Nursing Diagnosis, Risk, & Care Plan for DVT- Student Guide
A DVT is a blood clot that develops in the deep veins of the leg. It can be fatal if it moves to an artery in the lung and blocks blood flow, or causes a pulmonary embolism. Risk factors for DVT include cancer, surgery, pregnancy (especially during the first trimester), trauma such as fractures or sprains, prolonged immobility such as bed rest after surgery or injury, obesity, and age over 60 years old. This article highlights the nursing diagnosis, risk, and care plan for DVT.
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Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students, for learning purposes only, and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.
Deep Vein Thrombosis (DVT)
DVT is a blood clot that develops in the deep veins of the leg. A DVT can be fatal if it moves to an artery in the lung and blocks blood flow, or causes pulmonary embolism (PE). This issue is common among cancer patients, people who are immobile for an extended period of time such as after surgery or injury (for example a fracture), during pregnancy especially in the first trimester when the uterus is enlarging and compressing blood vessels leaving blood clot, and among elderly.
If left untreated, the blood clot can break off and cause a pulmonary embolism. The resulting blockage of the artery causes tissue death in the part of the lung it affects due to lack of oxygen, which is often fatal if not treated promptly.
Deep Vein Thrombosis Nursing Diagnosis
Nurses usually check for malnutrition in the body due to less intake of food. People with deep vein thrombosis are at risk for malnutrition because of immobility and inactivity. Moreover, these people take less food as a result of nausea or vomiting. In this nursing diagnosis, nurses must ensure that patients are getting enough food and have a balanced diet.
If left unchecked, imbalanced nutrition can lead to death from complications. One complication is heart failure due to loss of weight, which may cause shock or coma in the patient. The chance of heart failure increases as the amount of weight loss continues to increase, and it can lead to a fatal outcome if not treated soon enough.
Imbalanced Nutrition Nursing Care Plan
Nurses should monitor any changes in weight among people with deep vein thrombosis for malnutrition because it may cause shock or coma when left unchecked. If the patient’s weight changes by more than ten percent from baseline, nurses should intervene and offer a balanced diet to encourage the intake of food.
Impaired Wound Healing
People with DVT are at risk for impaired wound healing because their mobility may be affected so that they cannot move around as much as usual or at all. The immobility that is associated with DVT also reduces the chance for blood to circulate and remove dead cells from wounds, which can lead to wound infection or impaired healing of the wound.
Nurses should monitor any signs of bleeding at a deep vein thrombosis site on patients who have not had surgery such as a femoral DVT. If the patient has a wound that is not healing and they have developed an infection, nurses should assess for signs of impaired wound healing as one possible diagnosis to explain why it is not improving.
Impaired Wound Healing Nursing Care Plan
Nurses should encourage patients with deep vein thrombosis who have not had surgery to walk or be on their feet for at least one hour a day, even if they are using crutches or a cane, to help increase the blood flow and prevent impaired wound healing.
Mobility Impairment Risk
In the case of people with deep vein thrombosis, mobility impairment may happen as a result of long-term immobility from bed rest or injuries that prevent patients from moving around. Resting for an extended period will cause blood to pool in the legs and can lead to health risks such as DVT (deep vein thrombosis) or PE (pulmonary embolism).
Mobile impairment complications are diagnosed when the patient is unable to get out of bed and move independently, even with assistance. It can lead to serious complications if left untreated such as a heart attack or chronic kidney disease that results in dialysis treatment.
Mobility Impairment Risk Care Plan
Nurses should encourage people who have deep vein thrombosis to sit up in bed as often as possible throughout the day to prevent immobility and any complications from developing.
Along with this, the nursing care plan for deep vein thrombosis should include other interventions to reduce immobility such as walking and elevation of the legs while in bed. Such activities ensure that patients with deep vein thrombosis are not only able to do something but also that they can get out of bed when needed.
Post-Surgery DVT Nursing Care Plan
People who have undergone surgery for DVT or PE require post-surgical care and should be monitored in the hospital setting for a minimum of 48 hours after their procedure. Nurses should check for signs of DVT, PE, and other complications such as blood clots.
Immediately after surgery nurses need to assess the patient’s post-surgical status by checking their airway for signs of obstruction or injury; assessing skin coloration for pallor or cyanosis (a bluish tint); checking blood flow; measuring vital signs like temperature, pulse rate, and blood pressure; monitoring for signs of DVT or PE in the extremities.
Depression related to fear of developing DVT
This is another nursing diagnosis for people with deep vein thrombosis that can show up as a complication. Fear of developing DVT may lead to depression and anxiety, which in turn could result in feelings such as helplessness or guilt.
The fear of developing DVT can lead to depression and anxiety, which in turn could result in feelings such as helplessness or guilt. When it gets to this point, nurses should intervene and offer emotional support to patients with deep vein thrombosis.
Nursing Care Plan for Depression
If a patient has any depressive thoughts about their diagnosis, they should be encouraged to talk about these feelings with their doctor or nurse, and nurses are responsible for providing emotional support until the patient is ready to continue on without assistance.
Nurses can help by listening attentively and trying not to interrupt patients who need time before speaking again. Nurses could also encourage the use of healthy coping skills such as deep breathing, meditation, or other relaxation techniques.
Ineffective Tissue Perfusion
This is a deep vein thrombosis nursing diagnosis. The condition is diagnosed when a patient’s extremities, such as their feet or hands, appear cool to the touch. If nurses notice that a patient’s feet are cold to the touch, they should not assume that it is normal.
Ineffective Tissue Perfusion Nursing Care Plan
Nurses can help reduce ineffective tissue perfusion by encouraging patients with deep vein thrombosis to keep their extremities warmer than usual and avoid sitting or standing for prolonged periods of time. This is common among the nursing interventions for DVT.
Nurses should also monitor and notify the doctor if a patient’s feet are cold to the touch more than usual, or if they have any signs of redness in their legs like swelling or tenderness. The condition could be an indication that blood is not circulating properly through the body.
Risk Factors of DVT
-pulmonary embolism (PE) or lung clotting. In the lungs, this can result in shortness of breath and chest pain that worsens when breathing deeply or coughing.
Nurses should be aware of how to identify pulmonary embolism so they can provide an early diagnosis and intervene accordingly.
The risk for DVT increases during pregnancy due to the increased pooling of blood in the veins, which leads to a higher likelihood that clots may form. Pregnant women with deep vein thrombosis should be monitored closely as they are at high risk for developing complications.
People who are overweight or obese have an increased risk of developing deep vein thrombosis due to the presence of a larger amount of veins in their body that can be clogged with blood and clotting agents. Nurses should assess the patient’s weight status so they can identify if obesity is a factor in their DVT.
Chronic kidney disease
Chronic kidney disease is diagnosed when the kidneys can no longer effectively remove waste products from the body and regulate electrolytes like potassium. This condition may be accompanied by symptoms such as fatigue, confusion, or weight gain with little to no change in diet or exercise habits. Patients who have chronic kidney disease are at an increased risk of developing deep vein thrombosis because their blood is not circulating through the body as it should.
Limbs in a dependent position for more than four hours
This condition occurs when any limb, typically one that has been lying down and unattended for over four hours, develops swelling or becomes painful. Patients with this condition should be encouraged to stretch and move their limbs so that blood circulation is restored.
Patients who have a reserved or introverted personality are at an increased risk of developing deep vein thrombosis because they may not report any symptoms during the early stages, which gives DVT time to progress. Nurses should monitor patients who are introverted for signs of DVT.
Patients who have anticoagulated blood, or those taking medications like warfarin to thin their blood in order to prevent clotting, are at higher risk for developing deep vein thrombosis because the medication may not be able to stop the clotting process. Nurses should monitor patients who are on anticoagulants for signs of DVT. In some situations, anticoagulant therapy may be needed in the care plans.
Smoking cigarettes is a risk factor because smokers have poor circulation which can lead to many other potential health complications, such as chronic obstructive pulmonary disease and heart disease. Patients with poor circulation, or those who are smokers and have chronic lung disease, could be at an increased risk for developing deep vein thrombosis.
Patients with a previous diagnosis of deep vein thrombosis may also be at higher risk of getting it again because the condition can return repeatedly if not treated properly.
Patients who have undergone surgery are at an increased risk for developing deep vein thrombosis because of the trauma that occurs in their veins. Nurses should monitor these patients closely and encourage them to use crutches or a walking aid if possible, as this can help with blood circulation while they recover from surgery.
Patients who are elderly may be at risk for deep vein thrombosis because of a decrease in circulation and mobility. Nurses should assess the patient’s level of physical activity to see if they have an increased DVT risk due to advanced age.
Cancer patients undergoing chemotherapy or radiation therapy are at an increased risk for developing deep vein thrombosis due to the potential side effects of these treatments. Nurses should assess patients undergoing cancer treatment and monitor them closely for signs of DVT as they may not present with any symptoms until it has already progressed.
This is another risk for DVT. Patients who have recently sustained a traumatic injury may be at an increased risk for developing deep vein thrombosis due to the trauma. Nurses should assess patients who have recently sustained a traumatic injury and monitor them closely, as they are more likely than others to develop DVT if not treated properly.
Patients with the heavy menstrual flow or those taking birth control pills are at an increased risk of developing deep vein thrombosis. Nurses should assess these patients and monitor them closely, as they may not present with any symptoms until it has already progressed.
Patients who have taken antihistamines such as Benadryl to help relieve allergies or congestion might be at an increased risk for developing deep vein thrombosis because of the potential side effects. Nurses should assess these patients and monitor them closely as they may not present with any symptoms until it has already progressed.
The expected patient outcomes after the DVT nursing care plan are:
- The patient will be able to identify their personal risk factors and can develop a plan of action for avoiding them in the future.
- The patient will have fewer DVT symptoms or none at all.
- Increased tissue perfusion and mobility in the patient’s extremities.
- The DVT will be resolved or stopped progressing.
- The patient will not require hospitalization for DVT.
- Increased strength in the affected body part after DVT has been resolved. This will be seen through increased muscle endurance and strength.
- Ease of participation in daily activities. The patient is expected to be able to participate in their normal activities with little or no limitations.
- A sense of comfort and contentment. The DVT signs and symptoms will be resolved or stopped progressing and the patient will feel better.
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Deep vein thrombosis is a serious and dangerous condition for human beings. This condition can be potentially fatal if not treated properly. Nurses need to assess patients for risk factors such as previous DVTs, injury, advanced age, cancer treatment, heavy periods with or without birth control pills, and antihistamines use when the patient has allergies or congestion. As well as assessing their level of physical activity and mobility.
Nurses should also watch for DVT symptoms such as swelling, tenderness in the affected area, red or purple discoloration on the skin in the affected area, and pain when walking around. Once a patient is diagnosed with a deep vein thrombosis then nurses will need to assess how bad it is. If it is an acute DVT, nurses will need to assess the patient’s level of consciousness and any other injuries they may have sustained which could increase their risk for a deadly pulmonary embolism.