SPECIFIC NURSING INTERVENTION FOR DEEP VEIN THROMBOSIS:

• DEEP VEIN THROMBOSIS

Various nursing intervention for deep-vein thrombosis are in the following:

Position and rest

1. Keep the affected leg elevated and comfortable position.

2. Keep the head up of bed.

3. Immobilize the patient and initiate bed rest to reduce risk of clot mobilization.

4. Discourage positions that compromise blood flow.

5. The foot of the bed is elevated if there is marked swelling, additional elevation is provided with extra pillows or a foam wedge.

Observation

7. Check and monitor any sign of bleeding.

8. Check any sign of complication (Pulmonary embolism).

9. Be aware of the signs of signs of excessive bleeding, such as frequent and bilateral epitasis, hematuria (blood in the urine) and deep tissue bruising (purpura).

 

10. Check any sign of excessive bleeding complication of warfarin therapy.

11. 

Patient education

12. Discuss with patient the need to change method of contraception, if applicable (as oral contraceptives increase DVT risk).

13. Provide adequate knowledge to patient pertaining to warfarin therapy.

14. Advise the patient to take care when brushing teeth in order to reduce risk of bleeding gums.

15.  reduce alcohol  intake because it increases the anticoagulation effect

16. Instruct patient to carefully brushing teeth to avoid bleeding.

17. 

Medication

18. Administer oxygen as ordered in order to maintain tissue perfusion.

19. Administer anticoagulants as ordered to reduce the risk of additional clotting.

20. Carefully calculate heparin dose.

21. Use infusion pump to administer intravenous heparin.

22. Do not mix the heparinized solution with other medications.

23. Administer analgesics (Morphine) as ordered to manage pain.

24. Ensure a minimum intravenous fluid intake of 2500ml per day for proper hydration unless contraindicated to prevent increase blood viscosity.

25. 

Exercise

Active movement of the ankle and toes is encouraged.

Mobilization is started as soon as swelling has resolved.

Nutrition

1. Ensure intake of vitamin-k rich food including green, leafy vegetable.

Surgical care/post-operative care of the affected leg

q Flow in the deep veins can be accelerated and thrombus prevented by application of graduated compression (anti embolism) stockings.

q Apply warm compress to affected leg using a 2-hour-on, 2-hour-off schedule around the clock.

q Provide elastic compression stocking.

 

2. Assess for and reports sign and symptoms of Deep Vein Thrombosis.

3. Instruct patient to keep nasal mucosa hydrate and moist.