Deep vein thrombosis (DVT) is the progressive growth of a thrombi or a clot in the deep veins of the arms, legs and the pelvis. There are more or less 900,000 cases of DVTs in the USA identified each year and if left untreated, die of pulmonary embolism. DVT and Pulmonary Embolism (PE) are two significant venous thromboembolism (VTE) events that carry a significant universal healthcare problem. It affects the frail, the elderly and patient populations undergoing major surgery. The risk of getting DVT is known to be greater in men than women (Ferri, 2018). In the study conducted by Wang et al, (2016) it stated that the incidence of DVT varies from 93-124 cases per 100,000 in West Europe, 116 cases per 100,000 in the USA between 52-55 cases per 100,000 in Australia and New Zealand. Asians seemed to be luckier than the other patient population as there are lesser incidences of DVT in that part of the world.
Physical assessments include dry scaly skin, swelling of the extremity, redness, tenderness, pain on the site, enlarged veins and increased warmth on the affected site. Providers may observe low-grade fever and increased heart rate. Diagnostic tests include complete blood count; coagulation factors a D-dimer, ultrasound of the affected site and an ascending venogram if not confirmed by ultrasound but suspicions for DVT is high. Treatment for DVT includes low dose fractioned or unfractioned heparin subcutaneously given in lower quadrants of the abdomen. Patient could be sent home after educating them on how to administer it if they have no other health issues that impede them from getting the home treatment. Patients that are high risk could be admitted and could be given subcutaneous low molecular weight heparin (LMWH) like Lovenox that is 1 mg/kg every 12h or be on a heparin drip with an initial bolus of 5000 Units IV max. There should be a baseline PTT for patients on heparin drip or baseline Factor Xa for patients on LMWH. Patients should also start on Coumadin therapy 5 days after the commencement of heparin drip with a loading dose of 5mg-10 mg and adjusted according to PT/INR results. If patients cannot tolerate anticoagulant therapy, vena cava filters are available to prevent the clot from travelling to the lungs causing pulmonary embolism. While the patient is admitted, on heparin and not ambulating, an intermittent compression device should be attached to the lower extremities to help with circulation (Keller, Sabatino, Winland-Brown, Porter & Keller, 2015).
In preventing DVTs, patients should be encouraged to ambulate, passive exercises as abducting and adducting extremities, flexion of toes while seated, leg elevation and wearing of compression socks on long trips whether by plane or car.
For patients with DVTs, they should avoid injury to the affected leg, watch out for signs of bleeding, compliance on taking anticoagulants and going to scheduled blood test as needed. Avoidance of food rich in Vitamin K, avoid drinking alcohol and taking vitamin E, should be careful in taking antibiotics, thyroid hormones and NSAIDS (Keller et al, 2015).
If hospitalized for a week, patient on Coumadin should have a therapeutic level of INR before going home. Patients should see their primary care doctor 1 week after discharge to discuss on things that they are unsure of. Anticoagulant therapy for six months after the first episode and one year after if there is another episode. Patients should have a weekly INR check for Coumadin adjustments as needed.
References:
Ferri, F.F. (2018). Ferri’s clinical advisor. Philadelphia, PA: Elsevier
Keller, K.B, Sabatino, D., Winland-Brown, J.E., Porter, B.O. & Keller, M.B. (2015). Cardiovascular problems. In L.M. Dunphy, J.E. Winland-Brown, B.O.
Porter & D.J. Thomas (Eds.), Primary care: The art and science of advanced practice nursing( 4th ed., pp. 430-503).Philadelphia, PA: F.A. Davis Company
Palta, S., Saroa, R., & Palta, A. (2014). Overview of the coagulation system. Indian Journal of Anaesthesia, 58(5), 515–523. http://doi.org/10.4103/0019-5049.144643
Wang, K.-L., Chu, P.-H., Lee, C.-H., Pai, P.-Y., Lin, P.-Y., Shyu, K.-G., … Yeh, S.-J. (2016). Management of venous thromboembolisms: Part I. The consensus for deep vein thrombosis . Acta Cardiologica Sinica, 32(1), 1–22. http://doi.org/10.6515/ACS20151228A
