Nursing Care Plan: Deep Vein Thrombosis (DVT)

By: Anna Curran, RN, BSN, PHN

1. Definition

Blood clot formation in deep veins, usually in the legs, can lead to pulmonary embolism if dislodged.

2. Basic Assessment

• Check the affected limb for pain, swelling, warmth, redness
• Monitor vital signs, including respiratory status
• Assess the Homans' sign and dorsiflexion pain
• Document circumference measurements of the affected limb

3. Desired Outcomes

• Patient remains free from complications
• Patient demonstrates anticoagulation compliance
• Patient maintains limb circulation
• Patient performs prescribed exercises
• Patient verbalizes understanding of prevention

4. Nursing Diagnoses

• Impaired Physical Mobility related to pain/prescribed bedrest
• Risk for Injury (PE) related to clot formation
• Acute Pain related to inflammation
• Ineffective Peripheral Tissue Perfusion related to thrombosis
• Knowledge Deficit related to anticoagulation therapy

5. Nursing Interventions with Rationales

1. Anticoagulation therapy management
   • Rationale: Prevents clot progression
2. Monitor extremity circulation
   • Rationale: Detects complications early
3. Apply compression devices
   • Rationale: Promotes venous return
4. Early mobilization
   • Rationale: Prevents stasis
5. Patient education on prevention
   • Rationale: Reduces recurrence risk

6. Patient Evaluations

• Monitor anticoagulation levels
• Track limb measurements
• Assess pain levels
• Document circulation status

7. Critical Nursing Tips

• Know PE warning signs
• Monitor bleeding risk
• Remember contraindications for compression
• Check medication interactions