FACULTY OF NURSING
UNIVERSITY OF COLOMBO
ADULT HEALTH NURSING - II
CASE STUDY
Deep vein thrombosis - DVT
By
Name : M.M.Fasleem
Registration No: 2018N00120
Index No: N00105
Contents
1.
Introduction ................................................................................................................................................ 1
2.
Pathophysiology ......................................................................................................................................... 1
3.
History ........................................................................................................................................................ 4
4.
Current Treatment....................................................................................................................................... 4
5.
Nursing Process .......................................................................................................................................... 5
Assessment ........................................................................................................................................... 5
Nursing Diagnosis ................................................................................................................................ 6
Planning ................................................................................................................................................ 6
Implementation ..................................................................................................................................... 7
Evaluation ............................................................................................................................................. 8
6.
Recommendation for improvement ............................................................................................................ 8
Recommendation .................................................................................................................................. 8
Discharge Plan ...................................................................................................................................... 8
Conclusion ............................................................................................................................................ 9
7.
References .................................................................................................................................................. 9
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1. Introduction
Name
: Mr. C.S.Rajapaksha
Age
: 73 years
Sex
: Male
Religion
: Buddhist
Address
: 327/1, Kudamagalkanda, maggona.
Ward
: 15
BHT No
: 1931251
Date of admission
: 20/08/2022
Marital status
: Married
Education Level
: Graduate level
Occupation
: Lawyer (retired)
He is admitted to the ward with the complain of Right lower limb edema with severe pain. Patient having
diagnosed with right lower limb cellulitis with blistering wound and Deep vein thrombosis on warfarin.
Today is the 7th day of admission patient cellulitis swelling condition is reduced but still having pain. other
than that, the INR level is not achieved to a therapeutic level.
2. Pathophysiology
The formation of a blood clot in a deep vein, most commonly in the legs or pelvis. Superficial veins are
thick-walled muscular structures that lie just under the skin. Deep veins are thin walled and have less
muscle in the media. They run parallel to arteries and bear the same names as the arteries. It has valves
that permit unidirectional flow back to the heart. Other kinds of veins are known as perforating veins.
These vessels have valves that allow one-way blood flow from the superficial system to the deep system
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Three factors cause DVT
•
Stasis of blood (venous stasis)
o Venous stasis occurs when blood flow is reduced, as in heart failure or shock; when veins
are dilated, as with some medication therapies; and when skeletal muscle contraction is
reduced, as in immobility, paralysis of the extremities, or anesthesia
Ex:
Bed rest or immobilization
Obesity
History of varicosities
Spinal cord injury
Age (greater than 65 years)
•
Vessel wall injury
o Damage to the intimal lining of blood vessels creates a site for clot formation. Direct
trauma to the vessels, as with fractures or dislocation, diseases of the veins, and chemical
irritation of the vein from IV medications or solutions, can damage veins.
Ex:
Trauma
Surgery
Pacing wires
Central venous catheters
Dialysis access catheters
Local vein damage
Repetitive motion injury
•
Altered blood coagulation
o Increased blood coagulability occurs most commonly in patients for whom anticoagulant
medications have been abruptly withdrawn.
o Oral contraceptive use and several blood dyscrasias (abnormalities) also can lead to
hypercoagulability
o Normal pregnancy is accompanied by an increase in clotting factors that may not return
to baseline until longer than 8 weeks postpartum, increasing the risk of thrombosis
Clinical Manifestations
•
•
•
•
•
•
•
severe pain
fever
chills
malaise
swelling / unilateral limb edema
cyanosis of affected arm or leg
tenderness (Homans’ sign – pain in the calf after the foot is sharply dorsiflexed)
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Diagnostic Investigations
•
•
•
•
•
Venous duplex/color duplex ultrasound:
noninvasive test allows for visualization of the thrombus
Impedance plethysmography:
a noninvasive measurement of changes in calf volume corresponding to changes in blood volume
brought about by temporary venous occlusion with a high-pneumatic cuff.
Radioactive fibrinogen testing:
radioactive fibrinogen (fibrinogen I125) is administered via IV line. Images are taken through
nuclear scanning at 12 to 24 hours
Venography:
IV injection of a radiocontrast agent. The vascular tree is visualized, and obstruction is
identified.
Coagulation profiles:
PTT, PT/INR, circulating fibrin, monomer complexes, fibrinopeptide A, serum fibrin, D-dimer,
proteins C and S, antithrombin III levels, factor V Leiden, prothrombin gene mutation. Detect
intravascular coagulation or coagulopathies.
Complications
•
Pulmonary embolism
o A pulmonary embolism occurs when a blood vessel in your lung becomes blocked by a
blood clot (thrombus) that travels to your lungs from another part of your body, usually
your leg
o A pulmonary embolism can be fatal.
o Signs and symptoms of a pulmonary embolism include:
▪ Unexplained sudden onset of shortness of breath
▪ Chest pain or discomfort that worsens when you take a deep breath or when you cough
▪ Feeling lightheaded or dizzy, or fainting
▪ Rapid pulse
▪ Coughing up blood
•
Postphlebitic syndrome
o A common complication that can occur after deep vein thrombosis is a condition known
as postphlebitic syndrome, also called postthrombotic syndrome.
o This syndrome is used to describe a collection of signs and symptoms, including:
▪ Swelling of your legs (edema)
▪ Leg pain
▪ Skin discoloration
▪ Skin sores
o This syndrome is caused by damage to your veins from the blood clot. This damage
reduces blood flow in the affected areas. The symptoms of postphlebitic syndrome may
not occur until a few years after the DVT
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Treatment
•
Blood thinners
o Medications used to treat deep vein thrombosis include the use of anticoagulants, also
sometimes called blood thinners, whenever possible. These are drugs that decrease your
blood's ability to clot.
• Clotbusters
o doctor may prescribe different medications. more serious type of deep vein thrombosis or
pulmonary embolism, or if other medications aren't working,
Ex: thrombolytics called plasminogen activators given through IV
• Filters
o those who can't take medicines to thin your blood, a filter may be inserted into a large vein
- the vena cava - in abdomen.
o A vena cava filter prevents clots that break loose from lodging in your lungs
• Compression stockings
o These helps prevent swelling associated with deep vein thrombosis. These stockings are
worn on your legs from your feet to about the level of your knees.
o This pressure helps reduce the chances that your blood will pool and clot
3. History
patient doesn’t have any other disease condition but patient having admitted to the ward several times.
•
•
•
•
On 2016 with the complain of severe pain and swelling in the right lower limb diagnosed as DVT
as first time.
On 2018 for the thrombectomy surgery to the nagoda hospital.
On 2019 with the complain of septic shock with right lower limb cellulitis
On 15th February 2022 complain of right lower limb cellulitis with wound over gator area
Patient has done surgical treatment thrombectomy on 2018 and following regular hematology clinic follow
up for using warfarin for treatment for DVT
4. Current Treatment
7th days of admission (27.08.2022)
Route
Oral
Oral
Oral
Oral
Drug
Paracetamol
Pantaprazole
Vitamin C
Warfarin
Local application
Local application
Solution
IV
Betamethasone cream
Aquarin
Fibogel (laxative)
Pipracillin & Tazobactum
Dosage
1g
40 mg
100 mg
7 mg (D1)
7 mg (D2)
8 mg (D3)
0.1%
1 sachet
4.5 g
Time
6 hourly
bd
bd
6 pm
6 pm
6 pm
bd
bd
bd
6 hourly
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5. Nursing Process
Assessment
Subjective data
Today is the 7th day of admission, patient complaining of having pain in the right lower limb pain.
patient doesn’t have any other disease condition. He is a long term DVT patient on warfarin treatment
and following regular hematology clinic.
He is having only one son he is living in Australia with his wife and children. Now he is living with
his wife and she is having diabetic mallites with that he also controlled with diabetic diet.
He is educated worked as a lawyer now retired. patient know very well about his disease condition and
diet pattern.
Objective data
Physical assessment
During the general examination, swelling observed in the right limb. patient having blisters wound in
both lower limb; left limb is not infected, and right is limb is infected with cellulitis. redness observed
in the right lower limb no any discharges from the wound. extra cellular fluid discharge observed from
the right lower limb blister wound. No any pressure ulcers observed.
Patient having tenderness
BP: 115/70 mmHg
PR: 81 beats/min
RR: 24 res/min
Temperature: 36.5 ºC
Laboratory investigations
FBC – Full blood count
Para meter
WBC
Neutrophils
RBC
HGB
PLT
Result
17.86
14.71
5.18
15.9
151
CRP – C-reactive protein
Unit
103/μl
103/μl
106/μl
g/dl
103/μl
244 mg/L
Ref.range
4.00 – 11.00
2.00 – 7.00
3.5 – 5.5
11.0 – 16.0
150 - 450
normal - <6.0
Renal profile
Para meter
Urea
Serum creatinine
Sodium
Potassium
Chloride
Result
34
81
137
4.6
103
Unit
Mg/dl
μmol/L
mmol/L
mmol/L
mmol/L
Ref.range
17 - 45
65 - 104
136 – 145
3.5 – 5.3
97 - 111
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Liver profile
Para meter
AST
ALT
Alkaline phosphate
Total bilirubin
Total protein
Albumin
Globulin
Albumin/Globulin ratio
Result
118
41.22
57
2.9
6.3
3.2
3.1
1.03
Unit
U/L
U/L
U/L
Mg/dL
g/dL
g/dL
g/dL
Ref.range
0-37
10-40
30-120
0.20-1.10
6.0-8.0
3.7-5.0
2.0-4.0
Clotting profile
Para meter
Result
Unit
Ref.range
Prothrombin time
Control result
INR
APTT
Thrombin time
ISI
17.8
13.4
1.35
27.6
15.3
1.06
Secs
Secs
12-15
Secs
Secs
22-36
15-21
CBS – 136 mg/dL
Nursing Diagnosis
❖ Acute pain related to decreased venous blood flow & inflammation of subcutaneous as evidenced
by investigations & diagnosis
❖ Risk for bleeding related to anticoagulant therapy
❖ Impaired physical mobility related to pain as evidenced by patient complain
❖ Risk for venous thromboembolism related to history of long-term use of warfarin
❖ Risk for impaired skin integrity related to infectious process
❖ Risk for pressure ulcer related to long term best rest
Planning
❖ Acute pain related to decreased venous blood flow & inflammation of subcutaneous as
evidenced by investigations & diagnosis
Goal: To relieving pain
o Elevate leg to promote venous drainage and reduce swelling
o instruct the by stand to apply warm compress
o administer analgesics according to medical order
❖ Risk for bleeding related to anticoagulant therapy
Goal: To preventing Bleeding
o observe the patient for bleeding manifestation in the wound site, gums and for blood
with urine, blood with stool, blood with sputum
o Handle the patient carefully while doing any daily activity
o apply pressure on IV and venipuncture sites for at least 5 minutes
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❖ Impaired physical mobility related to pain as evidenced by patient complain
Goal: Assist to mobility and prevent other hazards of immobility
o provide wheelchair for mobility
o arrange the things that patient can easily reach
o keep the patient proper position to prevent venous stasis
o avoid hyperflexion at knees as in jackknife position (head & knees are up; pelvis & legs
are down)
o encourage the patient to walk according to medical order
o asses the patient for signs of pulmonary embolism such as chest pain, dyspnea, anxiety
❖ Risk for venous thromboembolism related to history of long-term use of warfarin
Goal: To preventing from venous thromboembolism
o assess for signs of venous embolism
o assess for signs of pulmonary embolism
o instruct the patient to regular clinic follow up
o proper use of medication
❖ Risk for impaired skin integrity related to infectious process
Goal: To protect skin integrity
o apply moisturizing cream to prevent from skin drying
o use antimicrobial cream to prevent from further infection to the left leg through the
blister wound
❖ Risk for pressure ulcer related to long term best rest
Goal: To prevent from pressure ulcer
o asses the pressure point for sings of redness and skin changes
o change the patient position every 2 hours
o keep pillows at the pressure points to prevent pressure ulcers
o giving back care and massage
Implementation
❖ To relieving pain
o Elevated the leg and administered analgesic according to medical order
o giving instruction about the warm therapy and how it’ll reduce the pain
❖ To preventing Bleeding
o Handled the patient carefully during the routine procedure and observed the patient for
bleeding
❖ Assist to mobility and prevent other hazards of immobility
o assist the patient with the help of by stand and teach the patient about the complication
related to the long-term bed rest
❖ To preventing from venous thromboembolism
o Assessed the patient for sings and symptoms of thromboembolism
o given antiplatelet medication according to medical order
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❖ To protect skin integrity
o Applied aqueous cream and betamethasone cream after the dressing procedure
❖ To prevent from pressure ulcer
o changed the patient position with the help of by stand and assessed the pressure points
o gave evening care with the support of by stand
Evaluation
❖
❖
❖
❖
❖
❖
Leg pain reduced
No any active bleeding occurs
Patient said thanks and patient understood well
No any thromboembolic signs occur
No any impaired skin integrity occurs
Patient kept under different positions every 2 hours
6. Recommendation for improvement
Recommendation
1) Daily usage of thrombolytic drugs without skip any of one day
2) Participate hematologic clinics regularly
3) Elevation of effected extremity: at least 10 to 20 degrees above the level of the heart to enhance
venous return and decrease swelling
4) Use of compression stockings to increase venous return
5) Early ambulation
6) Active and passive leg exercises to increase venous flow.
7) Encourage walking without longer period standing
8) Discourage crossing of legs and long periods of sitting (more than an hour at a time) such as car
and flight traveling
9) Avoid Potassium (K) contain foods such as green leafy vegetables, soybean oil and canola oil
10) Drink plenty of water
11) Avoid extra salt in food
12) limit animal fats in food
13) smoking cessation
14) avoid alcohol
Discharge Plan
•
•
•
•
•
•
•
•
There after don’t skip any medication of daily dose.
If you think you will forget, maintain a note for that separately
Use reminders in your smart phone to remember to take medications
Keep the follow up regularly
Wear stockings regularly
Maintain your hygiene of your legs to prevent from further development of cellulitis condition as
well as septic shock
Keep your legs safely prevent from blister injuries and wounds
Involve in regular exercise
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Conclusion
formation of a blood clot in a deep vein, most commonly in the legs or pelvis. Three factors cause
DVT they are stasis of blood (venous stasis), vessel wall injury and altered blood coagulation. Clinical
Manifestations are severe pain, fever, chills, malaise, swelling / unilateral limb edema, cyanosis of
affected arm or leg and tenderness. Investigations for the diagnosis of the disease are Venous duplex,
Impedance plethysmography, Radioactive fibrinogen testing, Venography and Coagulation profiles.
Major complications are Pulmonary embolism and Postphlebitic syndrome. The treatment methods
are Blood thinner medications, Clotbusters, Filter fixation into vena cava and wear Compression
stockings.
7. References
NETTINA, S. M., 2015. LIPPINCOTT MANUAL OF NURSING PRACTICE. Tenth Edition ed. New York: Wolters
Kluwer Health | Lippincott Williams & Wilkins.
Suzanne C. Smeltzer, E. R. F., Janice L. Hinkle, P. R. C., Brenda G. Bare, R. M. & Kerry H. Cheever, P. R., 2010.
Brunner & Suddarth’s textbook of medical-surgical nursing. Twelfth Edition ed. Philadelphia, New York: Wolters
Kluwer Health / Lippincott Williams & Wilkins.
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