Case of DVT

Mr. Digong is a 58-year-old man who is currently a client on an outpatient rehabilitation unit following a
left total knee replacement (TKR) five days ago. This afternoon during physical therapy he complained
that his left leg was unusually painful when walking. His left leg was noted to have increased swelling
from the prior day. He was sent to the emergency department to be examined.

Mr. Digong’s vital signs are temperature 36.7°C, blood pressure 110/50, pulse 65, and respiratory rate of
19. His oxygen saturation is 98% on room air. The result of a serum D-dimer is 7 μg/mL. Physical exam
reveals that his left calf circumference measurement is of an inch larger than his right leg calf
circumference. Mr. Digong’s left calf is warmer to the touch than his right. He will have a noninvasive
compression/doppler flow study (doppler ultrasound) to rule out a DVT in his left leg.

1. The health care provider in the emergency department chooses not to assess Mr. Digong for a
positive Homan’s sign. What is a Homan’s sign and why did the health care provider defer this
assessment?
 Homan's sign-knee extended, foot is dorsiflexed, if there is pain in calf then the result is positive
 This test was not used because it does not indicate a DVT nor does it rule one out, this test is not
commonly used, other tests such as the d-dimer and an ultrasound are used because their results
are much more conclusive than that of a Homan's sign.
2. Discuss the diagnostic cues gathered during Mr. Digong’s examination in the emergency department
that indicate a possible DVT.
 D-dimer Reference values:
 < or =250 ng/mL D-Dimer Units (DDU)
 < or =0.5 mcg/mL Fibrinogen Equivalent Units (FEU)
 D-dimer of 7 mg/mL
 Left calf circumference 3/4" > than Right
 Calf is warm
 BP 110/50=Low
 Pain
 Increased swelling
3. Discuss Virchow’s triad and the physiological development of a DVT.
3 factors that contribute to thrombosis
 Hypercoagulable State - malignancy, pregnancy and peri-partum period, oestrogen therapy,
trauma or surgery of lower extremity, hip, abdomen, or pelvis; IBD, nephrotic syndrome, sepsis,
thrombophilia
 Vascular Wall Injury (endothelial injury/dysfunction) - trauma or surgery, venepuncture,
chemical irritation, heart valve disease or replacement, atherosclerosis, indwelling catheters
 Circulatory Stasis (hemodynamic changes - stasis, turbulence) - A-fib, left ventricular
dysfunction, immobility or paralysis, venous insufficiency or varicose veins, venous obstruction
from tumor, obesity or pregnancy
The nurse who cared for Mr. Digong immediately following his knee surgery, when writing the
postoperative plan of care, included appropriate interventions to help prevent venous thromboembolism..
4. Discuss five nonpharmacological interventions the nurse included in the plan.
 Coughing and deep breathing-help venous return
 Mobilization-activate calf muscle pump
 Anti-embolism stockings-continuous stimulation of linear blood flow
 pneumatic compression devices
 ROM-another example of mobilization, preventing blood stasis
 Spirometry-another type of breathing exercise
5. Discuss the common pharmacologic therapy options for postsurgical clients to help reduce the
risk of a DVT.
  Warfarin (coumadin)
 Heparin (low molecular weight heparin)
 Enoxaparin sodium (lovenox)
 Aspirin
 Antithrombin
 Thrombin
 IVC filters
6. Mr. Digong’s noninvasive compression/Doppler flow study (doppler ultrasound) shows a small
thrombus located below the popliteal vein of his left leg. While a positive DVT is always of concern, why
is the health care provider relieved that the thrombus is located there and not in the popliteal vein?
 The popliteal vein is the main deep vein that returns blood from the foot and calf to the heart and
lungs, if this vein is occluded it will prevent blood flow from that extremity to the heart and
lungs. Whereas an occluded vein below the popliteal vein will not prevent all blood returning
from that extremity, it will only prevent some blood being returned to the heart and lungs.
7. Mr. Digong was admitted to the hospital for observation overnight. He is being discharged
back to the rehabilitation unit with the following prescribed discharge instructions:
Provide a rationale for each of the prescribed discharge instructions.
(a) bed rest with bathroom privileges (BRP) with elevation of left leg for 72 hours;
 -Bed rest with BRP with elevation of leg for 72 hours prevents dislodgement of the clot, and helps
return blood back to the heart
(b) thromboembolic devices (TEDs);
 helps blood flow return to the heart
(c) continue with enoxaparin 75 mg subcutaneously (SQ) every 12 hours;
 Enoxaparin 75 mg SQ q12hrs prevent clots from forming
(d) warfarin sodium 5 mg by mouth (PO) per day starting tomorrow;
 Warfarin sodium 5 mg PO q 24 hrs prevents clots from forming and will take place of the SQ
(e) nicotine transdermal system 21 mg per day for 6 weeks, then 14 mg per day for 2 weeks,
and then 7 mg per day for 2 weeks;
 Nicotine transdermal system 21 mg/day for 6 weeks, then 14 mg/day for 2 weeks, and then 7 mg/day
for 2 weeks smoking cessation, prevent future clots, and promotes blood flow through vasodilation
(f) acetylsalicylic acid 325 mg PO once daily;
 (ASA) Acetylsalicylic acid 325 mg PO once daily blood thinner to prevent clots, long term blood
thinner
(g) prothrombin time (PT) and international normalized ratio (INR) daily;
 PT and INR daily clotting factors to monitor and record levels to ensure anticoagulant therapy is
working INR in absence of anticoagulation therapy is 0.8-1.2. The target range for INR in
anticoagulant use (e.g. warfarin) is 2 to 3. In some cases, if more intense anticoagulation is thought to
be required, the target range may be as high as 2.5-3.5 depending on the indication for anticoagulation
(h) occult blood (OB) test of stools;
 OB test for stool Check for bleeds that can occur from being on blood thinners
(i) have vitamin K available; and
 Vit K available antidote for anticoagulant therapy
(j) vital signs every four hours.
 routine, but also ensure patient is responding to treatment or if any issues are occurring BP, HR, and
RR can help detect possible clot dislodgment to the lungs (PE) and a temperature can indicate an
infection from the dislodgement
8. Prioritize five nursing diagnoses to include in Mr. Digong’s plan of care when he returns to the
rehabilitation unit.
Ineffective tissue perfusion
Acute pain (in affected extremity)
Risk for impaired tissue integrity
Activity intolerance
At risk for PE and bleeding
9. Because of the DVT, Mr. Digong is at risk for postphlebitic syndrome (also called post-thrombotic
syndrome or PTS). Discuss the incidence, cause, symptoms, and prevention of this potential long-term
complication.

Incidence:
23-60% of patients in the two years following DVT of the leg. Of those, 10% may go on to develop
severe PTS, involving venous ulcers

Cause:
unclear, inflammation may play a role, as well as damage to the vessel from the thrombus, valve
incompetence, persistent venous obstruction, inc pressure in veins and capillaries, venous HTN induces
ruptures of the veins,subq hemorrhage, and inc tissue permeability which manifests pain, swelling,
discoloration and even ulcers

Signs and Symptoms:

pain (aching or cramping)
heaviness
itching or tingling
swelling (edema)
varicose veins
brownish or reddish skin discoloration
ulcer

Prevention:
prevention of recurrent DVT, ambulation, stockings, anticoagulant therapy, weight loss