticoagulants. There is also some variation in the anticoagulant regimen in relation to the time that oral anticoagulants are initiated and the route and type of heparin ordered (e.g., continuous intravenous heparin, intermittent intravenous heparin, adjusted-dose subcutaneous heparin, low-molecular-weight heparin).

Ineffective tissue perfusion: peripheral
Acute pain: affected extremity
Risk for impaired tissue integrity
Potential complications
pulmonary embolism
bleeding
Deficient knowledge, Ineffective therapeutic regimen management, or Ineffective health maintenance

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Source Credits: Nursing Care Planning Guides: For Adults in Acute, Extended and Home Care Settings by S. P. Ulrich and S. W. Canale BSN MSN / Nursing Care Plans by M. Doenges MF Moorehouse Alice Murr