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C O N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N T

Vascular disorders

By reading this article and writing a practice profile, you can gain Deep vein thrombosis: clinical
nursing management 47-54
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Deep vein thrombosis: clinical


nursing management This article has been
supported by an educational
grant from Tyco Healthcare.

NS 73 Wallis M, Autar R (2001) Deep vein thrombosis: clinical nursing management. in brief
Nursing Standard. 15, 18, 47-54. Date of acceptance: November 14 2000.
Authors
collaborative roles of patients with DVT, their Martha Wallis RGN, DipN,
Aims and intended learning outcomes
families and the healthcare professionals who RCNT, RNT, BA(Hons), is
The aim of this article is to enhance your knowl- provide hospital and home outreach services. Senior Lecturer, School of
edge of the clinical nursing management of DVT poses a threat to many hospitalised Nursing and Midwifery,
deep vein thrombosis (DVT). patients (Grace 1993); medical and surgical Chester College of Higher
After reading this article you should be able to: patients can be at risk up to six weeks post- Education. Ricky Autar RGN,
■ Differentiate the three categories of predispos- discharge (Scurr et al 1988). Research showed RMN, DN, BA(Hons), MSc, is
ing factors in the formation of a DVT using that 24 per cent of all patients with DVT died of Principal Lecturer, Faculty of
Virchow’s (1846) triad classification (Fig. 1). a pulmonary embolism (PE) within seven days of Health, De Montfort
■ Identify clinical signs and symptoms of DVT. having an operation (Sandler and Martin 1989). University, Leicester.
■ Discuss DVT diagnostic investigations used Conversely, 45 per cent of DVTs arise on the day
within clinical nursing practice. of operation (Nicolaides and Gordon-Smith Summary
■ Identify those patients who might be at risk of 1975). It is estimated that only one in nine cases The occurrence of a deep
developing a DVT. of DVT is clinically proven (Turner and Turner vein thrombosis is potentially
■ Describe the use of anticoagulant therapy. 1982). DVT can lead to the fatal complication of life threatening and rapid
■ Describe a research-based DVT risk assess- PE, estimated to cause 33,600 deaths a year assessment and treatment
ment tool. (Ishak and Morley 1981) and is thought to be are essential to prevent
■ Prepare a patient-teaching session that can be responsible for 10 per cent of all hospital deaths development of a pulmonary
used for a patient with DVT, prior to discharge (Sandler and Martin 1989). It should be acknowl- embolism. Prophylaxis and
from hospital. edged that DVT is usually preventable within risk assessment are
collaborative DVT care pathways (Cheater 1996), important aspects of DVT
and practitioners can use a recommended proto- management.
Introduction
col within professional nursing practice (ECS
Deep vein thrombosis, the formation of a 1997, NIH 1986). Such DVT prophylaxis proto- Key words
thrombus in one of the deep veins of the body, cols can be examined and used in combination ■ Patient assessment
is the single most preventable thrombo-embolic with DVT risk assessment tools. ■ Vascular disorders
disorder, and is asymptomatic in many cases.
DVT risk assessment tools can provide systematic These key words are based
Predisposing factors to DVT
data on which to base nursing care plans. on subject headings from the
Structured patient teaching and the attainment The formation of a DVT can be due to one or a British Nursing Index. This
of an optimum safe lifestyle are paramount. combination of three predisposing factors, article has been subject to
Responsibilities and promotion of self-care known as Virchow’s triad (Fig. 1). Several condi- double-blind review.
strategies are integral to the respective intra- tions can contribute to the factors identified.

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thus stasis of venous blood in the affected vein.


Fig. 1. Virchow’s triad of factors predisposing to deep vein thrombosis
Localised blood coagulation ensues, with a
Stasis of venous circulation thrombus composed of erythrocytes, thrombo-
cytes and fibrin. The thrombocytes and fibrin
can detach and travel to the lungs, forming a
pulmonary embolism (Clark and Kumar 1994).
A DVT can develop in any deep veins, but will
develop in the lower limbs in an estimated 60
per cent of cases (Fig. 2) (Love 1990a); there is a
higher incidence in the left leg than in the right
(Havig 1977).
Trauma to veins Blood coagulation In the venous circuit of the lower limbs, the
factors most likely site of a DVT is in the deep leg veins
Source: Bergqvist et al (1988)
(60 per cent of cases), with other sites including
the femoral veins (22 per cent) and popliteal
Trauma Localised trauma and direct vascular veins (7.8 per cent) (Love 1990a, Tyco
damage caused by, for example, surgical Healthcare).
procedures, intravenous (IV) injection or
therapeutic interventions might cause serious TIME OUT 1
endothelial damage to veins and vein dilation, Think about DVT patients
which predisposes to DVT formation (Arcelus you have nursed and explain
et al 1991). Patients undergoing total hip the potential predisposing
replacement (THR) might be placed at high risk factors of the DVT episode using
due to twisting of the femoral vein during information from your reading.
surgery (Fitzgerald 1997). Patients receiving Looking at Figure 2, which lower limb veins
multiple IV injections/infusion medication therapy, are prone to DVT formation?
as in chemotherapy and systemic antibiotics,
might be at increased risk (Hoyt 1991).
Blood coagulation factors Hypercoagulation –
Signs and symptoms of DVT
due to blood dyscrasia, dehydration, malignancy
or oral contraceptives – has the potential to alter There are up to six signs and symptoms that
normal blood haemostasis mechanisms (Sartwell might demonstrate a DVT episode (Box 1).
and Stolley 1982). Research has shown that However, it should be acknowledged that in up
women who take contraceptives and smoke to 50 per cent of cases, there are few or no
double their risk to DVT (Fahey 1988). significant physical abnormalities or clinical signs
Stasis of venous circulation Circulatory to be detected (Barnes et al 1978, Turner and
problems can be caused by bed rest, frailty and Turner 1982). If signs are present, any resolution
immobility in older patients, cardiovascular of the DVT might be demonstrated by a reduc-
disorders and post-operative immobilisation tion in signs and symptoms.
(Arcelus et al 1991). Long-haul flights are Abnormal swelling of the affected limb This
thought to predispose to thrombi formation due can be due to localised oedema resulting from:
to restricted mobility, but recent research ■ Thrombosis occlusion of the affected deep
indicates that the risk might be due to the vein, which impedes venous blood return and
Box 1. Signs and symptoms reduced air pressure in airplanes (Bendz et al can also affect the efficiency of collateral
of deep vein thrombosis 2000). Patients who are obese or immobile are venous drainage.
at high risk of developing venous circulatory ■ Capillary damage, causing leakage of
■ Abnormal swelling of problems. Immobility can deprive the deep veins intravascular fluid into the surrounding tissues
affected limb of the lower limbs of the pumping action of the (extravasation), distal to the thrombosis site.
■ Warmth of affected limb calf muscles (calf muscle pump), leading to stasis Bilateral baseline limb-girth measurements
■ Localised tenderness and of venous blood, particularly behind the valve should be performed daily, and form an impor-
pain cusps of deep veins, which can predispose to tant part of ongoing patient monitoring.
■ Dilation of veins thrombus formation. Warmth of affected limb In some cases, the
■ Colour changes of affected affected limb feels warm to the touch. This
limb might be due to localised venous congestion
Formation of a DVT
■ Pyrexia and accumulation of tissue metabolites in the
(Game 1989) DVTs often originate around the venous valve affected limb (Clark and Kumar 1994).
cusp site, leading to a reduced blood flow and Localised pain Lower limb pain might be

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experienced in the calf muscle region during Fig. 2. Deep veins of the right leg
dorsiflexion movements of the foot – this is
referred to as a diagnostic positive Homan's
sign. Localised symptoms are commonly due to
oedema in the tissues surrounding the site of
thrombophlebitis (inflammation of vein where
clot is present). Pain is not always present, for Femoral
example, in cases where there is a small sized vein
thrombus with few localised inflammatory
activities (Game 1989). However, in cases of
iliofemoral vein thrombosis, extreme pain can
present (Clark and Kumar 1994). Popliteal
Dilation of veins Due to the venous thrombus vein
occlusion of the respective vein, a distal dilatation
Anterior
of veins might occur as a result of systemic and
tibial vein
peripheral venous circulatory-stasis obstruction
(Tortora and Anagnostakos 1996).
Colour changes of the leg Initially, as a result REFERENCES
Arcelus JI et al (1991) Venous
of the venous thrombosis, pallor of the leg thromboembolism prophylaxis and risk
might be the only indicator. In other cases, a Posterior assessment in medical patients. Seminars
peripheral skin erythema (redness) of the tibial vein in Thrombosis and Hemostasis. 17, Suppl
3, 313-318.
affected limb occurs immediately over the DVT Arthur VA (1995) Written patient
site, which might be due to the superficial information: a review of the literature.
thrombophlebitis (Hinchliff 1996). Anterior Posterior Journal of Advanced Nursing. 21, 6,
view view 1081-1086.
Pyrexia A systemic increase in body temperature Autar R (1996) Nursing assessment of clients
to 39-40°C can be caused by the accumulation at risk of deep vein thrombosis DVT. The
of tissue metabolites at the site of the thrombosis Venometer The Venometer test is quick to carry Autar DVT Scale. Journal of Advanced
Nursing. 23, 4, 763-770.
formation, and intravascular thrombophlebitis out and aims to reduce time between the Barnes RW et al (1978) Efficiency in patients
occurs (Brooker 1998, Marieb 1998). potential DVT presentation and confirmed undergoing total hip replacement.
diagnosis. A portable venometer machine can Clinical Orthopaedics and Related
TIME OUT 2 Research. 132, 61-67.
be used at the patient’s bedside, which has a Basford L and Slevin O (1995) Theory and
Reflect on a patient you have pneumatic leg (thigh) cuff attached to measure Practice of Nursing an Integrated
nursed recently with a venous drainage. Approach to Patient Care. Edinburgh,
Campian Press.
confirmed clinical diagnosis of Ultrasound Doppler testing This measures Bendz B et al (2000) Association between
DVT. Did he or she present with venous flow by placing a Doppler probe over acute hypobaric hypoxia and activation
any of the described signs and veins, and the procedure can be performed with of coagulation in human beings. The
Lancet. 356, 9242, 1657.
symptoms? Given what you know about DVT the patient standing. This test is useful for Bergqvist D et al (1988) The economics of
clinical presentation, list five significant differentiating between a DVT and muscle strain general thrombo embolic prophylaxis.
indicators that would demonstrate the or haematoma (Lewis and Collier 1992). World Journal of Surgery. 12, 349, 355.
British National Formulary (2000) British
resolution of a DVT. Reflect on your list and Venography This can detect a thrombus using a Medical Association and Royal
discuss this with a colleague. radiopaque intravenous (IV) injection technique Pharmaceutical Society Great Britain. No
via the dorsal foot vein. It is suggested that 39.
Brooker C (1998) Human Structure and
many below-knee thrombi can be detected Function, Nursing Application and
Asymptomatic In 50 per cent of cases the DVT only by venography (Clark and Kumar 1994). Clinical Practice. Second edition. London,
has no initial observable symptoms and, of Plethysmography This detects any obstruction Mosby.
Brown R et al (1998) Setting up a
patients with a PE, up to 75 per cent might to the venous flow of blood from the leg. nurse-led anticoagulant clinic.
have no sign of a preceding DVT (Clark and Results are recorded before, during and after Professional Nurse. 14, 1, 21-23.
Kumar 1994, Sandler and Martin 1989). As it is exercise using a pneumatic cuff applied to the Caprini JA et al (1991) Clinical assessment of
venous thromboembolic risk in surgical
estimated that only one in nine cases will present patient’s femoral region (Hodder 1994). In cases patients. Seminars in Thrombosis and
clinically, all patients who are identified to be at of DVT, there will be significantly less volume of Hemostasis. 17,
risk should be carefully assessed, examined and venous return than in the non-affected limb Suppl 3, 304-312.
Caprini J et al (1988) Role of compression
monitored (Turner and Turner 1982). (Smeltzer and Base 1996). modalities in a prophylactic program for
Radioactive fibrinogen scanning This test can deep vein thrombosis. Seminars in
be performed to define the location of a clot and Thrombosis and Hemostatis. 14, Suppl
Specific diagnostic assessment 77-78.
any subsequent secondary emboli. Radioactive Cheater F (1996) Care pathways: tools for
Clinical diagnosis might be confirmed by the fibrinogen is administered intravenously and in the clinical audit? Audit Trends.
following techniques: patients who develop a DVT, it will be 4, 2, 73-75.

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transformed into fibrin. Daily leg scanning is sion of the thrombus, must be considered in
performed to monitor the DVT episode (Lewis respect of two potential sites of lower limb
and Collier 1992, Smeltzer and Base 1996). venous circuit (Walker and Davidson 1985):
Haematology screening There are numerous ■ At the blood vessel wall site of trauma or
haematology screening methods that detect the disease.
fibrin degradation product, D-dimer, which is ■ Wherever venous blood flow has become tur-
released into the circulation during a DVT bulent, such as pooling of blood around the
episode (O’Shaughnessy and Thomas 1999). vein valve cusps, within which blood flow is
One such technique that is often used in A&E already retarded.
only requires a fingerprick specimen. The defective blood flow prevents the dispersal
Some researchers demonstrate the D-dimer esti- of newly developed fibrin, and this prevents
mation to be the ‘gold standard’ screening clotting enzymes coming into contact with
technique for all DVT patients (Turkstra et al circulating inhibitors and clearance via the liver
1998). However, it should be noted that raised (Gitel et al 1979). In the turbulent blood flow,
levels of D-dimer do occur during the mechanisms aggregation of thrombocytes increases, predis-
of active fibrinolysis, and might not be specific to posing to thrombus formation. Unfortunately,
all DVT episodes (O’Shaughnessy and Thomas once vein valve cusps become structurally
1999). Raised D-dimer levels can indicate the pres- damaged, they are unable to prevent retrograde
ence of DVT/PE in patients up to the age of 40, venous blood flow, which might predispose to
but the test can be less specific in older patients varicose veins and pooling of blood between
(O’Shaughnessy and Thomas 1999). D-dimer has damaged and healthy valve cusps. Even a single
a high negative-predictive value, and could reduce episode of DVT might cause irreversible damage
Clark M, Kumar P (1994) Clinical Medicine.
Third edition. London, Baillière Tindal. the need for further investigations by 75 per cent, to the vessel wall and valve cusp structure, pre-
Cormack DFS, Reynolds W (1992) Criteria leading to an earlier hospital discharge for the disposing to a potential recurrence of DVT
for evaluating the clinical and practical patient (O’Shaughnessy et al 1998). (Smeltzer and Base 1996). Furthermore, venous
utility of models used by nurses.
Journal of Advanced Nursing. 17, 12, leg ulcers can arise between ten and 15 years
1472-1478.
TIME OUT 3 after the initial episode (Lowe 1979).
Department of Health (1998) The Crown Which of the diagnostic
Report. Review of Prescribing Supply and
Administration of Medicines: A Report techniques presented are
Therapeutic interventions
on the Supply of Medicines Under Group used within your area of
Protocols. London, The Stationery Office. practice to confirm potential A tripartite regimen of prophylaxis should
Department of Health (1992) The Patient’s
Charter. London, HMSO. DVT cases? List the types of D-dimer include subcutaneous heparin (short-term
Downie G et al (1999) Pharmacology and haematology testing used in your area of prescription), anti-embolism stockings and
Drug Management for Nurses. Second practice, discuss with a colleague, and refer specific pre- and post-operative physiotherapy
edition. Edinburgh, Churchill Livingstone.
European Consensus Statement (1997) to any clinical audits being undertaken in for surgical cases. Specific regimens for medical
Prevention of Venous Thromboembolism. relation to haematology screening. cases might include subcutaneous heparin (five
London, Med-Orion Publishing. days) and oral warfarin anticoagulation (long-
Fahey VA (1988) Venous Thromboembolism.
Vascular Nursing. Philadelphia, Saunders. term prescription), anti-embolism stockings and
Fennerty A et al (1988) Anticoagulants in specific physiotherapy exercise programmes.
venous thromoembolism. British Medical
High-risk DVT groups
Research supports the advantages of early
Journal. 297, 1285-1288.
Fitzgerald R (1997) Managing the risk of Significant factors relating to age, weight, anticoagulation programmes following medical
venous thromboembolism in gender, health, illness and lifestyle, alongside assessment and diagnosis of DVT, reducing the
orthopaedics. Orthopaedics. 20, trauma and surgical intervention, might place a risk of PE to less than 1 per cent (Levine et al
Suppl 6.
Game C (1989) Disorders of blood vessels. In patient at high risk of developing a DVT (Autar 1996). It must be acknowledged that while a
Medical Surgical Nursing: A Core Text. 1996). All patients who experience DVT are at clinical improvement of DVT does occur, the
First edition. Edinburgh, Churchill risk of potential acute and chronic complica- achievement of a complete clot breakdown via
Livingstone.
Gitel SN et al (1979) The effect of total hip tions. Systemic protective responses, termed the natural fibrinolytic system occurs at a very
replacement and general surgery on acute phase reaction (APR), are provoked in low rate, as anticoagulants have no pharma-
antithrombin III in relation to venous response to trauma/blood vessel damage such cological action in lysing existing thrombi
thrombosis. Journal of Bone and Joint
Surgery. 61a, 5, 653-656. as might occur in DVT (Lowe 1979). Antico- (Haslett et al 1999).
Grace R (1993) Thrombo prophylaxis: a agulant prophylaxis should help to reduce the The cumulative incidence of recurrent DVT as a
review. British Journal of Hospital severity and duration of the APR post-operatively result of a single DVT episode is 5 per cent after
Medicine. 49, 1, 720-726.
Haslett C et al (1999) Davidson's Principles (Love 1990a). Special attention is focused on the three years and 30 per cent after eight years
and Practices of Medicine. Eighteenth blood-clotting inhibitor antithrombin III and the (Prandoni et al 1996). The patient with a DVT
edition. Edinburgh, Churchill Livingstone. fibrinolytic agent plasmin. has the added risk of developing post-phlebitic
Havig O (1977) Deep vein thrombosis and
pulmonary embolism. Acta Chinurgica The responses that occur during the APR syndrome (PPS). This chronic disorder occurs as a
Scandinavia. Suppl 478, 1-20. episode with formation of a DVT, and the exten- consequence of previous venous damage and

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circulatory disruption. Chronic venous circuit TIME OUT 4


damage includes venous valve incompetence
due to thrombosis, and a slow endogenous Within your trust, is
fibrinolysis preceding venous hypertension. The a formalised clinical
potential of incomplete clot lysis and develop- assessment protocol used?
ment of venous vascular reflux is also well recog- What are the commonly used
nised (Havig 1977). PPS presents as a brown anticoagulant regimens within your own
discolouration of the lower limb with localised nursing practice? What exclusion criteria for
redness, stasis-dermatitis and hollow ulceration anticoagulant prescription are in use in your
occurring over the medial and lateral malleoli. hospital trust protocol/policy? Do you think
While the disease-free period of PPS can be more these should be amended in any way?
than 20 years, reported cases rate at 30 per cent
with a previous history of DVT (Havig 1977).
Anticoagulant therapeutic regimens Traditional
regimens dictated the use of IV standardised or
Anticoagulant therapy
unfractionated heparin (UFH) regimen for 48
Heparin therapy promotes the action of hours, with an initial loading dose of an oral
antithrombin and factor III, which inhibits factor anticoagulant, such as warfarin. However, sur-
X and XI in anticoagulant doses. It also slows the veys and audits of heparin therapy have since
clotting time by inhibition of prothrombin- deemed UFH to be inappropriate as it could
thrombin, and further prevents fibrinogen to prolong the activated partial thromboplastin
fibrin conversion (Brooker 1998, Downie et al time, which is the most widely applied
Hinchliff SM (1996) Physiology for Nursing
1999, Rang et al 1995). laboratory technique for therapeutic monitoring Practice. Second edition. London,
In conjunction with heparin, oral anticoagulant of heparin (Mattison et al 1996, O’Shaughnessy Baillière Tindall.
therapy is initiated, using warfarin as a first et al 1998). Hirsh J, Hoak J (1998) Management of deep
vein thrombosis and pulmonary
choice anticoagulant. Phenindione oral antico- More recently, low molecular weight heparin embolism. American Heart Association.
agulant should be used if the patient is allergic (LMWH) has been a successful treatment for 93, 2212-2245.
to warfarin (BNF 2000). Warfarin inhibits the DVT (O’Shaughnessy and Thomas 1999). This Holford CP (1976) Graded compression
stockings for preventing deep vein
vitamin K-dependent clotting factors and some has been demonstrated to be a safe and effec- thrombosis. British Medical Journal.
naturally occurring proteins C and S (anticoagu- tive treatment for cases of proximal DVT 6042, 2969-2970.
lants). Warfarin therapy should be overlapped (Levine et al 1996). It has the added benefit for Hoyt B (1991) Deep vein thrombosis in the
surgical intensive care unit. Surgical
with heparin therapy for four to five days. the patient of early discharge – patients on Clinics North America. 71, 4, 811-830.
Initial therapeutic doses, such as 10mg war- LMWH undergo a mean of 1.1 day’s hospital Ishak MA, Morley KD (1981) Deep venous
farin per day, might be given for two days, with care. They can then receive specialised super- thrombosis after total hip arthroplasty.
British Journal of Surgery. 68, 429-432.
subsequent doses adjusted according to the vised care at home for five to seven days. Levine M et al (1996) Treatment of venous
international normalised ratio (INR). Standardised hospital treatment using UFH thrombosis with intravenous
For DVT patients receiving anticoagulant thera- requires patients to spend some 6.5 days in unfractionated heparin, administered in
hospital as compared with subcutaneous
py, an INR in the range 2.5-3.0 is desirable unless hospital (Levine et al 1996). Researchers indi- LMWH administered at home. New
the patient has experienced a recent thrombosis. cate that LMWH has a longer half life, better England Journal of Medicine. 334,
Treatment is usually maintained for approxi- bioavailability, can be administered as a fixed or 677-680.
Lewis SM, Collier IC (1992) Medical-Surgical
mately three to six months (BNF 2000, Fennerty weight-related dose via daily subcutaneous Nursing Assessment and Management of
et al 1988, Pout et al 1999). injection, and has a more predictable antico- Clinical Problems. Third edition. St Louis
However, in cases of recurrent thrombo- agulant response (BNF 2000, Rang et al 1995, MO, Mosby.
Love C (1990a) Deep vein thrombosis: threat
embolic episodes, a more prolonged or lifelong Trounce and Gould 1990). to recovery. Nursing Times. 86, 6, 40-43.
therapy might be advocated (BNF 2000, Downie Love C (1990b) Deep vein thrombosis:
et al 1999). methods of prevention. Nursing Times.
Patient information 86, 6, 52-55.
Criteria for receiving anticoagulant therapy Lowe LW (1979) The role of anticoagulants in
Following medical assessment and examination, Nurses are well placed to care for patients with hip surgery. In McKibben B (Ed) Recent
potential DVT patients are referred for Doppler DVT, provide patient education and initiate Advance in Orthopaedics. Edinburgh,
Churchill Livingstone.
ultrasound scanning and haematological investi- strategies for optimum health promotion Lowry M (1995) Knowledge that reduces
gations. Patients with a negative or equivocal scan activities (Lowry 1995). Providing written for- anxiety creating patient information
result and negative D-dimer test are discharged malised information helps to reinforce verbal leaflets. Professional Nurse. 10, 5, 318-
320.
back to the GP for further management. information given during nurse-patient or Mackie C (1996) Nurse practitioner
Patients with a positive scan and D-dimer doctor-patient discussions, leading to increased managing anticoagulant clinics. Nursing
result will be screened using exclusion criteria to patient compliance (Arthur 1995). DVT patients Times. 92, 1, 25-26.
Marieb HN (1998) Human Anatomy and
see if they are suitable to receive the prescribed require a wide range of information, covering Physiology. Fourth edition. Menlo Park
therapeutic anticoagulant regimen. the clinical condition, therapeutic treatments CA, Benjamin Cummings.

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Box 2. Thrombosis risk and lifestyle changes to reduce alcohol con- appropriate form of prophylaxis. Two DVT
factor assessment tool sumption and smoking and increase physical patient risk assessment tools are available:
exercise. Specialist anticoagulant and nurse-led ■ Thrombosis risk factor (TRF) assessment tool
■ Demographic data of DVT treatment services can provide written for medical and surgical patients (Arcelus et al
patient: to include age and patient advice on DVT, as well as access to 1991, Caprini et al 1991).
gender 24-hour telephone helplines (Brown et al ■ The Autar (1996) DVT risk assessment scale.
■ Health status: previous 1998, Mackie 1996, Pout et al 1999). Thrombosis risk factor (TRF) DVT assessment
medical history of DVT or Patient information about anticoagulant therapy, tool The TRF assessment tool is specific to
PE (= 3 factors), covering safe administration, self-assessment medical and surgical patients, with some
cardiovascular, chronic and uptake of monitoring services, is provided inclusion of specialist medical disorders,
respiratory disease during structured patient teaching/discussion orthopaedic, gynaecology and surgical risk
■ Circulatory stasis: bed rest sessions (Brown et al 1998, DoH 1992, Pout et factors. Within UK hospital trusts, DVT specialist
period 72 hours, obesity al 1999). Additional written information is practice case referrals are received from medical,
(20 per cent of ideal body provided, to reinforce patient education, using surgical and specialist surgical arenas, into
weight), leg oedema, in-service literature and the Department of specialist DVT clinical care pathways (Brown et al
ulceration and localised Health’s anticoagulant patient record booklet 1998, Pout et al 1999). Nurse practitioners are
circulatory stasis (DoH 1998). well placed to implement preventive measures,
■ Trauma to blood vessels: since this coincides with the high dependency
pelvic surgery, genitourinary nursing regimens used for post-operative cases.
Management of DVT cases
surgery, orthopaedic, total Individual patient assessment can be undertaken
hip prosthesis, long Within specialist nursing practice, the DVT clinical using the TRF tool to identify demographic data,
bone/pelvic fractures, history care pathway (Cheater 1996, Wilson 1997) allows previous medical history and health status,
of general major surgery multi-professional agency, collaborative care inclusive of their clinical condition on admission
■ Blood clotting factors: programmes to include specific regimens of DVT to hospital or during the TRF assessment activity
hypercoagulable states, prophylaxis. Specified programmes can be offered (Box 2). The TRF tool can be used to identify the
inflammatory bowel to DVT patients to provide nursing care manage- total number of risk factors pertaining to the
disease, pregnancy/post ment that can be assessed, planned, implemented patient.
partum (<1 month) and evaluated by the physician, pharmacist, physio- Within the TRF tool, a DVT prophylaxis protocol
hormone therapy therapist and specialist nurse practitioner, in is presented. Patients presenting with one or more
partnership with the patient and his or her family factors are at risk of developing a DVT. Those who
(Basford and Slevin 1995, DoH 1992). score two or more risk factors are placed in the
Box 3. Autar DVT risk moderate- to high-risk category and those with
assessment factors more than four factors identified are at high risk of
Physiotherapy
developing a DVT. Prophylaxis is aimed at reducing
■ Age-specific group It is paramount that DVT collaborative care the incidence of DVT, especially post-operatively
■ Build and body mass index programmes include the physiotherapist to (Caprini et al 1988). Graduated compression anti-
(BMI) encourage specific ambulatory regimes. For embolism stockings and early ambulation are
■ Mobility each patient, an initial assessment begins with recommended for cases at all three levels of risk.
■ Trauma risk factors discussion and observation of the patient’s Anticoagulant therapy is recommended for mod-
■ Surgical interventions actual and achievable ambulation capacity: erate to high-risk patients, consisting of heparin
■ Specific risk category ■ Independent walking activity (achieved by alone or heparin combined with warfarin, depend-
■ High-risk diseases patient). ing on whether the risk is moderate or high.
■ Active walking exercises (ten times hourly). Autar DVT risk assessment scale The Autar
Walking activities will significantly help to DVT scale was devised in 1996, based on
Box 4. Autar DVT reduce deficits in venous blood flow by activat- Virchow’s (1846) triad of risk factors. This
assessment risk categories ing skeletal calf muscle pumps. It is also impor- particular tool can be used for the nursing
tant to make optimum use of the respiratory sys- assessment of all patients at risk of DVT and
Score Risk tem (respiratory pumps), to encourage specified comprises seven risk factors (Box 3) which are
<6 No risk breathing mechanisms and to initiate collabora- further subdivided. Each factor is given a score
>10 Low risk tive skeletal and respiratory pump exercises and the total is added up to find the category of
(<10 per cent) (Love 1990b). risk of the patient being assessed (Box 4).
11-14 Moderate risk The summative total score provides a discrimi-
(11-40 per cent) native and predictive index to DVT, and while
Nurse’s role: risk assessment
>15 High risk high-risk patients might be easily recognised, it
(>41 per cent) The prevention of DVT is important and can be is important to identify those who are at low to
(Adapted from Autar 1996)
achieved by comprehensive DVT risk assessment moderate risk, as they are often missed (Autar
undertaken on admission, followed by the most 1996).

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While similarities between the TRF and the In line with strategies of defensive documenta-
Autar risk assessment tools include age, body tion and the importance of records and record
weight, mobility, surgery and specialist surgery, keeping (UKCC 1996), the Autar tool contains
each tool has a unique and specific risk assess- an assessment protocol illustrating the four cat-
ment and score category. The Autar scale egories of risk, and an individual patient scoring
places considerable emphasis on providing five data component to be completed within 24
sub-classified risk categories within the age, hours of the patient’s admission. Nurses and Box 5. Holistic assessment
BMI, and mobility components. General sur- physicians will need to evaluate collaboratively
gery is also differentiated to include minor, the extent to which the chosen assessment tool Local assessment
major and emergency major procedures. is applicable to their clinical nursing practice ■ Skin lesions (lower limbs)
Specialist surgery includes five categories. (Autar 1996, Cormack and Reynolds 1992). ■ Gangrene
A special risk category included in the Autar Within a 24-hour admission period, either of the ■ Recent vein ligation
DVT scale illustrates the potential high risk of chosen tools might be used by specialist nurse- ■ Localised limb oedema
DVT in women who are receiving contraceptive led pre-operative assessment clinics or within ■ Recent skin graft (lower
therapy, or during pregnancy and the puerperi- DVT care pathways and all ward-based admis- limbs)
um. Women aged 35-44 who are taking oral sion programmes (Smith 1992). ■ Limb deformity (it might not
contraception have a 2.5 greater incidence of be possible to obtain an
DVT compared to those aged 20-34 (Sartwell TIME OUT 5 effective compression stock-
and Stolley 1982). With the Autar DVT scale, ing in cases of extreme
women aged 20-34 are assessed as score 1, and Which DVT individualised deformity)
those aged 35-44 accrue a score of 2. While patient risk assessment tool is
oestrogen levels are considerably reduced during used within your clinical Systemic assessment
the puerperium, they do remain higher than practice? Explain the advantages ■ Ischaemia
normal, leading to increased plasma concentra- and disadvantages of the specified tool used. ■ Vascular disorders
tion which results in an increased blood coagu- ■ Arteriosclerosis
lability (Autar 1996). The pregnancy/puerperium ■ Chronic/congestive cardiac
group is assigned a score of 3. failure (CCF)
Anti-embolism stockings
With reference to high-risk disease, the Autar ■ Pulmonary oedema (where it
DVT scale illustrates a definitive risk assessment In line with evidence-based nursing practice, occurs secondary to CCF,
assigned to each of ten high-risk disorders: ulcer- anti-embolism stockings are used widely in the compression stockings might
ative colitis, polycythaemia, sickle cell anaemia, UK for all low-risk patients and are combined increase venous return and
haemolytic anaemia, chronic heart disease, with other prophylaxis for moderate- and high- venous pressure)
myocardial infarction, malignancy, cerebral vascu- risk groups. Graduated compression stockings
lar accident (CVA), varicose veins and previous are designed to achieve a pressure gradient, (Adapted from Tyco Healthcare
DVT. For patients with a confirmed DVT who have with pressure increasing from the ankle to the 1999)
a history of previous DVT, the aggregate score thigh. The sequential compression profile of the
assigns the patient into the immediate moderate- stocking is aimed to mimic the deep leg vein calf
to high-risk category, depending on the number muscle pumps, to promote efficient and effec- Mattison I et al (1996) Experience from
of risk factors present. Autar (1996) also high- tive emptying of vein circuits and respective outpatient treatment of deep vein
thrombosis with low molecular heparin.
lights patient groups who are placed at high risk valvular systems without adverse effects on arte-
Blood Coagulation and Fibrinolysis. 7,
of having an increased blood ‘thrombogenic rial circulation (Barnes et al 1978, Holford 1976). 399-406.
mechanism’ and who might succumb to a DVT. The nurse’s role in fitting anti-embolism National Institute of Health (1986)
Consensus Development Conference on
As the focus of this article is the nursing man- stockings In conjunction with professional and
the prevention of venous thrombosis and
agement of confirmed DVT cases, information clinical judgement, and the chosen risk pulmonary embolism. Journal of the
about external pneumatic compression (PC) assessment tools, practitioners also need to American Medical Association. 256, 744-
749.
garments has not been presented. But in both undertake specific holistic assessment strategies
Nicolaides AN, Gordan-Smith I (1975) A
the Autar and the TRF tools, thromboprophylaxis to ensure efficacy and safe wearing of the Rational Approach to Prevention in
components refer to intermittent or continuous stockings (Box 5). It is necessary to include Thrombo-Embolism Aetiology. Advances
in Prevention and Management.
mechanical systems (PC systems). In general, PC localised physical assessment of the lower limbs
Lancaster, Medical and Technical
sleeve garments can be obtained as foot gar- and systemic assessment of the patient’s health Publishing.
ments, knee length and thigh length, and work status. Orem D (1985) Nursing Concepts for
Practice. Second edition. London, Mosby.
on the principle of aiding venous return and Accurate measurement and safe fitting of the
O’Shaughnessy DF, Thomas M (1999) Use of
preventing venous stasis. PC garments are often stockings is of paramount importance to achieve D-dimer in deep vein thrombosis.
used in conjunction with specified anticoagulant optimum prophylaxis and patient compliance Thrombosis. Spring, 5.
O’Shaughnessy DF et al (1998) The
therapeutic regimens during perioperative care (Lowry 1995). Anti-embolism stockings are
outpatient management of deep vein
programmes for patients undergoing THR and frequently available in knee-length, thigh-length thrombosis. Journal of Accident &
total knee replacement (TKR) surgery. and special thigh-length with waistbelt versions, Emergency Medicine. 15, 292-293.

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Vascular disorders

and might be colour coded to distinguish Patients need to be actively involved in health
between different types and sizes. Below-knee promotion activities, including self-assessment
stockings are used for patients whose thigh (Orem 1995), review and maintenance of
circumference measures more than 33 inches lifestyle changes, medication regimens, dietary
(84cm), and for specific orthopaedic surgical intake, smoking and alcohol consumption.
procedures where the patient is to have wound Patients and nurse practitioners require for-
incision above the popliteal joint, such as a malised education about graduated compression
femoral prosthesis or THR. Full-length stockings stockings.
should be fitted in all other cases to achieve Health education should be an active and
protection of the femoral vein. They must not be explicit nursing intervention. All patients are at
rolled down as this can cause a tourniquet effect risk of developing a DVT six weeks after
of the femoral circulation and can predispose to discharge from hospital (Scurr et al 1988). It
a localised DVT. should be acknowledged that a history of DVT
increases the likelihood of recurrence by 68 per
Pout G et al (1999) Nurse-led outpatient TIME OUT 6 cent (Hirsh and Hoak 1998). Innovative specialist
treatment of deep vein thrombosis.
Nursing Standard. 13, 19, 39-41. Which type of anti-embolism nursing programmes promote the care pathway
Prandoni P et al (1996) The long-term stocking is offered to patients for confirmed DVT cases, whereby patients
clinical course of acute deep vein
with DVT in your workplace, referred into home care/outreach programmes
thrombosis. Annals of Internal Medicine.
125, 1, 1-6. and how many pairs are offered are discharged in less than two days of hospital
Rang HP et al (1995) Pharmacology. Third on prescription? Indicate the ways in admission (Levine et al 1996)
edition. Edinburgh, Churchill Livingstone.
which you would assess patients for their
Sandler DA, Martin JF (1989) Autopsy
proven pulmonary embolism in hospital stockings, and compare your findings with TIME OUT 7
patients: are we detecting enough deep the information in Box 5.
vein thrombosis? Journal of the Royal
Now that you have completed
Society of Medicine. 82, 203-205.
Sartwell PE, Stolly PD (1982) Oral the article, you might like to
contraceptives and vascular diseases. To encourage safe use and optimum patient think about writing a practice
Epidemiology Review. 4, 95-109.
compliance, it is important to demonstrate the profile. Guidelines to help you write
Scurr JH et al (1988) Deep venous
thrombosis: a continuing problem. British correct fitting technique of the stocking. This and submit a profile are outlined on page 57.
Medical Journal. 297, 28. should be supported by a follow-up discussion
Smeltzer SC, Base G (1996) Brunner &
session, to elicit the do’s and don’ts when wear-
Suddarth Textbook of Medical and
Surgical Nursing. Eighth edition. New ing the stocking. Fitting guides on individual
York NY, Lippincott. patient assessment, practical fitting, wearability,
Smith T (1992) Deep vein thrombosis.
and maintenance are supplied with the stockings.
Journal of Community Nursing. 6, 9, 18.
Tortora G, Anagnostakos P (1996) Principles
of Anatomy and Physiology. Seventh
edition. New York NY, Harper & Rowe. Conclusion
Trounce J, Gould D (1997) Clinical
Pharmacology for Nurses. Thirteenth While clinical diagnosis of DVT is the role of the
edition. London, Churchill Livingstone. physician, nurses also have a role in primary pre-
Turkstra F et al (1996) Reliable rapid blood
vention. Receiving patients into medical, general
test for the exclusion of venous
thromboembolism in symptomatic and specialist surgical settings requires for-
outpatients. Thrombosis and malised DVT patient risk assessments to be
Haemostasis. 76, 1, 9-11.
undertaken as an integral part of a revised
Turner A, Turner J (1982) An unexpected
killer. Nursing Mirror. 155,64-65. admission assessment by nurse practitioners
Tyco Healthcare (1999) Thrombo embolic responsible for DVT cases and their direct clinical
deterrent TED anti embolism stockings.
nursing programmes. Using patient risk assess-
Gosport, Tyco.
United Kingdom Central Council for ment tools enables practitioners to undertake an
Nursing, Midwifery and Health Visiting in-depth patient history to establish the category
(1996) Standards for Records and Record
of DVT risk on admission.
Keeping. London, UKCC.
Virchow R (1846) cited in Bergqvist D et al Within assessment, planning, implementation
(1988) The economics of general and evaluation of individualised patient care
thrombo embolic prophylaxis. World
programmes, there is significant opportunity for
Journal of Surgery. 12, 349, 355.
Walker ID, Davidson JF (1985) Fibrinolysis. In practitioners to undertake formal and structured
Thompson JR (Ed) Blood Coagulation and patient teaching activities (Arthur 1995, Lowry
Haemostasis: A Practical Guide. Third
1995). It is the nurse’s role to inform, teach and
edition. Edinburgh, Churchill Livingstone.
Wilson J (1997) Introduction to Integrated advise patients in relation to anticoagulant
Care Management: The Path to Success. medications, physiotherapy exercises and the
Oxford, Butterworth Heinemann.
practical wearability of anti-embolism stockings.

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