Deep vein thrombosis (DVT) is a common and potentially life-threatening condition that requires prompt medical attention. As a nurse, understanding the nursing care plans and nursing diagnosis for DVT is crucial to providing the best care for clients. This guide provides a comprehensive overview of DVT nursing care plans and nursing diagnoses, including common symptoms, nursing interventions, nursing management, and treatment options.
What is Deep Vein Thrombosis?
Thrombophlebitis is the inflammation of the vein wall resulting in the formation of a thrombosis (blood clot) that may interfere with the normal blood flow through the vessel.
Typically, venous thrombophlebitis occurs in the lower extremities. It may also occur in superficial veins such as cephalic, basilic, and greater saphenous veins, which usually is not life-threatening and does not necessitate hospitalization, or it may happen in a deep vein, which can be life-threatening because clots may travel to the bloodstream and cause a pulmonary embolism.
Three contributing factors (known as Virchow’s triad) can lead to the development of deep vein thrombosis (DVT), which includes venous stasis, hypercoagulability, and vessel wall injury.
Venous stasis occurs when blood flow is decreased, as in immobility, medication therapies, and in heart failure. Hypercoagulability occurs most commonly in clients with deficient fluid volume, pregnancy, oral contraceptive use, smoking, and some blood dyscrasias. Venous wall damage may occur secondary to venipuncture, certain medications, trauma, and surgery. The objective of treatment of DVT involves preventing the clot from dislodgement (risking pulmonary embolism) and reducing the risk of post-thrombotic syndrome.
DVT is a common venous thromboembolic (VTE) disorder with an incidence of 1.6 per 1000 annually. Even in clients who do not get pulmonary emboli, recurrent thrombosis and “post-thrombotic syndrome” are major causes of morbidity. DVT is a major medical problem accounting for most cases of pulmonary embolism. Only through early diagnosis and treatment can the morbidity be reduced (Schick, 2023).
Nursing Care Plans
The nursing care plan for the client with deep vein thrombosis includes: providing information regarding the disease condition, treatment, and prevention; assessing and monitoring anticoagulant therapy; providing comfort measures; positioning the body and encouraging exercise; maintaining adequate tissue perfusion; and preventing complications.
Here are five (5) nursing care plans (NCP) and nursing diagnoses for patients with deep vein thrombosis (DVT):
- Impaired Gas Exchange
- Ineffective Peripheral Tissue Perfusion
- Acute Pain
- Deficient Knowledge
- Risk For Bleeding
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.
- 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
- 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).
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.
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023
The definitive guide to nursing diagnoses is reviewed and approved by NANDA International. In this new version of a pioneering text, all introductory chapters have been rewritten to provide nurses with the essential information they need to comprehend assessment, its relationship to diagnosis and clinical reasoning, and the purpose and application of taxonomic organization at the bedside. A total of 46 new nursing diagnoses and 67 amended nursing diagnostics are presented.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions from NANDA-I 2021-2023 and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other care plans for hematologic and lymphatic system disorders:
- Anaphylactic Shock | 4 Care Plans
- Anemia | 6 Care Plans UPDATED!
- Aortic Aneurysm | 4 Care Plans
- Deep Vein Thrombosis | 5 Care Plans UPDATED
- Disseminated Intravascular Coagulation | 4 Care Plans
- Hemophilia | 5 Care Plans
- Leukemia | 5 Care Plans
- Lymphoma | 3 Care Plans
- Sepsis and Septicemia | 6 Care Plans
- Sickle Cell Anemia Crisis | 6 Care Plans
References and Sources
Recommended journals, books, and other interesting materials to help you learn more about deep vein thrombosis nursing care plans and nursing diagnosis:
- Aslam, S., Mirza, R., & Shaukat, H. (2017). Obesity and Smoking are Risk Factors for Deep Vein Thrombosis in general population – a comparative clinical study. Pakistan Journal of Medical & Health Sciences, 11(4).
- Behera, C., Devassy, S., & Gupta, S. K. (2017). Leg massage by mother resulting in fatal pulmonary thromboembolism. Medico-Legal Journal, 86(3).
- Bhutta, B. S., Alghoula, F., & Berim, I. (2022). Hypoxia – StatPearls. NCBI. Retrieved March 27, 2023.
- Douketis, J. D. (2023). Perioperative management of patients receiving anticoagulants. UpToDate.
- Doyle, G. R., & McCutcheon, J. A. (2015). Clinical Procedures for Safer Patient Care. BC Open Textbook Project.
- El-Tallawy, S. N., Nalamasu, R., Salem, G. I., LeQuang, J. A. K., Pergolizzi, J. V., & Christo, P. J. (2021). Management of Musculoskeletal Pain: An Update with Emphasis on Chronic Musculoskeletal Pain. Pain and Therapy, 10.
- Endig, H., Michalski, F., & Beyer-Westendorf, J. (2016). Deep Vein Thrombosis – Current Management Strategies. Clinical Medicine Insights: Therapeutics.
- Gebhard, C. E., Zellweger, N., Gebhard, C., Hollinger, A., Chrobok, L., Stahli, D., Schönenberger, C. M., Todorov, A., Aschwanden, M., & Siegemund, M. (2021, December 25). Prone Positioning as a Potential Risk Factor for Deep Vein Thrombosis in COVID-19 Patients: A Hypothesis Generating Observation. NCBI. Retrieved March 27, 2023.
- Gonthier, M.-C., Gendron, N., Eloy, P., Bourrienne, M.-C., Alhenc-Gelas, M., Pouplard, C., Tardy, B., Szymezak, J., Burdet, C., Gkalea, V., Faille, D., & Ajzenberg, N. (2021, September 24). Heparin-induced Thrombocytopenia Diagnosis: A Retrospective Study Comparing Heparin-induced Platelet Activation Test to 14 C-serotonin Release Assay. NCBI. Retrieved March 29, 2023.
- Gupta, N., Zhao, Y.-Y., & Evans, C. E. (2019, September). The stimulation of thrombosis by hypoxia. Thrombosis Research, 181.
- Hoffer, E. K., & Cho, K. J. (2022, August 15). Imaging in Deep Venous Thrombosis of the Lower Extremity: Practice Essentials, Computed Tomography, Magnetic Resonance Imaging. Medscape Reference. Retrieved March 27, 2023.
- Hotoleanu, C. (2020, April). Association between obesity and venous thromboembolism. Medicine Pharmacy Reports, 93(2).
- Keenan, L., Kerr, T., Duane, M., & Van Gundy, K. (2019, January). Systematic Review of Hormonal Contraception and Risk of Venous Thrombosis. The Linacre Quarterly, 85(4).
- Keiter, J. E., Johns, D., & Rockwell, W. B. (2015). Importance of Postoperative Hydration and Lower Extremity Elevation in Preventing Deep Venous Thrombosis in Full Abdominoplasty: A Report on 450 Consecutive Cases Over a 37-Year Period. Aesthetic Surgery Journal, 35(7).
- Klaiber, U., Stephan-Paulsen, L. M., Bruckner, T., Müller, G., Auer, S., Farrenkopf, I., Fink, C., Dörr-Harim, C., Diener, M. K., Büchler, M. W., & Knebel, P. (2018). Impact of preoperative patient education on the prevention of postoperative complications after major visceral surgery: the cluster randomized controlled PEDUCAT trial. Trials, 19(288).
- Lee, C. W.-S., Muo, C.-H., Liang, J.-A., Sung, F.-C., Kao, C.-H., & Yeh, J.-J. (2014, March). Pulmonary embolism is associated with current morphine treatment in patients with deep vein thrombosis. The Clinical Respiratory Journal, 9(2).
- Nicolas, D., Nicolas, S., Hodgens, A., & Reed, M. (2023, March). Heparin Induced Thrombocytopenia – StatPearls. NCBI. Retrieved March 29, 2023, from
- The North American Thrombosis Forum. (2022, February 17). Patient Pulse: Pain Relievers and Anticoagulation – What’s the Story? North American Thrombosis Forum. Retrieved March 27, 2023.
- Ouellette, D. R., & Mosenifar, Z. (2020, September 18). Pulmonary Embolism (PE) Clinical Presentation: History, Physical Examination, Complications. Medscape Reference. Retrieved March 28, 2023.
- Patel, K. (2019, June 5). Deep Venous Thrombosis (DVT): Practice Essentials, Background, Anatomy. Medscape Reference. Retrieved March 27, 2023.
- Schick, M. (2023, January 19). Deep Vein Thrombosis – StatPearls. NCBI. Retrieved March 27, 2023.
- Schreiber, D., & Brenner, B. E. (2020, October 30). Anticoagulation in Deep Venous Thrombosis: Advantages of Anticoagulant Therapy, Initial Anticoagulation Therapy, Long-Term Anticoagulation. Medscape Reference. Retrieved March 29, 2023.
- Sehgal, I. S., Dhooria, S., Agarwal, R., & Behera, D. (2017, December 30). Use of a Flexible Cryoprobe for Removal of Tracheobronchial Blood Clots. Respiratory Care. Retrieved March 27, 2023.
- Triffin, M., & Ketchum, D. (2020, May 18). Is Sitting With Your Legs Crossed Bad for You? Here’s What to Know | livestrong. Livestrong.com.
- Umerah, C. O., & Momodu, I. I. (2022, July). Anticoagulation – StatPearls. NCBI. Retrieved March 29, 2023.
- Unver, S., Kivanc, G., & Aiptekin, H. M. (2018). Deep breathing exercise education receiving and performing status of patients undergoing abdominal surgery. NCBI. Retrieved March 27, 2023.
- Vyas, V., & Goyal, A. (2022). Acute Pulmonary Embolism – StatPearls. NCBI. Retrieved March 27, 2023.
- Wade, R., Paton, F., & Woolacott, N. (2016). Systematic review of patient preference and adherence to the correct use of graduated compression stockings to prevent deep vein thrombosis in surgical patients. Journal of Advanced Nursing, 73(2).
- Wayne, G. (2023, March 18). Risk for Bleeding – Nursing Diagnosis & Care Plan. Nurseslabs. Retrieved March 28, 2023.
- Xu, L., Fu, C., Zhang, Q., He, C., & Wei, Q. (2021). The effectiveness of exercise training in treating venous thromboembolism: a systematic review. The Physician and Sportsmedicine, 49(1).
- Yu, A., Ding, W., Lin, W., Cai, J., & Huang, W. (2022, January). Application of pulmonary rehabilitation in patients with pulmonary embolism (Review). Experimental and Therapeutic Medicine, 23(1).
- Zhang, Y., Jin, J., Song, B., Wang, Y., & Liang, M. (2021, April 15). Vascular boot warming improves clinical outcomes of patients with deep vein thrombosis in lower extremities. NCBI. Retrieved March 27, 2023.