EVIDENCE-BASED PRACTICE PROTOCOL



EVIDENCE-BASED PRACTICE PROTOCOL

Prevention and Management of Deep Vein Thrombosis (DVT)

|Definitions |A DVT is the formation of a blood clot that does not break down in a deep vein of the body. Because the clot does not break down, it |

| |can become large and obstruct the normal flow of blood in the vein. |

|Considerations |Deep veins of the lower extremities are the most common sites for a DVT. |

| |If the clot breaks into smaller pieces, it becomes an embolus which can travel to vital organs and cause life-threatening conditions |

| |such as a heart attack, stroke, or pulmonary embolism. |

|Risk Factors related to |Diseases: |

|Virchow’s Triad |Peripheral vascular disease, Incompetent peripheral vascular valves or under high pressure, tumors/cancer (causing stasis) |

| |Thrombophilias, thrombocytosis, primary proliferative polycythemia, myocardial infarction, lupus, inflammatory bowel disease, nephritic|

|[pic] |syndrome (causing coagulation changes) |

| |HTN, unmanaged/poorly managed diabetes (causing vessel wall damage) |

| |Procedures: |

| |Surgical procedures, indwelling vascular catheters (causing both coagulation changes and vessel wall damage) |

| |Lifestyles: |

| |Cigarette smoking (causing coagulation changes and vessel wall damage), obesity (causing coagulation changes) |

| |Clinical Scenarios/Situations: |

| |Trauma and burns (causing coagulation changes and vessel wall damage) |

| |Sepsis (causing vessel wall damage) |

| |Estrogen therapy, hormonal contraceptives, pregnancy, w/in 6 weeks post-partum (causing coagulation changes) |

| |Immobility or reduced mobility (causing stasis) |

| |Aging (causing stasis and coagulation changes) |

|Risk Assessment /Prevention|Patients at highest risk for DVT are those who 1) uhave undergone major surgery including that of the hip and knee, 2) suffered trauma |

|Interventions |3) are older, and 4) have had a DVT in the past; risk assessment tools such as the Wells score/criteria are often used |

| | |

| |Prevention Interventions |

| |Mobility-foot pumps, compression stockings |

| |Exercise, early ambulation following surgery |

| |Close management of CHF, HTN and/or Diabetes |

| |Smoking cessation, weight management, prevention of dehydration |

| |Pharmacologic interventions (see below) |

|Management Interventions |Recognize and report signs/symptoms of a DVT including: |

| |unilateral edema pain in extremity |

| |erythema calf tenderness |

| |pale leg & cool with diminished arterial pulse |

| |+ Homan’s sign (discomfort in the calf muscles on forced foot dorsiflexion w/ knee straight; NOTE: Homan’s sign is neither sensitive |

| |nor specific; Present in 50% of patients without DVT) (Schreiber, 2009) |

| |(Use SBAR-CUS when reporting s/s to healthcare provider) |

| | |

| | |

| | |

| |Recognize and report (call 911) for signs/symptoms of a pulmonary emboli (PE) including: |

| |Unexplained sudden onset of shortness of breath |

| |Chest pain or discomfort that worsens with deep breath or cough |

| |Lightheadedness or dizziness Hemoptysis Anxiety |

| | |

| |Interventions may include; |

| |Use of elastic compression stockings or foot pumps when immobolized in bed or chair |

| |Anticoagulant therapy and monitoring |

| |Monitoring Vitamin K intake (green leafy vegetables, soybean oil, and canola oil) |

| |Increasing fluids and avoiding alcohol |

|Pharmacological |Goals: 1) prevent clot formation, 2) stop clot from getting bigger, 2) prevent clot from breaking loose and resulting in an embolus, |

|Considerations |and 4) prevent DVT from reoccurring. |

| | |

| |Pharmacologic treatment options include: |

| |Anticoagulants (blood thinners) - heparin, enoxaparin (Lovenox), and warfarin (Coumadin) |

| |Antiplatelets - aspirin, clopidogrel (Plavix), ticlopidine (Ticlid), prasugrel (Effient), cilostazol (Pletal), abciximab (ReoPro), |

| |eptifibatide (Integrilin), tirofiban (Aggrastat), or dipyridimole (persantine) |

| |Vitamin K antagonists - coumarin |

| |Clot busters (in emergency setting only) - tissue plasminogen activator (tPA) |

| | |

| |Herbal products may include ingredients that contain coumarin, inhibit platelet activity, or inhibit platelet aggregation – check with |

| |physician before use of these agents alone or in combination with anticoagulants, antiplatelets, or vitamin K antagonists |

|Patient/Family |Basic disease instruction including S/S of DVT extension & pulmonary embolism; complications |

|Education |Lifestyle modification related to smoking and weight management |

| |Indications & actions of medications/herbals; dose & schedule; target INR & lab work; missed dose strategy) |

| |Medication interactions (that increase or decrease INR); diet (foods to avoid, limit, & eat) |

| |Self-care (i.e., leg elevation, avoid crossing legs & standing for long periods); anticoagulant safety issues (avoid sharp objects & |

| |injury; monitor common bleeding sites – gums, nose, GI, GU, skin; actions to take if bleeding) |

| |Dental considerations (soft bristle toothbrush; notifying dentist) |

| |Cultural considerations of animal derived products (heparin) and alternative synthetic options for whom animal derived products are |

| |objectionable |

|Documentation |NDPs should address NEED FOR: |

| |Assessment of circulatory system (A963) |

| |Skilled teaching related to circulatory system (A964) |

| |Skilled teaching related to prescribed medications (A460) |

| |Coumadin (warfarin) therapy (A946) or other anticoagulant therapy (A948) |

| |Skilled teaching related to injection therapy (A631) |

| |Skilled administration of injection (A632) |

| |Venipuncture (A800) |

| |Narrative |

| |Plan for next visit |

References:

Agency for Healthcare Research and Quality. (January 2003). Diagnosis and Treatment of Deep Venous Thrombosis and

Pulmonary Embolism. Evidence Report/Technology Assessment, 1-6.

Esmon, C. (2009). Basic mechanisms and pathogenesis of venous thrombosis. Blood Reviews, 23(5), 225-229. DOI: 10.1016/j.blre.2009.07.002

Mayo Clinic (2009). Deep vein thrombosis (DVT). Retrieved May 27, 2010, from

vein-thrombosis/DS01005

NICE clinical guideline 92. (2008). Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. Retrieved July 8, 2010, from

Schreiber, D. (2009). Deep venous thrombosis and thrombophlebitis. Retrieved May 27, 2010, from



Selby, R., & Geerts, W. (2009) Prevention of venous thromboembolism: consensus, controversies, and challenges.

Hematology. 286-292. Accessed July 8, 2010, from



Skinner, N., & Moran, R. (2008). Case Management Adherence Guidelines Version 1.0 Deep Vein Thrombosis (DVT). Case Management Society of American: Aston, PA. Retrieved July 12, 1010 from

The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism. (2008). Retrieved July 8, 2010, from

Van Wicklin, S., Ward, K., & Cantrell, S. (2006). Home study program. Implementing a research utilization plan for prevention of deep vein thrombosis. AORN Journal, 83(6), 1351. Retrieved from CINAHL with Full Text database

Summary of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy

CHEST 2004; 126:163S-696S. Retrieved July 12, 2010 from

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