Table of Contents:

1. Venous Thromboembolism (VTE) 3. Pulmonary Embolism (PE)

2. Deep Vein Thrombosis (DVT) 4. Anticoagulants

Deep Vein Thrombosis & Pulmonary Embolism

1. Venous Thromboembolism

Cardiovascular
Venous thromboembolism (VTE) occurs when a blood
clot forms in a vein:
TABLE 1. VIRCHOW TRIAD: VTE RISK FACTORS
y Deep vein thrombosis (DVT): Clot is lodged in a
deep vein, typically in the legs.
Prolonged immobility
y Pulmonary embolism (PE): Clot breaks loose and (bed rest, long flights)
travels to the lungs, blocking blood flow. Stasis of blood
Older age (>60)
flow y Atrial fibrillation
Risk factors:
y Varicose veins

VTEs are caused by stasis of blood flow,
y Obesity
endothelial injury, and hypercoagulability
(FIGURE 1 & TABLE 1).
y Trauma (hip fracture)
#1 Priority = prevention: y Abdominal and pelvic
y Clients with a history of VTEs are at high risk for surgeries
Endothelial injury
VTE recurrence. y Venous injury
y Teach clients VTE prevention measures (see TABLE 2). (phlebotomy), IV drug use
y Educate clients with a history of VTEs on
recognizing PE symptoms (dyspnea, chest pain).

Malignancy

Birth control and

FIGURE 1. VIRCHOW TRIAD hormone therapy
containing estrogen
Hypercoagulability

Pregnancy and
postpartum
y Tobacco use
y Dehydration

 Risk factors and prevention: Virchow Triad identifies blood stasis, endothelial injury, and
hypercoagulable states as key factors in VTE development. Prevention measures include avoiding
prolonged immobility and smoking cessation.

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1. Venous Thromboembolism, Continued

FIGURE 2. DEEP VEIN THROMBOSIS

TABLE 2. VTE PREVENTION MEASURES

Avoid immobility and prolonged sitting, such

as long flights (ambulate frequently, exercise as
tolerated, early ambulation following surgery).

Encourage smoking cessation.
y Stay well hydrated; avoid alcohol.

Cardiovascular
y Avoid birth control and hormone replacement
therapy containing estrogen.
y Encourage weight loss for overweight clients.
y Avoid wearing constrictive clothing.

Additional prevention may be required:

Anticoagulants (enoxaparin)
Diagnostics:

Compression stockings and sequential

A D-dimer test detects a protein released when the
compression devices (SCDs) (see TABLE 3)
body breaks down a clot.
y D-dimer indicates a possible clot.
y An ultrasound of the affected extremity visualizes
TABLE 3. COMPRESSION STOCKINGS & SCDS SAFETY POINTS blood clot location and size.
Interventions:
Proper fitting maximizes effectiveness and prevents
DVT care focuses on:
skin breakdown.
1. Treating the thrombosis
2. Avoiding bleeding complications
Compression stockings:
3. Preventing pulmonary embolism

Measure leg size to ensure adequate sizing.
y Too tight =distal perfusion. 1. Treat the thrombosis:
y Too loose = ineffective.
Administer anticoagulants (heparin,
y Remove wrinkles in the stockings and avoid enoxaparin, direct oral anticoagulants) to
rolling them down to preventperfusion. prevent clot growth and additional clot
SCDs: formation (TABLE 5).
y Ensure two fingers can fit between the leg and y Warfarin takes 5-7 days to reach a therapeutic
SCD sleeve. INR; clients must receive heparin or enoxaparin
in the meantime as “bridge” therapy.

Elevate the affected extremity above heart level
2. Deep Vein Thrombosis (DVT)
toblood return.
y DVT is a blood clot lodged in a deep vein, typically
Encourage ambulation to improve venous
in the femoral or iliac veins of the leg (see FIGURE 2). return and prevent additional clot formation.
Assessment findings:
Bed rest is no longer routinely
y Clients with DVT may be asymptomatic. recommended for clients with DVT unless
y Symptoms are localized to the affected extremity indicated by HCP.
and result from inflammation caused by the clot: y Avoid prolonged standing.

Tenderness

Swelling, warmth, and erythema
y Full or tight feeling

 DVT and PE symptoms: DVT symptoms include tenderness, swelling, warmth, and erythema in the
affected extremity. PE symptoms include dyspnea, chest pain, and decreased pulse oximetry.

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2. Deep Vein Thrombosis (DVT), Continued
2. Avoid bleeding complications:

Implement bleeding precautions. FIGURE 3. INFERIOR VENA CAVA FILTER

#1 priority for clients receiving anticoagulants
or thrombolytics = bleeding precautions
(see TABLE 4).

Frequently monitor PTT (for heparin) and
PT/INR (for warfarin) (see TABLE 5).

Cardiovascular
y Titrate medication as prescribed.

If PTT is critically high, #1 priority = assess
for signs of bleeding (see TABLE 4).
y Monitor CBC to assess for bleeding
(hemoglobin).

TABLE 4. BLEEDING PRECAUTIONS

3. Pulmonary Embolism (PE)

Frequently assess for signs of bleeding:
y Altered mental status
PE is an emergent, life-threatening condition.
y Blood in stool, emesis, or urine y PE is a blockage of one or more pulmonary arteries,
y Bleeding from gums or injection sites usually caused by a dislodged DVT that disrupts
y Unusual bruising blood flow to the lungs.
y Report signs of unusual bleeding to HCP
With a PE, there is sufficient ventilation (V)
immediately tohemorrhage risk. but reduced perfusion (Q), leading to a V/Q
y Avoid invasive procedures (rectal temperatures, mismatch and respiratory failure (FIGURE 4).
IM injections). y Pulmonary artery obstruction  Pulmonary
y Use a soft-bristle toothbrush and electric razor. hypertension  Right heart failure + Obstructive
shock perfusion

3. Prevent pulmonary embolism: FIGURE 4. PULMONARY EMBOLISM

DVTs can break loose and cause a PE.
To prevent:

Do not massage the affected extremity.

Do not apply SCDs to an extremity with
a clot.
y Clients who cannot tolerate anticoagulants
or have recurrent clots may require surgical
intervention to prevent PE:

Insertion of an inferior vena cava filter to
catch clots and prevent PE (see FIGURE 3)
y Thrombectomy to remove blood clot

 Bleeding precautions: The #1 priority for  PE prevention: To prevent dislodgement of a DVT,

clients taking anticoagulants is implementing avoid massaging the affected extremity, and do
bleeding precautions. This includes using a not apply sequential compression devices (SCDs)
soft-bristle toothbrush and an electric razor. to an extremity with signs of a clot.
The nurse should avoid invasive procedures
such as rectal temperatures and administering
IM medications.

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3. Pulmonary Embolism (PE), Continued
Assessment findings: 2. Monitor for and treat shock:
Symptoms usually develop suddenly and include: y Initiate continuous cardiac monitoring.
y Respiratory symptoms caused bygas exchange:
Monitor for tachycardia and hypotension, which

Dyspnea, hypoxemia indicate shock.

Pleuritic chest pain y Anticipate continuous hemodynamic
y Cough monitoring with a central and/or arterial
y Cardiac symptoms caused byperfusion: line.

Cardiovascular
y HR,BP y Administer IV fluids to maintain perfusion.
y Altered mental status, feeling of
Administer and titrate vasopressors if
“impending doom” hypotension persists despite IV fluid
administration.
Diagnostic testing to visualize embolus size and
location includes: 3. Assess and treat the embolism:

CT angiogram of the chest with contrast y Administer anticoagulants (heparin) (see TABLE 5).

Ventilation-perfusion (V/Q) lung scan y Unstable clients may require fibrinolytic
Interventions: (thrombolytic) therapy (tPA) to dissolve the clot.

Implement bleeding precautions for clients on
PE is a life-threatening condition that requires urgent
anticoagulant or fibrinolytic therapy (see TABLE 4).
intervention. PE care focuses on:
y Anticipate surgical removal of the clot
1. Maintaining adequate oxygenation and
(pulmonary embolectomy) for clients who are
perfusion
hemodynamically unstable or cannot tolerate
2. Monitoring for and treating shock
anticoagulants.
3. Assessing and treating the embolism
1. Maintain adequate oxygenation and perfusion:

#1 priority with PE = improving oxygenation.

Position client in Fowler position with lower
extremities dependent toventilation and
venous return to the heart.
y Maintain bed rest tooxygen demand.

Monitor pulse oximetry and arterial blood gas
(ABG) levels.

Administer supplemental oxygen.
y Prepare for endotracheal intubation
and mechanical ventilation for severe
hypoxemia.
y Assess respiratory status frequently, including
rate, depth, and effort.

 PE interventions: If PE is suspected, position the client in the Fowler position, monitor pulse oximetry,
and provide supplemental oxygen.

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4. Anticoagulants

TABLE 5. ANTICOAGULANTS

Implement bleeding precautions for all clients on anticoagulants (see TABLE 4).

Do not give antiplatelet medications (ASA, clopidogrel) to clients taking anticoagulants.
● Notify HCP if bleeding occurs.

Cardiovascular
Heparin ● Risk for HIT: If a client develops thrombocytopenia, stop heparin and notify HCP.
● Monitor PTT when giving IV heparin.
heparin (unfractionated)
● Have antidote for bleeding: Protamine sulfate
Low-molecular weight
heparin (LMWH)
enoxaparin
dalteparin

● Monitor INR: Takes 5-7 days to reach therapeutic levels

Vitamin K antagonist ● Keep vitamin K intake consistent: Do not suddenly increase or decrease intake of
warfarin leafy green vegetables.
● Have antidote for bleeding: Vitamin K

Direct oral ● Unlike warfarin, DOACs work quickly and do not require INR monitoring.
anticoagulants (DOACs)
rivaroxaban
apixaban
dabigatran

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  What three factors contribute to VTE  To prevent dislodgement of a DVT, do not _____
development according to the Virchow Triad? the affected extremity, and do not apply _____
VTE prevention measures include avoiding to an extremity with a clot.
prolonged _____ and _____ cessation.
 If PE is suspected, position the client in the
 What are the symptoms of a DVT? What are the _____ position, monitor pulse oximetry, and
symptoms of a PE?

Cardiovascular
provide supplemental _____.

 The #1 priority for clients taking anticoagulants

is to implement _____. This includes using a(n)
_____ toothbrush and a(n) _____ razor. The
nurse should avoid invasive procedures such
as _____ temperatures and avoid administering
medications via _____ (what route?).

dyspnea, chest pain, decreased pulse oximetry 3. bleeding precautions; soft-bristle, electric; rectal, IM 4. massage, SCDs 5. Fowler, oxygen
Answers: 1. blood stasis, endothelial injury, and hypercoagulability; immobility, smoking 2. tenderness, swelling, warmth, and erythema of the affected extremity;

References:

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Attributions:
(2023). Lewis’s medical-surgical nursing: Assessment and
management of clinical problems (12th ed.). Elsevier. y Virchow Triad: Created with [Link]

Ignatavicius, D., Heimgartner, N., & Rebar, C. (Eds.). (2024). y DVT: James Heilman, MD, CC BY-SA 4.0, via Wikimedia
Medical-surgical nursing: Concepts for clinical judgment Commons, modified with [Link]
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y Inferior Vena Cava Filter: [Link]
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