Assessment and Diagnosis

• Venous disorders warrant careful assessment and history taking. High risk patients are those who have undergone a major surgery; those who have history of cardiovascular disease, hypercoagulation, varicose veins, neoplastic disease; or amongst the elderly, pregnant women who takes contraceptive pills and obese individuals.
• Assessment of signs and symptoms would require the following key points:
  • Limb pain
  • Ankle engorgement
  • Edema
  • Functional impairment
  • Differences in leg circumference bilaterally from thigh to ankle
  • Increase in surface temperature of the leg
  • A feeling of heaviness
  • Homan’s sign

Prevention

To prevent deep venous thrombosis and its possible complications, the following should be observed:

• Patients should wear elastic compression stockings.
• Patients should observe special body positioning and perform indicated exercise.
• Patients should use intermittent pneumatic compression.
• In surgical patients, subcutaneous unfractioned or low molecular weight heparin is administered.

Management

Medical Management

• Anti – coagulation Therapy
  • Anti – coagulation therapy is indicated for patients with thrombophlebitis or DVT, recurrent embolus formation and leg edema (from heart failure) in order to prevent and reduce blood clotting. This therapy is also indicated for the elderly population with hip fractures (requires prolonged immobilization)
    • Unfractioned Heparin – administered subcutaneously to prevent foomation of DVT or by IV. Given adjuct with oral anti – coagulant like warfarin. While under this treatment course, International Normalized Ratio or INR, partial thromboplastin time and platelet count is continuously monitored.
    • Thrombolytic Therapy – if heparins prevent DVT formation, thrombolytics on the other hand dissolves clots and thrombus. It has a lesser damage on the venous valves and reduced incidence of chronic venous insufficiency. However, use of thrombolytics could make the patient prone to bleeding, and so, if bleeding becomes uncontrolled, the therapy is immediately stopped.
• Surgical management – there are cases where anti – cougulant and thrombolytic therapy are contraindicated so the goal of treatment will be surgery.
  • Thrombectomy –removal of the thrombosis
  • Placement of a thrombi filter after the thrombectomy to sift emboli and thrombus.

Nursing Management

• Assessing and monitoring anti – coagulant therapy
  • To prevent overdose of heparin, nurses should be able to calculate the dosage of the medications and administer them accurately. Laboratories should be monitored and referred if within outside the normal limits.
  • Monitoring and managing potential complications
    • Bleeding – bleeding is the prime complication of patients undergoing anti- coagulant therapy. Nurses should be keen to monitor and detect signs of bleeding like bruises and nose bleeds. If bleeding occurs, fresh frozen plasma transfusion is initiated and Vitamin K is administered as ordered.
    • Drug interactions
    • Thrombocytopenia – taking in heparin for five days or more could cause decrease in platelet count.  Regular and close monitoring is recommended.
    • Provide rest and comfort
      • Bed rest
      • Analgesics
      • Warm compress to affected area
      • Elastic compression stockings (evenly distributes pressure over the entire calf areas)
      • Elevation of affected extremity