Nursing management begins with a thorough assessment of the patient's health history. Key factors include trauma to veins, peripherally inserted central catheters, varicose veins, recent pregnancy or childbirth, surgery, bacteremia, prolonged bed rest, atrial fibrillation, COPD, heart failure, cancer, coagulation disorders, myocardial infarction, spinal cord injury, stroke, prolonged travel, recent bone fractures, and dehydration. Review medication intake, particularly oral contraceptives, hormone therapy, corticosteroids, and excessive vitamin E.
Evaluate for clinical signs such as edema in the extremities, cyanosis of the extremities, neck, back, and face, pain, and increased extremity size compared to the unaffected side. Upon palpation, look for taut, shiny, warm skin, redness, and tenderness. Diagnostic findings may include elevated D-dimer levels and confirming with venous compression on duplex ultrasound, CT, magnetic resonance, or contrast venogram studies.
Next, the nurse formulates the nursing diagnosis and goals based on the assessment and the patient's clinical problems.
Nursing Diagnosis:
Nursing Goals:
Nursing Interventions:
Nursing interventions for patients with venous thromboembolism include the following:
Collaboration and Patient Education:
Evaluation
Finally, the nurse evaluates the patient’s response and modifies the care plan accordingly.
Nursing management of a patient with venous thrombosis involves a thorough history assessment, including varicose veins and coagulation disorders.
Evaluate for clinical manifestations such as edema of extremities and diagnostic findings like elevated D-dimer levels.
Based on the assessment, the nurse formulates the following diagnoses:
Acute pain related to tissue ischemia secondary to vascular inflammation, as evidenced by patient reports, pain rated 8 out of 10.
Ineffective peripheral tissue perfusion related to impaired venous return secondary to immobility as evidenced by edema in the left lower leg
Then, the nurse collaboratively sets goals to relieve pain and decrease edema.
Nursing interventions include administering prescribed analgesics and anticoagulants.
Monitor the anticoagulant effect through appropriate lab results, such as INR and aPTT.
Reposition bed-bound patients every two hours and encourage leg and foot exercises to prevent venous stasis.
Assist ambulatory patients with walking 4-6 times daily.
Apply intermittent pneumatic compression or graduated compression stockings as needed.
Finally, the nurse evaluates the patient’s response and modifies the care plan accordingly.
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