5 Deep Vein Thrombosis Nursing Care Plans

Impaired Gas Exchange

Clients with deep vein thrombosis (DVT) can experience impaired gas exchange due to altered blood flow to the alveoli and changes in the alveolar-capillary membrane. DVT can obstruct blood flow to the lungs, reducing the amount of blood that reaches the alveoli, where gas exchange takes place. Additionally, changes in the alveolar-capillary membrane, such as inflammation and increased permeability, can further impair gas exchange by reducing the diffusion of oxygen and carbon dioxide between the lungs and the bloodstream.

Nursing Diagnosis

• Impaired Gas Exchange

May be related to

• Altered blood flow to alveoli or to major portions of the lung
• Alveolar-capillary membrane changes–active bleeding, airway or alveolar collapse, atelectasis, excessive secretions, or pulmonary effusion/edema

Possibly evidenced by

• Apprehension
• Cyanosis
• Dyspnea
• Hypercapnia
• Hypoxemia
• Restlessness
• Somnolence

Desired Outcomes

• The client will demonstrate adequate ventilation and oxygenation by ABGs within the client’s normal range.
• The client will report or display resolution or absence of symptoms of respiratory distress.

Nursing Assessment and Rationales

1. Assess the level of consciousness and changes in mentation.
Initial signs of systemic hypoxemia include restlessness and irritability, followed by progressively decreased mentation. Reduced oxygenation is a risk factor for thrombosis since the incidence of thrombosis is increased under systemic or local hypoxia. Hypoxia occurs when oxygen demand is greater than oxygen supply, for example, when blood flow is reduced by immobility or reduced by trauma (Gupta et al., 2019).

2. Auscultate lungs for areas of decreased and absent breath sounds and the presence of adventitious sounds (crackles).
Non-ventilated areas may be identified by the absence of breath sounds. Crackles may be seen in fluid-filled tissues and the airway or may indicate cardiac decompensation. A client with a developing pulmonary embolism (PE) may exhibit dyspnea. Dyspnea may be acute and severe in central PE, whereas it is often mild and transient in small peripheral PE (Vyas & Goyal, 2022).

3. Monitor vital signs. Observe changes in cardiac rhythm.
Tachycardia, tachypnea, and BP changes are associated with progressing hypoxemia and acidosis. Alterations in heart rhythm and extra heart sounds may indicate increased cardiac workload related to worsening ventilation imbalance. PE may become apparent when the client exhibits hypotension (systolic blood pressure less than 90 mm Hg or a drop in SBP of 40 mm Hg or more from baseline) (Vyas & Goyal, 2022).

4. Assess respiratory rate and rhythm. Observe for use of accessory muscles, nasal flaring, and pursed lip breathing.
Tachypnea and dyspnea are indicative of pulmonary obstruction. Dyspnea and increased work of breathing may be the first or only signs of subacute pulmonary embolism. Severe respiratory distress and failure accompany moderate to a severe loss of functional lung units. Shock and right ventricular dysfunction confer a poor prognosis and predict mortality. Clients with PE and a coexisting DVT are also at an increased risk for death (Vyas & Goyal, 2022).

5. Observe for generalized duskiness and cyanosis in the earlobes, lips, tongue, and buccal membranes.
This is suggestive of systemic hypoxemia. Late signs of hypoxia include bluish discoloration of the skin and mucous membranes, where vasoconstriction of the peripheral vessels causes cyanosis. Cyanosis is most easily seen around the lips and in the oral mucosa. However, the nurse should never assume the absence of cyanosis means adequate oxygenation (Doyle & McCutcheon, 2015).

6. Assess activity tolerance, such as reports of weakness and fatigue, vital sign changes, or increased dyspnea during exertion. Encourage rest periods, and limit activities to client tolerance.
These guidelines help in determining the response of the client to resume activities and the ability to engage in self-care. The nurse may use the six-minute walk test to assess the response of oxyhemoglobin saturation to exercise or activities, as well as the total distance the client can walk in six minutes on a ground level (Bhutta et al., 2022).

7. Monitor ABGs or pulse oximetry.
Hypoxemia is present in varying degrees, depending on the degree of airway obstruction, cardiopulmonary status, and presence and degree of shock. Respiratory alkalosis and metabolic acidosis may also be present. Arterial oxygen saturation refers to the amount of oxygen bound to hemoglobin in arterial blood. ABGs are useful tools to evaluate hypoxia because they can also shed light on the etiology of the disease process (Bhutta et al., 2022).

8. Evaluate sleep patterns, noting reports of difficulties and whether the client feels well-rested.
The client may have difficulty sleeping due to the feeling of dyspnea. Nocturnal trend oximetry provides information about oxyhemoglobin saturation over a period (usually overnight). This test is primarily used to assess the adequacy or need for oxygen supplementation at night. The use of overnight trend oximetry as a surrogate for a diagnostic sleep study is possible, however, a formal sleep study should be used whenever possible (Bhutta et al., 2022).

Nursing Interventions and Rationales

1. Check the client frequently and arrange for someone to stay with the client, as indicated.
This assures that changes in condition will be noted and that assistance is readily available. The client may manifest neurological symptoms such as restlessness, headache, and confusion with moderate hypoxia, therefore, the client must be assessed and checked as frequently as possible to avoid further deterioration of the client’s condition (Bhutta et al., 2022).

2. Assist with frequent changes of position, and encourage ambulation as tolerated.
Turning and ambulation enhance the aeration of different lung segments, thereby improving oxygenation. The ACCP Consensus Conference on Antithrombotic and Thrombolytic Therapy for venous thromboembolism recommended ambulation as tolerated for clients with DVT. Therefore, early ambulation on day 2 after initiation of outpatient anticoagulant therapy, in addition to effective compression, is strongly recommended. Early ambulation without ECS is not recommended (Patel, 2019).

3. Encourage coughing, deep breathing exercises, and suctioning as indicated.
Increases oxygen delivery to the lungs by mobilizing secretions and enhancing ventilation. Deep breathing exercises are used to decrease the incidence and severity of pulmonary complications such as pneumonia, atelectasis, and hypoxemia. During exercise education, the nurse explains and demonstrates how to take a deep, slow breath, and how to exhale slowly, three to five times every one to two hours. Clients who performed deep breathing exercises had better pulmonary function compared to the performing no exercise group (Unver et al., 2018).

4. Keep the head of the bed elevated.
This promotes maximal chest expansion, making it easier to breathe and enhancing physiological and psychological comfort. A prone position should be avoided. In COVID-19 acute respiratory distress syndrome (ARDS), a prone position is frequently applied. During prone ventilation, the client’s position remains nearly unchanged, with minimal movements limited to the head and limbs. Therefore, the prone position can be a potential contributor to blood flow changes in these clients (Gebhard et al., 2021).

See also: Patient Positioning: Complete Guide and Cheat Sheet for Nurses

5. Assist with chest physiotherapies, such as postural drainage and percussion of the non-affected area, and with an incentive spirometer.
This facilitates deeper respiratory effort and promotes drainage of secretions from lung segments into bronchi, where they may more readily be removed by coughing or suctioning. Pulmonary rehabilitation can significantly improve dyspnea, overall health, and exercise endurance in clients with PE. The existing evidence suggests that pulmonary rehabilitation is a potential treatment for alleviating post-PE syndrome, which improves the quality of life and prognosis of clients with PE (Yu et al., 2022).

6. Provide supplemental humidification, such as ultrasonic nebulizers.
Nebulization gives moisture to mucous membranes and helps liquefy secretions to facilitate airway clearance. Dry nasal mucosa occurs when the flow is greater than or equal to 4 L/minute, therefore humidification is necessary for clients using low-flow oxygen devices (Bhutta et al., 2022).

7. Provide oxygen therapy with an appropriate method as ordered.
Oxygen therapy can help increase oxygen levels and enhance tissue perfusion, decreasing the risk of hypoxia and other related complications. Oxygen therapy may be indicated for clients with low PaO2 that is less than 60 or SaO2 less than 90, and this can be achieved by increasing the percentage of oxygen in the inspired air that reaches the alveoli (Bhutta et al., 2022).

8. Provide adequate hydration, either oral (PO) or IV, as indicated.
Increased fluids may be given to decrease the hyperviscosity of blood, which can potentiate thrombus formation, or support circulating volume and tissue perfusion. A low fluid volume state can lead to hemoconcentration and low venous flow. Clients who experienced a VTE were found to have elevated biochemical indices of dehydration, in comparison to clients who had not (Keiter et al., 2015).

Pharmacologic interventions

9. Administer medications, as indicated:

• 9.1. Thrombolytic agents, such as alteplase, anistreplase, reteplase, streptokinase, tenecteplase, and urokinase
  These agents are intended to bring about clot lysis (breakdown of the clot) and immediate normalization of venous blood flow. The use of thrombolytic medications to lyse DVT can cause intracranial bleeding, though this is infrequent, and death or impairment can result. The need should be compelling when thrombolysis is considered in a setting of known contraindications (Patel, 2019).

• 9.2. Morphine sulfate and anti-anxiety agents
  These are given to decrease pain or anxiety and improve the work of breathing, maximizing gas exchange. However, caution should be practiced when giving morphine because current morphine use is associated with PE in DVT clients. The risk of PE increased with augmented morphine dosage only in clients treated with morphine within the past 30 days, according to a study (Lee et al., 2014).
  
• 9.3. Anticoagulants
  The mainstay of medical therapy has been anticoagulation since the introduction of heparin in the 1930s. Other anticoagulation drugs have subsequently been added to the treatment armamentarium over the years, such as vitamin K antagonists and low-molecular-weight heparin (LMWH). Long-term coagulation is necessary to prevent the high frequency of recurrent venous thrombosis or thromboembolic events (Patel, 2019).

10. Prepare the client for a lung scan.
This may reveal the pattern of abnormal perfusion in areas of ventilation, reflecting ventilation and perfusion mismatch, confirming the diagnosis of pulmonary embolism and the degree of obstruction. The absence of both ventilation and perfusion reflects alveolar congestion or airway obstruction. The planar ventilation/perfusion scan is an established diagnostic test for suspected PE. V/Q scanning is mostly performed for clients in whom computed tomographic pulmonary angiography (CTPA) is contraindicated or inconclusive, or when additional testing is needed (Vyas & Goyal, 2022).

11. Prepare for and assist with bronchoscopy.
The purpose of this procedure is to remove blood clots and clear the airway. During flexible bronchoscopy, clots can be removed piecemeal by biopsy forceps, dislodged using a Fogarty catheter, or removed en bloc using either suctioning or a cryoprobe (Sehgal et al., 2017).

12. Prepare for surgical intervention, if indicated.
Vena caval ligation or insertion of an intracaval umbrella is intended for clients with recurrent emboli despite adequate anticoagulation, when anticoagulation is contraindicated, or when septic emboli arising from below the renal veins unresponsive to treatment; Pulmonary embolectomy is often done as a last resort treatment of PE. Traditional venous thrombectomy is performed by surgically exposing the common femoral vein and saphenofemoral junction through a longitudinal skin incision. Care must be taken to avoid dislodging the clot or breaking it into small fragments because pulmonary embolus will result (Patel, 2019).

13. Assist the client to deal with fear and anxiety that may be present.
Feelings of fear and severe anxiety are associated with the inability to breathe and may actually increase oxygen consumption and demand. Encourage the client to express their feelings so that the client may regain some sense of control over emotions. Provide the client with brief explanations of what is happening and the expected effects of outcomes. This may allay anxiety related to the unknown and help reduce fears concerning personal safety.