VENOUS
THROMBOSIS
Presented by: Student
Department of Nursing, Florida Atlantic University
NUR3145: Pharmacotherapeutics
Dr. Stacey Ravid
July 17, 2022
DEFINITION OF THE DISEASE:
The term venous thrombosis, or thrombophlebitis, describes
the presence of thrombus in a vein and the accompanying
inflammatory response in the vessel wall (Norris, 2018).
Thrombi can develop in the superficial (SVT) or the deep veins
(DVT) . DVT most commonly occurs in the lower extremities.
DVT of the lower extremity is a serious disorder that can be
complicated by pulmonary embolism, recurrent episodes of
DVT, and development of chronic venous insufficiency.
Venous thrombosis is associated with stasis of blood,
increased blood coagulability, and vessel wall injury
(Norris, 2018).
Deep Vein Thrombosis. (2021). [Illustration]. Avis Hospitals.
https://www.avisvascularcentre.com/how-to-prevent-dvt-from-coming-back/
EPIDEMIOLOGY:
According to Patel (2021):
Deep venous
thrombosis usually
affects individuals older
than 40 years. The
incidence increases
with age in both sexes.
Existing data suggest
that about 80 cases per
100,000 population
occur annually.
Approximately 1 person
in 20 develops a DVT in
the course of his or her
lifetime.
The male-to-female
ratio is 1.2:1, indicating
that males have a
higher risk of DVT than
females.
About 600,000
hospitalizations per year
occur for DVT in the
United States.
Severe pulmonary
embolism (PE) from DVT
causes 300,000 deaths
annually in the United
States.
PATIENT PRESENTATION:
•
Many people with venous thrombosis are
asymptomatic; as much as 50% of people
with DVT are asymptomatic (Norris, 2018).
•
According to Norris (2018), when present the
most common signs and symptoms of
venous thrombosis are those related to the
inflammatory process including:
•
•
•
•
•
•
Pain
Swelling
Deep muscle tenderness
Fever
General malaise
Elevated white blood cell count and
erythrocyte sedimentation rate
[Illustration]. (2022). Zero to Finals.
https://zerotofinals.com/medicine/haematology/dvt/
PATIENT PRESENTATION:
• A 66 years old female arrived at the
emergency room complaining of leg pain
and swelling in her left leg.
• The patient has just returned form a trip in
Europe a week ago.
• The patient smokes one pack of cigarettes
a day and has been a smoker for 30 years.
• The patient is obese with a BMI of 30.
She is 5 ft. 10in. tall and weighs 210 pounds.
VITAL SIGNS:
•
•
•
•
•
•
Temperature 99.6 F (37.6 C)
Heart rate 106
Respirations 20
SpO2 96% on room air
Blood Pressure 148/90
Pain 6 out of 10 in the left lower extremity
Neurological: Patient is alert and oriented x4, cranial nerves intact,
PEERLA, and able to ambulate with normal gait. Patient denies
numbness and weakness.
PHYSICAL
EXAMINATION :
Respiratory: expansion of lungs is symmetrical, trachea is midline,
and the lungs are clear to auscultation.
Cardiac: S1/S2 audible, there is no no murmurs or extra sounds.
GI: Abdomen without tenderness or masses. Active bowel sounds
heard in all abdomen quadrants.
Extremities: full range of motion in all extremities.
Peripheral Vascular: Left leg is erythematous and edematous with a
4-cm difference between the left and right calf diameters. Left calf
is warm and tender to touch.
Health Navigator. (2022). Deep
Vein Thrombosis [Photograph].
Health Navigator.
https://www.healthnavigator.org.
nz/health-a-z/d/deep-veinthrombosis/
Brachial pulses +2 bilaterally
Pedal pulses +2 bilaterally
PAST MEDICAL HISTORY:
Heart failure: Impaired cardiac function with congestive heart failure or
acute myocardial infarction increases risk of thrombosis.
Smokes one pack of cigarettes a day. Smoking appears to increase
coagulability and predispose to venous thrombosis.
Long airplane travel poses a threat to DVT because of prolonged sitting
and increased blood viscosity.
The patient denies surgical history.
TWO MEDICATIONS TO
PRESCRIBE:
1. Warfarin (Coumadin)
10 -15mg/day PO, then 2 -10mg/day PO based
on PT or INR
2. Rivaroxaban (Xarelto)
10mg/day PO starting within 6-10 hours after
surgery, continuing for 35 days after hip
replacement or 12 days after knee
replacement
MEDICATION USE:
Warfarin (Coumadin): Treatment of patient with atrial fibrillation, artificial
heart valves or valvular damage that makes patient susceptible to
thrombus and embolus formation; prevention and treatment of venous
thrombosis, pulmonary embolism, embolus with atrial fibrillation, or systemic
emboli after myocardial infarction (Karch & Tucker, 2020).
Rivaroxaban (Xarelto): prevention of DVTs that may lead to pulmonary
embolism in patients undergoing knee or hip replacement surgery
(Karch & Tucker, 2020).
MECHANISM
OF ACTION:
Warfarin (Coumadin): causes a decrease
in the production of vitamin K–
dependent clotting factors in the liver.
The eventual effect is a depletion of
these clotting factors and a prolongation
of clotting times (Karch & Tucker, 2020).
Rivaroxaban (Xarelto): is factor Xa
inhibitors that stop the coagulation
cascade at this early step (Karch &
Tucker, 2020).
SIDE EFFECTS:

The most encountered adverse effect of anticoagulants is bleeding
ranging from bleeding gums with tooth brushing to severe internal
hemorrhage.

Warfarin has been associated with alopecia and dermatitis, bone
marrow depression, prolonged and painful erections, nausea, GI
upset, diarrhea, and hepatic dysfunction secondary to drug toxicity.
Other symptoms include headache, dizziness, and lethargy (Karch &
Tucker, 2020).
 Rivaroxaban: can result in hematoma, back pain, wound secretions,
abdominal pain, pruritus, anxiety, fatigue, syncope, depression,
muscle spasm, and pain in extremities (Karch & Tucker, 2020).
CONTRAINDICATIONS:
 The anticoagulants are contraindicated in the presence of known allergy to the drugs to
avoid hypersensitivity reactions.
 They should not be used with any conditions that could be compromised by increased
bleeding tendencies such as hemorrhagic disorders, recent trauma, spinal puncture, GI
ulcers, recent surgery, intrauterine device placement, tuberculosis, presence of indwelling
catheters, and threatened abortion.
 The oral anticoagulants are contraindicated in pregnancy because fetal injury and death
have occurred; in lactation because of the potential risk to the baby; and in renal or
hepatic disease, which could interfere with the metabolism and effectiveness of these
drugs.
 Caution should be used in patients with heart failure, thyrotoxicosis, senility, or psychosis
because of the potential for unexpected effects; and in patients with diarrhea or fever
which could alter the normal clotting process by loss of vitamin K from the intestine or
activation of plasminogen.
 Oral anticoagulants come with black box warnings of the risk of hemorrhage with spinal
puncture or anesthesia
INTERACTIONS WITH OTHER MEDICATIONS:

Warfarin has documented drug–drug interactions with a vast number of other drugs . It is a
wise practice never to add or take away a drug from the regimen of a patient receiving
warfarin without careful patient monitoring and adjustment of the warfarin dose to prevent
serious adverse effects.

Rivaroxaban must be used with caution with antifungals, erythromycin, ritonavir, phenytoin, and
rifampin because of alterations in metabolism.

All of these drugs should be used with caution if combined with any other drugs or herbs known to
increase bleeding effects.
LABORATORY TESTS FOR
PATIENTS ON THIS MEDICATION:
• aPPT measures activity of intrinsic pathway of coagulation
•
•
•
•
used to adjust dose of rivaroxaban
INR standardized measure of prothrombin time levels used
to adjust dose of warfarin
PT measures time required for clotting to occur used to
adjust dose of warfarin
Renal and hepatic function tests for drug metabolism and
excretion
Complete blood count to assess bleeding
Karch, A. & Tucker, B. (2020). [Table] Focus on Nursing Pharmacology. 8th Ed.
Philadelphia, PA: Wolters Kluwer.
-Injectable vitamin K is used to reverse the effects of
warfarin.
THE
ANTIDOTE
FOR AN
OVERDOSE:
-Vitamin K promotes the liver synthesis of several
clotting factors. Because of the way in which vitamin
K exerts its effects, there is a delay of at least 24
hours from the time the drug is given until some
change can be seen (Karch & Tucker, 2020).
-This occurs because there is no direct effect on the
warfarin, but rather an increased stimulation of the
liver which produces the clotting factors.
-The US Food and Drug Administration approved
andexanet alfa in May 2018, with the trade name
Andexxa as an antidote for adults taking apixaban
or rivaroxaban when reversal of their anticoagulant
action is needed because of life-threatening or
uncontrolled bleeding (Brooks, 2019).
-Access is limited, pending approval of generation 2
manufacturing process (Brooks, 2019).
NURSING CONSIDERATIONS:
1. Assess for any known allergies to these drugs to avoid potential hypersensitivity reactions. Also screen for conditions
that could be exacerbated by increased bleeding tendencies.
2. Screen for pregnancy and lactation because of the potential for risks to the baby; renal or hepatic disease, which could interfere
with the metabolism, excretion, and effectiveness of these drugs; heart failure; thyrotoxicosis; senility or psychosis because of the
potential for unexpected effects; and diarrhea or fever, which could alter the normal clotting process.
3. Assess baseline status before beginning therapy to determine any potential adverse effects. This includes body temperature, skin
color, lesions, and temperature; affect, orientation, and reflexes; pulse, blood pressure, and perfusion; respirations and adventitious
sounds; clotting studies, CBC, and stool guaiac; and ECG, if appropriate.
4.Evaluate for therapeutic effects of warfarin: PT 1.5 to 2.5 times the control value, or INR of 2 to 3 to evaluate the
effectiveness of the drug dose.
5. Evaluate the patient regularly for any sign of blood loss such as petechiae, bleeding gums, bruises, dark-colored
stools, dark-colored urine
NURSING CONSIDERATIONS
6. Make sure that the patient receives regular follow-up and monitoring for the measurement of
clotting times.
7. Maintain antidotes on standby in case of overdose.
8. Mark the chart of any patient receiving anticoagulants to alert the medical staff that there is a
potential risk for increased bleeding.
9. Provide increased precautions against bleeding by using pressure dressings, avoiding IM injections,
and avoiding rubbing of subcutaneous injection sites because of the risk of blood loss.

There is a black box warning for rebound thromboembolic events
when anticoagulants are suddenly stopped.

CRITICAL
THINKING
COMPONENT:
Educate patients to not abruptly stop the medication unless
authorized by the physician.

Establish safety precautions to protect the patient from injury such as
use of an electric razor, soft toothbrush, fall resistant footwear, and
avoidance of contact sports to decrease the risk of bleeding.

Educate patients to apply firm pressure to any area of bleeding for
five minutes.

Monitor the patient carefully when any drug is added or withdrawn
from the drug regimen for interactions that would change the
effectiveness of the anticoagulant.
REFERENCES:
●
•
Brooks, M. (2019). CHMP Backs Factor Xa Reversal Agent Andexanet (Ondexxya). Medscape.
https://www.medscape.com/viewarticle/909733
Karch, A. & Tucker, B. (2020). Focus on Nursing Pharmacology. 8th Ed. Philadelphia, PA:
Wolters Kluwer.
•
Norris, T. L. (2018). Lippincott CoursePoint for Norris: Porth's Pathophysiology, 10th Edition.
VitalSource Bookshelf.
•
Patel, K. (2021). Deep Venous Thrombosis (DVT): Practice Essentials, Background, Anatomy.
Medscape. https://emedicine.medscape.com/article/1911303-overview
•
Pfadt, E., & Carlson, D. S. (2011). Acute deep vein thrombosis. Nursing, 41(6), 72.
https://doi.org/10.1097/01.nurse.0000397940.14656.52