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5 Deep Vein Thrombosis Nursing

Care Plans
UPDATED ON MARCH 18, 2022 BY PAUL MARTIN, BSN, R.N.

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Thrombophlebitis is the inflammation of the vein wall resulting in the formation of a

thrombosis (blood clot) that may interfere 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 a
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.

Nursing Care Plans

The nursing care plan for the client with deep vein thrombosis include: providing
information regarding disease condition, treatment, and prevention; assessing and
monitoring anticoagulant therapy; providing comfort measures; positioning the body
and encouraging exercise; maintaining adequate tissue perfusion;
perfusion; and preventing
complications.

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Here are five (5) nursing care plans (NCP) and nursing diagnosis for patients with
deep vein thrombosis (DVT):

1. Impaired Gas Exchange

2. Ineffective Peripheral Tissue Perfusion
3. Acute Pain
4. Deficient Knowledge
5. Risk For Bleeding

1. Impaired Gas Exchange

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Impaired Gas Exchange
Nursing Diagnosis

Impaired Gas Exchange

May be related to

Altered blood flow to alveoli or to major portions of the lung

Alveolar-capillary membrane changesactive bleeding, airway or alveolar
collapse, atelectasis, excessive secretions, or pulmonary effusion/edema

Possibly evidenced by

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Apprehension
Cyanosis
Dyspnea
Hypercapnia
Hypoxemia
Restlessness
Somnolence

Desired Outcomes

Client will demonstrate adequate ventilation and oxygenation by ABGs within

client’s normal range.
Client will report or display resolution or absence of symptoms of respiratory
distress.

Nursing Interventions Rationale

Initial signs of systemic hypoxemia

Assess level of consciousness and include restlessness and irritability,
changes in mentation. followed by progressively decreased
mentation.

Auscultate lungs for areas of decreased Non-ventilated areas may be identified

and absent breath sounds and the by the absence of breath sounds.
presence of adventitious sounds
(crackles).
Monitor vital signs. Observe changes in
cardiac rhythm.
Assess respiratory rate and rhythm.
Observe for use of accessory muscles,
nasal flaring, and pursed lip breathing.
Observe for generalized duskiness and
cyanosis in the earlobes, lips, tongue,
and buccal membranes.
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.
Monitor the client frequently and
arrange for someone to stay with the
client, as indicated.
Provide brief explanations of what is
happening and expected effects of an
intervention.
Encourage expression of feelings and
inform the client and significant others
of normalcy of anxious feelings and
sense of impending doom.
Crackles may be seen in fluid-filled
tissues and airway or may indicate
cardiac decompensation.
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.
Tachypnea and dyspnea indicative of
pulmonary obstruction. Dyspnea and
increased work of breathing may be first
or only sign of subacute pulmonary
embolism. Severe respiratory distress
and failure accompany moderate to
severe loss of functional lung units.
Suggestive of systemic hypoxemia.
These guidelines help in determining the
response of the client to resume
activities and ability to engage in self-
care.
Provides assurance that changes in
condition will be noted and that
assistance is readily available.
Relieves anxiety related to unknown and
may help decrease fears regarding
personal safety.
Understanding basis of feelings may
help the client regain some sense of
control over emotions.
Assist with frequent changes of position, Turning and ambulation enhance
and encourage ambulation as tolerated. aeration of different lung segments,
thereby improving oxygenation.

Increases oxygen delivery to the lungs

Encourage coughing, deep breathing
by mobilizing secretions and enhancing
exercises, and suctioning as indicated.
ventilation.

Inability to breathe properly increases

Assist client to deal with the fear and
oxygen consumption and demand,
anxiety that may be present.
therefore, worsening the anxiety level.

Promotes maximal chest expansion,

making it easier to breathe and
Keep the head of bed elevated.
enhancing physiological and
psychological comfort.

Hypoxemia is present in varying degrees,

depending on the degree of airway
obstruction, cardiopulmonary status, and
Monitor ABGs or pulse oximetry.
presence and degree of shock.
Respiratory alkalosis and metabolic
acidosis may also be present.

May reveal the pattern of abnormal

perfusion in areas of ventilation,
reflecting ventilation and perfusion
mismatch, confirming the diagnosis of
Prepare the client for a lung scan.
pulmonary embolism and degree of
obstruction. Absence of both ventilation
and perfusion reflects alveolar
congestion or airway obstruction.

Facilitates deeper respiratory effort and

Assist with chest physiotherapy, such as
promotes drainage of secretions from
postural drainage and percussion of the
lung segments into bronchi, where they
non-affected area and incentive
may more readily be removed by
spirometer.
coughing or suctioning.

Nebulization gives moisture to mucous

Provide supplemental humidification,
membranes and helps liquefy secretions
such as ultrasonic nebulizers.
to facilitate airway clearance.
Provide oxygen therapy with an
appropriate method as ordered.
Provide adequate hydration either oral
(PO) or IV as indicated.
Administer medications, as indicated:
Thrombolytic agents, such as
alteplase (Activase, tPA),
anistreplase (APSAC, Eminase),
reteplase (Retavase),
streptokinase (Kabikinase,
Streptase), tenecteplase (TNKase)
and urokinase (Abbokinase)
Morphine sulfate and anti-anxiety
agents
Prepare for and assist with
bronchoscopy.
Prepare for surgical intervention, if
indicated.
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Maximizes available oxygen for gas
exchange, reducing work of breathing.
Increased fluids may be given to
decrease hyperviscosity of blood, which
can potentiate thrombus formation, or
support circulating volume and tissue
perfusion.
These agents intended to bring about
clot lysis (breakdown of the clot) and
immediate normalization of venous
blood flow.
These are given to decrease pain or
anxiety and improve work of breathing.,
maximizing gas exchange.
The purpose of this procedure is to
remove blood clots and clear the airway.
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.
 1. Impaired Gas Exchange

Next
Ineffective Peripheral Tissue
Perfusion

Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.

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more information, check out our privacy policy.

Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)

An awesome book to help you create and customize effective nursing care
plans. We highly recommend this book for its completeness and ease of use.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales

A quick-reference tool to easily select the appropriate nursing diagnosis to plan

your patient’s care effectively.
NANDA International Nursing Diagnoses: Definitions & Classification,
2021-2023 (12th Edition)

The official and definitive guide to nursing diagnoses as reviewed and approved
by the NANDA-I. This book focuses on the nursing diagnostic labels, their
defining characteristics, and risk factors – this does not include nursing
interventions and rationales.
Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-
2023 NANDA-I® Updates

Another great nursing care plan resource that is updated to include the recent
NANDA-I updates.
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-
5(TM))

Useful for creating nursing care plans related to mental health and psychiatric
nursing.
Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition

Claims to have the most in-depth care plans of any nursing care planning book.
Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care
plans.