PAGE 82 JOURNAL OF VASCULAR NURSING SEPTEMBER 2006

www.jvascnurs.net

Venous thromboembolism: Scope of the

problem and the nurse’s role in risk assessment
and prevention
Ruth Morrison, RN, BSN, CVN

Deep vein thrombosis and pulmonary embolism, comprising different manifestations of the same clinical entity
referred to as venous thromboembolism, are a significant cause of morbidity and mortality. Despite pulmonary
embolism being considered the most preventable cause of in-hospital death, the use of appropriate thrombopro-
phylaxis remains suboptimal in many patients. Nurses are on the frontline of thrombosis prevention. By playing an
essential role in diagnosis and risk assessment, applying timely preventive methods, and providing vital educational and
psychologic support for patients with venous thromboembolism, skilled nursing intervention can save lives. (J Vasc Nurs 2006;
24:82-90)

Venous thromboembolism (VTE) is one of the most com-
mon, yet highly preventable, causes of in-hospital death. Mani-
festing as deep vein thrombosis (DVT) and its potentially fatal
complication pulmonary embolism (PE), the condition is recog-
nized as a major national health problem. In the United States,
approximately 1 to 2 million people each year have DVT, and,
according to the Coalition to Prevent Deep-Vein Thrombosis
(www.preventdvt.org), more Americans are thought to die each
year from PE than from breast cancer, acquired immune defi-
ciency syndrome, and highway fatalities combined. Most pa-
tients who have a fatal PE die within the initial 30-minute period,
providing a very small window for effective treatment and thus
explaining the high fatality rate associated with this condition. It
has been estimated that approximately 10% of hospital deaths
can be attributed to PE, making VTE the most common prevent-
able cause of hospital death and disability.1,2
VTE places a huge burden on health care resources. In addition
to delayed discharge or readmission to hospital, up to 30% of
patients with VTE develop long-term post-thrombotic complica-
tions, such as leg pain, swelling, and ulcers,3 which have a major
impact both on patients’ lives and health care resources.
Primary prevention of VTE is a major focus in health care
management. The implementation of appropriately targeted throm-
Ruth Morrison is from the Brigham and Women’s Hospital,
Boston, Massachusetts.
The author received editorial/writing support in the preparation
of this article, funded by sanofi-aventis, New Jersey. The author,
however, was fully responsible for content and editorial deci-
sions for this article.
Address reprint requests to Ruth Morrison, RN, BSN, CVN,
Brigham and Women’s Hospital, 75 Francis Street, Boston, MA
02115 (E-mail: RMorrison@partners.org).
1062-0303/2006/$32.00
Copyright © 2006 by the Society for Vascular Nursing, Inc.
doi:10.1016/j.jvn.2006.05.002
boprophylaxis has been described as one of the most important
strategies for improving in-hospital safety.4 However, despite the
availability of regularly updated consensus guidelines, thrombopro-
phylaxis continues to be underused or inappropriately prescribed in
a large proportion of medical and surgical patients.5-8 For example,
in the U.S. clinical registry of patients, DVT-FREE, 71% of 5451
hospitalized patients received no prophylaxis in the 30-day period
before the diagnosis of DVT.9
WHY IS VENOUS THROMBOEMBOLISM
UNDERDIAGNOSED AND UNDERPROPHYLAXED?
Although the health risks posed by VTE are now widely
accepted, many health care providers continue to underesti-
mate the extent of the problem. One reason for this is that
DVT and PE are often clinically silent. Improved surgical
procedures mean that the incidence of DVT and PE in the
perioperative period is low, and it is rare for surgeons to see
VTE in any of their own patients. Furthermore, because
hospital stays are now shorter, the majority of symptomatic
thromboembolic complications in surgical patients occur after
hospital discharge.10
Although VTE was originally considered to be a disease
primarily seen in surgical patients, many medical patients are
also at high risk of developing thrombosis. The incidence of
VTE in general medical patients is 10% to 20%, but the
incidence is much higher in certain groups, such as critically
ill patients (up to 80%) or patients who have had a stroke
(20%–50%).11 Current VTE management guidelines clearly
highlight the risk factors for medical patients (eg, immobility
and chemotherapy) and recommend thromboprophylaxis for
medical patients at high risk for thrombosis.11 However, lack
of adherence to guidelines in nonsurgical patients continues to
contribute to the problem of inadequate prophylaxis, leaving
many patients vulnerable to DVT and PE.5
Another reason for the underuse of thrombophylaxis is
concern over the safety of anticoagulant drugs, particularly
with respect to the risk of bleeding complications during
heparin-based thromboprophylaxis. However, there is now
Vol. XXIV No. 3 JOURNAL OF VASCULAR NURSING PAGE 83
www.jvascnurs.net

TABLE I

PREVENTING VENOUS THROMBOEMBOLISM: THE NURSE’S ROLE

Clinical role
● Be alert for signs and symptoms of DVT or PE.
● Individual risk assessment on admission and continuing assessment during hospital stay.
● Encourage early mobilization and leg exercises.
● Assessment/fitting of GCS: Assess contraindications by physical assessment, clinical history, and measuring/fitting
stockings. Check integrity of the patient’s skin at regular intervals; provide patients with written and verbal
information on how to wear and care for the GCS.
● Fitting IPC devices. Note: Efficacy depends on proper sizing and application.
● Monitor patients for bleeding complications and advise patients on the importance of notifying care providers in the
event of nose or gum bleeding or hematuria.
● Contribute in daily rounds and monitor patient progress.
● Accountable for administering pharmacologic measures including both oral and injectable medications.
Patient education
● Provide patients on oral anticoagulants with information on medications/foods that affect INR.
● Provide information on VTE and its prevention. Advise on possible lifestyle changes in at-risk patients (eg, weight
loss, stopping smoking, regular exercise).
● Psychosocial support of patients with VTE via support groups.
● Educating patients and their families, colleagues, and the public on signs, symptoms, treatment, and prevention of
DVT and PE.
Guidelines and continuing education
● Initiation of, and monitoring compliance with, local VTE management guidelines.
● Involvement in the design of written, formal strategies, and prophylaxis policies.
● Provide and undertake education and training initiatives.
● Assist in meeting quality assurance/JCAHO standards.
● Promote interdisciplinary communication— key to successful VTE prevention.

DVT, Deep vein thrombosis; PE, pulmonary embolism; GCS, graduated compression stockings; IPC, intermittent pneumatic compression; INR,
international normalized ratio; VTE, venous thromboembolism; JCAHO, Joint Commission on Accreditation of Healthcare Organizations.

substantial clinical evidence confirming that both unfraction-
ated heparin (UFH) and low molecular weight heparin
(LMWH) provide effective and safe thromboprophylaxis;
studies have shown little or no increase in the rates of
clinically important bleeding.11-13 The consequences of un-
prevented VTE are potentially much more severe and far
outweigh any justification for not using effective and recom-
mended methods of thromboprophylaxis.
Finally, cost is a factor underlying reluctance to increase
the use of thromboprophylaxis. Pharmacologic and physical
methods of thromboprophylaxis do incur additional expense,
but effective prevention reduces the number of patient read-
missions and the length of hospital stay. Preventing VTE also
reduces the risk of long-term morbidity caused by the life-
long complications that can ensue, such as pulmonary hyper-
tension, devastating leg ulcers from post-phlebitic syndrome,
and chronic leg pain and swelling from chronic venous
insufficiency.14-16 This presents a delayed burden of throm-
bosis often overlooked.15 Preventing DVT with the use of
effective thromboprophylaxis in high-risk patients and mini-
mizing the risk of DVT recurrence will reduce the frequency
of such post-thrombotic complications and have an enormous
impact on the quality of life and long-term cost of care.
The scope of the problem is thus clear: VTE represents a
serious clinical condition contributing to significant morbidity
and mortality. But what role can nurses play in reducing the
burden of VTE? Over the past 10 years, the channels of com-
munication between physicians and nurses have broadened.
Nurses take part in daily rounds and have more input on patient
care decision-making. Nurses and physicians need to work
together to take responsibility and be accountable for the pa-
tient’s protection against VTE. Next, we discuss the nurse’s role
in diagnosis and risk assessment, the application of preventive
methods, and the involvement in patient education that positively
impacts nursing practices. A summary of key nursing practices
for VTE prevention is shown in Table I.
DIAGNOSIS OF VENOUS THROMBOEMBOLISM:
A CLINICAL PROBLEM
Diagnosis of DVT is most frequently performed using
noninvasive vascular ultrasound. This has replaced the
venogram, which was invasive and often painful, and in-
creased the risk of phlebitis. PE is most often diagnosed with
the noninvasive imaging test, chest computed tomography;
lung scans are used less frequently although still relied on if
PAGE 84 JOURNAL OF VASCULAR NURSING SEPTEMBER 2006
www.jvascnurs.net

TABLE II

SIGNS AND SYMPTOMS OF VENOUS THROMBOEMBOLISM AND POST-THROMBOTIC SYNDROME

Condition: Deep vein thrombosis Pulmonary embolism Post-thrombotic syndrome

Signs and symptoms: Calf pain, tenderness, or both Tachypnea (respiratory rate ⬎ 20 Leg pain
Swelling (with/without pitting breaths/min) Lower limb swelling
edema) Dyspnea Venous leg ulceration
Swelling (below knee ⫽ distal Tachycardia (heart rate ⬎ 100 bpm) Varicose veins
vein thrombosis; up to Pleuritic or central chest pain Superficial thrombophlebitis
groin ⫽ proximal vein Cyanosis Venous hypertension
thrombosis) Hemoptysis
Warmth Sudden collapse
Erythema and discoloration Cough
Dilated superficial veins Sweating
Cyanosis
bpm, Beats per minute.

TABLE III

RISK FACTORS FOR VENOUS THROMBOEMBOLISM11

Predisposing (inherent) factors Exposing (acquired) risk factors

Increasing age (⬎ 40 y) Surgery (particularly major orthopedic surgery, cancer surgery,

Obesity neurosurgery)
History of smoking Trauma (major or lower limb)
Pregnancy (and postpartum period) Immobility
History of VTE Paralysis
Family history of VTE Cancer therapy (chemotherapy, radiotherapy, hormonal therapy)
Cancer Central venous catheterization/pacemaker
Heart or respiratory failure Acute medical illness (eg, pneumonia, sepsis)
Inflammatory bowel disease Estrogen-containing oral contraceptives
Diabetes mellitus Hormone replacement therapy
Nephrotic syndrome Selective estrogen receptor modulators
Thrombophilia Myeloproliferative disorders
Neurological disease with extremity paresis Paroxysmal nocturnal hemoglobinuria
Varicose veins/vein stripping Hospitalization
VTE, Venous thromboembolism.

the patient is allergic to contrast dye. The patient should also
expect to have an electrocardiogram, a chest x-ray film, and
blood work including a D-dimer. However, routine screening
of patients for VTE is neither clinically nor economically
efficient.11 This is where the physical examination and thor-
ough family history are crucial, and where nurses have a vital
role in screening for signs and symptoms associated with
VTE. Diagnosis presents a clinical challenge; VTE has few
specific symptoms and is clinically silent in many patients,
such that diagnosis can prove difficult and unreliable. Nurses
must be vigilant for the few signs and symptoms associated
with VTE (Table II).
Diagnosis of PE is also difficult because classic signs and
symptoms are often absent in patients. A thorough history and
physical examination often provide the first clue for early diag-
nosis of PE (Table II). With increasing age of the patient, PE
may masquerade as other illnesses, such as acute coronary
syndromes or exacerbation of chronic lung disease, meaning that
accurate diagnosis of PE is particularly difficult when patients
present with concurrent illnesses, such as pneumonia or conges-
tive heart failure.
Although recognition of the symptoms or signs of early VTE
is important, it will not prevent all clinically important symp-
tomatic thromboembolic events. With routine diagnostic screen-
Vol. XXIV No. 3 JOURNAL OF VASCULAR NURSING PAGE 85
www.jvascnurs.net

VENOUS THROMBOEMBOLISM RISK ASSESSMENT MODEL

FOR SURGICAL AND MEDICAL PATIENTS

STEP 1: EXPOSING RISK FACTORS ASSOCIATED WITH CLINICAL SETTING

Assign 1 factor Assign 2 factors Assign 3 factors Assign 5 factors

Minor surgery Major surgery Major surgery (2-3 hr) Elective major lower extremity
Immobilizing plaster cast (> 60 min) arthroplasty
Medical patient Arthroscopic surgery Hip, pelvis, or leg fracture (< 1 month)
currently at bedrest (> 60 min) Stroke (< 1 month)
Sepsis (< 1 month) Laparoscopic surgery Multiple trauma (< 1 month)
Acute myocardial (> 60 min) Acute spinal cord injury (< 1 month)
infarction (< 1 month) Central venous access Major surgery lasting over 3 hours
Congestive heart failure
(< 1 month)
Serious lung disease
inc. pneumonia (< 1 month)
Abnormal pulmonary function
(COPD)
History of prior major surgery

BASELINE RISK FACTOR SCORE (If score = 5, go to step 4):

_______________________________________________________________________________________
STEP 2: PREDISPOSING RISK FACTORS ASSOCIATED WITH PATIENT

PATIENT RISK FACTORS Assign 1 factor unless otherwise noted

MOLECULAR__________________
CLINICAL SETTING INHERITED ACQUIRED
Age 41 to 60 years (1 factor) Factor V Leiden (3 factors) Positive Lupus anticoagulant (3 factors)
Age 60 to 74 years (2 factors) Positive Prothrombin 20210A Elevated anticardiolipin antibodies (3 factors)
Age over 75 years (3factors) (3 factors) Heparin-induced thrombocytopenia
History of SVT, DVT/PE Elevated serum homocysteine (3 factors)
(3 factors) (3 factors)
Family history of DVT/PE (3 factors) Other thrombophilia (3 factors)
Previous malignancy (2 factors)
Active malignancy or chemotherapy
(3 factors)
Varicose veins
Swollen legs (current)
History of inflammatory bowel disease
Obesity (BMI > 30)
Obesity (BMI > 40) (2 factors)
Obesity (BMI > 50) (3 factors)
Oral contraceptive or
hormonal replacement therapy
History of unexplained stillborn infant,
recurrent spontaneous abortion ( 3),
premature birth with toxemia or growth
-restricted infant
Pregnancy or postpartum (< 1 month)

TOTAL ADDITIONAL PREDISPOSING RISK FACTORS SCORE:____

__________________________________________________________________________________________________
STEP 3: TOTAL RISK FACTORS (EXPOSING + PREDISPOSING):____
STEP 4: RECOMMENDED PROPHYLACTIC REGIMENS FOR EACH RISK GROUP
Low Risk (1 factor) Moderate Risk (2 factors) High Risk (3-4 factors) Highest Risk (5 or more factors)

No specific measures LDUH (q 12 h) LDUH (q 8 h), or Pharmacological: LMWH, LDUH (q 8 h ),

Early ambulation or IPC or GCS, IPC, or LMWH alone, oral anticoagulants, or fondaparinux
or LMWH or in combination with alone or in combination with IPC or GCS
IPC or GCS

Abbreviations: LMWH, low molecular weight heparin; LDUH, low-dose unfractionated heparin; IPC, intermittent pneumatic compression;
GCS, graduated compression stockings.

Figure 1. Example of an easy-to-use, practical thrombosis risk-assessment model (RAM). Updated from Caprini JA, Arcelus JI, Reyna JJ.
Effective risk stratification of surgical and nonsurgical patients for venous thromboembolic disease. Semin Hematol 2001;38(2 Suppl 5):12-9.
Data courtesy of J. A. Caprini, 2006.
PAGE 86 JOURNAL OF VASCULAR NURSING SEPTEMBER 2006
www.jvascnurs.net

RISK FACTORS
1 Personal history of DVT or No = 0 Yes = 3 NA = 0
PE
2 Family history of DVT or PE No = 0 Yes = 3 NA = 0
(any blood relative)
3 Malignancy: current or No = 0 Yes = 2 NA = 0
previous
4 Personal history of recent MI No = 0 Yes = 1 NA = 0
or stroke ( 1 month)
5 Recent major surgery lasting No = 0 Yes = 2 NA = 0
> 60 min ( 1 month)
6 Currently on BCP, HRT, or No = 0 Yes = 1 NA = 0
hormonal therapy for breast
or prostate cancer
7 Current or recent acute No = 0 Yes = 1 NA = 0
inflammatory or
infectious process (< 1
month)
8 Currently immobile (unable No = 0 Yes = 1 NA = 0
to ambulate in the inpatient
setting)
9 History of unexplained No = 0 Yes = 1 NA = 0
stillborn infant,
recurrent spontaneous
abortion, premature birth
with preeclampsia, or
growth-restricted infant
10 Swollen legs No = 0 Yes = 1
11 Varicose veins No = 0 Yes = 1
12 Obesity (BMI 30 kg/m2) No = 0 Yes = 1
13 Age 40 = 0 41–60 = 1 61– 74 = 2 75 = 3
Total DVT risk score _________
Figure 2. Deep vein thrombosis risk-assessment questionnaire to be answered by the patient. BCP, birth control pill; BMI, body mass index;
DVT, deep vein thrombosis; HRT, hormone replacement therapy; MI, myocardial infarction; PE, pulmonary embolism. Courtesy of J. A.
Caprini, 2006.

ing accepted to be inefficient, individualized assessment of VTE
risk offers a logical and effective way to identify and appropri-
ately prophylax at-risk patients.
VENOUS THROMBOEMBOLISM RISK
ASSESSMENT
Risk factors for venous thromboembolism
The risk of VTE varies greatly according to the individual
patient and the clinical situation. A number of risk factors for
VTE have been identified (Table III), which can be considered as
either predisposing factors relating to the patient (eg, age, inher-
ited thrombophilia, and underlying illness such as cancer or
chronic lung disease) or exposing risk factors caused by the
clinical situation (eg, duration/type of surgery, prolonged immo-
bility, and trauma). Many hospitalized patients have several VTE
risk factors, and the effects are cumulative.17 For example, a
patient admitted for surgical resection of lung cancer is at high
risk of VTE because of the operation, the presence of malig-
nancy, the period of immobility after surgery, and potentially the
prothrombotic effects of cancer chemotherapy.
Assessing risk
Accurate, individual risk assessment allows thrombopro-
phylaxis to be targeted appropriately. Risk assessment models
(RAMs) have been developed to predict the level of throm-
botic risk in a given patient from the number and type of risk
Vol. XXIV No. 3 JOURNAL OF VASCULAR NURSING
www.jvascnurs.net
factors with which the patient presents. With information
obtained from the patient’s clinical history and physical
examination, current RAMs offer nurses a simple tool that
directly links VTE risk to specific recommendations for VTE
prevention. An example RAM is shown in Figure 1.18 Scoring
of VTE risk factors allows the level of risk to be categorized
according to the American College of Chest Physicians guide-
lines (low, moderate, high, or highest) and matched with
specific recommendations for prophylaxis.11 There are clear
benefits in making the patient an active partner in this process.
Figure 2 represents a simple patient history questionnaire that
can be completed by the patient at the time of the initial
encounter. Nurses are central to facilitating this process—
working with the patient in this way greatly simplifies data
collection and subsequent assessment.
Every hospitalized patient should be assessed for VTE risk
factors and prescribed prophylactic measures included in the
patient’s admission orders. Most hospitals use a nursing assess-
ment form. This form serves as a catalyst for achieving the
objectives of the hospitalization and implementing patient care
plans. Ideally, the risk assessment for VTE should be incorpo-
rated into the initial nursing assessment form.
Methods of prevention
Nurses execute the orders for VTE prophylaxis, regardless
of which modality or combination of modalities, and will be
responsible for ongoing administration and monitoring. Pre-
vention methods can be either pharmacologic (eg, UFH,
LMWH, fondaparinux, or warfarin) or mechanical (eg, early
mobilization, graduated compression stockings, or intermit-
tent pneumatic compression devices). Current methods are
summarized in Table IV.11,19,20
Nurses are accountable for administering pharmacologic
measures including both oral and injectable medications. Unless
anticoagulants are contraindicated, heparin-based thrombopro-
phylaxis (ie, with UFH or LMWH) is currently the mainstay of
pharmacologic prophylaxis for patients at moderate, high, or
highest risk of VTE who require rapid, safe, and effective
prophylaxis before, during, or after a period of increased VTE
risk, such as surgery or prolonged immobilization. Vitamin K
antagonists, such as warfarin, have been used safely and effec-
tively for many years in VTE treatment and for secondary
prevention in patients at high risk for recurrence. However,
warfarin is considered by many nurses to be a problematic
medication; a narrow therapeutic window requires frequent mon-
itoring and dose adjustment, whereas numerous factors can
contribute to over- or undertreatment, including medical condi-
tions and concomitant therapies, variations in dietary vitamin K
intake, alcohol use, dosing errors, and patient adherence to
treatment.19
Most mechanical methods of thromboprophylaxis aim to
reduce venous stasis and thus the propensity for clot formation.
They find particular use in patients at low risk of VTE and in
those with a contraindication to pharmacologic therapy, and can
also be used as an adjunct to pharmacologic therapy in patients
at very high thromboembolic risk. The nurse will have an active
role in the implementation of mechanical prophylaxis methods.
In the first instance, the nurse will encourage able patients to
PAGE 87
ambulate as early as possible and avoid prolonged bedrest. If
graduated compression stockings are recommended, they should
be prescribed by the health care provider and the patient should
be measured accurately by the nurse for a correct fit. At dis-
charge, specific compression is prescribed depending on the
degree of symptoms, such as pain, swelling, or discoloration.
Application and troubleshooting of intermittent pneumatic com-
pression devices (which work by rhythmically compressing the
lower extremities to increase venous flow) are also nursing
responsibilities. Studies have shown such devices to be effective,
although their usefulness can be limited by incorrect use, poor
compliance, and the inability to continue after hospital dis-
charge.11 Nurses are well positioned to educate the patient on
their use and benefits, and thus improve compliance.
Patient education and awareness
It is recommended that the patient becomes an active partner
in the prophylaxis decision-making process, and this is where the
nurse can play a vital role. Not only must nurses be vigilant for
signs and symptoms in their patients, but it is important to ensure
the patient is aware of signs and symptoms to encourage self-
reporting. Nurses also discuss lifestyle modifications and pre-
ventable risk factors (eg, smoking, obesity), educating both the
patients and their families. Ensuring the patient is informed is
particularly important in light of the trend toward shortened
hospital stays or treatment as an outpatient. Such time constraints
can be very frustrating for the patient as well as for the nurse:
Advocate for your patients and be proactive.
For a patient informed of increased thromboembolic risk or
for those who have previously experienced an event, psychologic
effects may be apparent, presenting in some cases as extreme
anxiety or a constant fear of death (often expressed as a “time
bomb waiting to happen”). Support groups led by physicians and
nurses, such as the one established at Brigham and Women’s
Hospital, Boston, can provide invaluable support to patients and
their families at this time.
Wider education: Coalition to fight the killer
As a response to the mounting public health crisis, in Feb-
ruary 2003 more than 60 organizations assembled to discuss the
urgent need to make DVT a top public health priority. At this
meeting, co-hosted by the American Public Health Association
and Centers for Disease Control, participants agreed to establish
a coalition of organizations committed to educating the public
and health care community about DVT and the importance of
recognizing risk factors and implementing early measures. Co-
alition members include the American Nurses Association,
American Academy of Nurse Practitioners, and American As-
sociation of Managed Care Nurses. One of the early outcomes
for the coalition was the development of a White Paper, a useful
resource that describes in simple terms the scope of the problem,
risk factors, and practical measures for prevention (visit www.
preventdvt.org to download a copy).
Consensus guidelines and continuing education
The current consensus guidelines published by the American
College of Chest Physicians highlight the need for a coordinated
 PAGE 88
TABLE IV

SUMMARY OF CURRENT AMERICAN COLLEGE OF CHEST PHYSICIANS’ RECOMMENDED METHODS FOR PREVENTION OF
VENOUS THROMBOEMBOLISM11,19,20

Method Mode of action Strategy Patient population Benefits Disadvantages

Pharmacologic*
UFH Indirect thrombin Primary prevention Moderate- or high-risk ● Effective prevention of ● Risk of HIT
inhibitor (Factors Xa surgical patients DVT and PE ● Risk of osteoporosis (with
and ILa) At-risk medical patients ● Lower acquisition costs long-term use)
relative to LMWH ● Vigilance recommended in
● No need for coagulation those with severe renal
monitoring at impairment, low body
prophylactic doses weight, or very high
bleeding risk
● Twice- or three-times daily

JOURNAL OF VASCULAR NURSING

dosing schedule
LMWH Indirect thrombin Primary prevention Moderate-, high-, and ● Effective prevention of ● Risk of HIT or osteoporosis
inhibitor (Factors Xa Secondary prevention highest-risk surgical DVT and PE with long-term use; although
and ILa) patients ● Once-daily dose suitable lower relative to UFH

At-risk medical patients for outpatient therapy,
Patients with cancer at which may bring
risk of recurrence convenience and cost
benefits
● No need for coagulation
monitoring
Vitamin K antagonists Inhibits synthesis of Primary prevention Highest-risk patients: ● Effective prevention of
(eg, warfarin) vitamin K- dependent Secondary prevention surgery, trauma, SCI recurrent VTE
clotting factors Patients at risk of ● No risk of HIT or
recurrence osteoporosis (with long-
term use)
● Convenient oral
administration
● Suitable for long-term
prophylaxis
● Low acquisition costs
relative to heparins
www.jvascnurs.net
● Vigilance recommended in
those with severe renal
impairment, low body
weight, or very high
bleeding risk
● Higher acquisition cost
relative to UFH
● Regular monitoring and dose
adjustments required to
maintain therapeutic INR
● Inter-patient dose variability
● Lag of ⱖ 4 days until
therapeutic coagulation
levels achieved
● May require periprocedural
“bridging” with LMWH or
UFH
● Significant interactions with
range of drugs and foods
● Contraindicated in patients
with active bleeding or

SEPTEMBER 2006
hypersensitivity, on
NSAIDs, and during
pregnancy
● Dose sensitivity in geriatric
patients with increased
major bleeding
 Vol. XXIV No. 3
TABLE IV

(CONTINUED)

Fondaparinux Indirect thrombin Primary prevention Highest-risk orthopedic ● Effective prevention of ● Vigilance recommended in
inhibitor (Factor Xa) surgery patients DVT and PE those with severe renal
● Once-daily injection impairment, low body
● No need for coagulation weight, or very high
monitoring bleeding risk
Mechanical
Ambulation (early and Reduces venous stasis Primary prevention Low-risk patients ● Cheap and easy to ● Limited efficacy
“aggressive”) implement in able ● Limited in patients with
patients impaired mobility
Graduated compression Physical reduction of Primary prevention Low-risk patients, or as ● No increased risk of ● Limited efficacy (not
stockings venous combination bleeding complications suitable for high or highest-
stasis/promotion of therapy with ● Useful adjunct to risk patients)

JOURNAL OF VASCULAR NURSING

venous return LMWH or UFH in pharmacologic therapy ● Efficacy can be reduced by
high-risk patients, ● May help prevent post- poor fitting
or in patients thrombotic syndrome ● May aggravate peripheral
contraindicated to (known to minimize and/ arterial disease

www.jvascnurs.net
pharmacologic or prevent venous stasis
therapy ulcers)
● Inexpensive
IPC Rhythmic compression Primary prevention Low-risk patients or as ● No increased risk of ● Use limited by poor
of the lower combination bleeding complications compliance, incorrect use,
extremities to therapy with ● Useful adjunct to and the inability to be used
increase both mean LMWH or UFH in pharmacologic therapy after hospital discharge
and peak venous high-risk patients, ● Relatively low-cost, ● May aggravate peripheral
flow or in those reusable devices arterial disease
contraindicated to
pharmacologic
therapy
IVC filters Physical barrier to filter Secondary prevention Patients at high risk for ● No increased risk of ● Filters can become blocked
thrombotic debris in patients with PE with bleeding complications over time
PE contraindication to ● Effective measure in ● Venous collaterals develop
or pulmonary anticoagulation or selected high-risk around the IVC
hypertension in whom patients
anticoagulation is
ineffective

DVT, Deep vein thrombosis; GCS, graduated compression stockings; HIT, heparin-induced thrombocytopenia; INR, international normalized ratio; IPC, intermittent pneumatic compression; IVC, inferior
vena cava; LMWH, low molecular weight heparin; NSAID, nonsteroidal anti-inflammatory drug; PE, pulmonary embolism; SCI, spinal cord injury; UFH, unfractionated heparin; VTE, venous
thromboembolism *All pharmacologic anthithrombotic agents are associated with an increased bleeding risk.

PAGE 89
PAGE 90 JOURNAL OF VASCULAR NURSING
www.jvascnurs.net
approach to the detection, prevention, and treatment of DVT.11
Every hospital should have a thromboprophylactic policy based
on the clinical evidence in consensus guidelines. Integrated 7.
clinical care pathways are one way of achieving this. As struc-
tured, multidisciplinary care plans, they are designed to support
the implementation of clinical guidelines and help reduce un-
necessary variations in patient care and outcomes. They can also 8.
support the development of care partnerships and empower
patients and health care professionals. Central to this are local
continuing medical and nursing education initiatives that are key 9.
to improving awareness and adherence to VTE management
guidelines. Hospital audits have shown that thromboprophylaxis
rates significantly improve after educational programs have been 10.
put in place, particularly when local hospital data on the inci-
dence of VTE are used to highlight the need for prophylaxis.21,22
Also take time to educate yourself: Review recent literature and 11.
published research in treatment and prevention, be familiar with
diagnostic modalities to explain test procedures accurately, and
understand preventive modalities to optimize care. Overall
awareness of VTE prophylaxis and well-educated physicians and 12.
nurses should help to decrease the incidence of VTE.
CONCLUSIONS
Nurses are on the frontline in the prevention of thrombosis. 13.
Both DVT, and its potentially life-threatening complication PE,
can have long-term effects on patient health and their future
management. Skilled nursing intervention can save lives through
vigilance for clinical signs and symptoms that arouse suspicion
for acute VTE, and assessment of a patient’s VTE risk on 14.
admission and throughout their hospital stay. As an essential part
of a multidisciplinary team, nurses will help meet and maintain
quality assurance standards and compliance to guidelines that
will directly translate into improved patient care. Through edu- 15.
cating patients, their families, colleagues, and, indeed, them-
selves, nurses can make a real impact on a largely preventable
condition that is one of the nation’s leading causes of death. 16.
17.
REFERENCES
1. Sandler DA, Martin JF. Autopsy proven pulmonary embo-
lism in hospital patients: are we detecting enough deep vein 18.
thrombosis? JR Soc Med 1989;82:203-5.
2. Lindblad B, Eriksson A, Bergqvist D. Autopsy-verified
pulmonary embolism in a surgical department: analysis of 19.
the period from 1951 to 1988. Br J Surg 1991;78:849-52.
3. Prandoni P, Lensing AW, Cogo A, et al. The long-term
clinical course of acute deep venous thrombosis. Ann Intern
Med 1996;125:1-7. 20.
4. Shojania KG, Duncan BW, McDonald KM, et al. Making
health care safer: a critical analysis of patient safety practices.
Evid Rep Technol Assess (Summ) 2001;(43):i-x,1-668. 21.
5. Anderson Jr, FA, Tapson VF, Decousus H, et al. IMPROVE,
a multinational observational cohort study of practices in
prevention of venous thromboembolism in acutely ill med-
ical patients: a comparison with clinical study patient pop-
ulations. Blood 2003;102:3l9a. 22.
6. Stratton MA, Anderson FA, Bussey HI, et al. Prevention of
venous thromboembolism: adherence to the 1995 American
SEPTEMBER 2006
College of Chest Physicians consensus guidelines for
surgical patients. Arch Intern Med 2000;160:334-40.
Arnold DM, Kahn SR, Shrier I. Missed opportunities for
prevention of venous thromboembolism: an evaluation of
the use of thromboprophylaxis guidelines. Chest 2001;120:
1964-71.
Bergmann JF, Mouly S. Thromboprophylaxis in medical
patients: focus on France. Semin Thromb Hemost 2002;
28(Suppl 3):51-5.
Goldhaber SZ, Tapson VF. A prospective registry of 5,451
patients with ultrasound-confirmed deep vein thrombosis.
Am J Cardiol 2004;93:259-62.
White RH, Romano PS, Zhou H, et al. Incidence and time
course of thromboembolic outcomes following total hip or
knee arthroplasty. Arch Intern Med 1998;158:1525-31.
Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous
thromboembolism: the Seventh ACCP Conference on Anti-
thrombotic and Thrombolytic Therapy. Chest 2004;126(3
Suppl):338S-400S.
Koch A, Bouges S, Ziegler S, et al. Low molecular weight
heparin and unfractionated heparin in thrombosis prophy-
laxis after major surgical intervention: update of previous
meta-analyses. Br J Surg 1997;84:750-9.
Kakkar VV, Cohen AT, Edmonson RA, et al. Low molec-
ular weight versus standard heparin for prevention of venous
thromboembolism after major abdominal surgery. The
Thromboprophylaxis Collaborative Group. Lancet 1993;
341:259-65.
Bergqvist D, Jendteg S, Johansen L, et al. Cost of long-term
complications of deep venous thrombosis of the lower ex-
tremities: an analysis of a defined patient population in
Sweden. Ann Intern Med 1997;126:454-7.
Kahn SR. The post-thrombotic syndrome: the forgotten
morbidity of venous thrombosis. J Thromb Thrombolysis
2006;21(1):41-8.
Eberhardt RT, Raffetto JD. Chronic venous insufficiency.
Circulation 2005;111:2398-409.
Wheeler HB. Diagnosis of deep vein thrombosis. Review of
clinical evaluation and impedance plethysmography. Am J
Surg 1985;150(4A):7-13.
Caprini JA, Arcelus JI, Reyna JJ. Effective risk stratification
of surgical and nonsurgical patients for venous thromboem-
bolic disease. Semin Hematol 2001;38(2 Suppl 5):12-9.
Ansell J, Hirsh J, Poller L, et al. The pharmacology and
management of the vitamin K antagonists: the Seventh
ACCP Conference on Antithrombotic and Thrombolytic
Therapy. Chest 2004;126(3 Suppl):204S-33S.
Bauer KA. Fondaparinux: a new synthetic and selective
inhibitor of Factor Xa. Best Pract Res Clin Haematol 2004;
17:89-104.
Anderson Jr, FA Wheeler HB, Goldberg RJ, et al. Changing
clinical practice. Prospective study of the impact of continu-
ing medical education and quality assurance programs on
use of prophylaxis for venous thromboembolism. Arch In-
tern Med 1994;154:669-77.
Peterson GM, Drake CI, Jupe DM, et al. Educational cam-
paign to improve the prevention of postoperative venous
thromboembolism. J Clin Pharm Ther 1999;24:279-87.