DVT and Homan's sign

[HarmonyW]

I have been told two seperate things by two different teachers about DVT signs. One is saying to use Homan's sign of forcefully dosiflex the foot to check for DVT. Calf pain would indicate a positive Homan's sign and possible DVT. Another teacher is telling me they do not do Homan's anymore because of possibly dislodging the clot and to squeeze the calf with both hands instead to check for calf pain. I asked the other teacher about this and she said no squeezing the calf could dislodge the clot and not to do that. Help! Which should I do?

[klone, MSN, RN]

As someone else mentioned, I would not perform it if the pt already had s/sx of DVT.

For those who work with pp women, do you check DTRs and for clonus? I would think checking for clonus would carry the same risks as checking for Homans sign.

[Music in My Heart]

Homans' sign is of little practical value these days. Off the top of my head, I recall the predictability being on the order of 30%. When faced with the non-zero risk of throwing a clot, what's the value given that the D-dimer and ultrasound are how it's diagnosed.

[belgarion]

We were taught how to do it and then we were taught NOT to do it. I don't think I have ever done it with a real patient.

[dudette10, MSN, RN]

I just learned the other day that new research in pre-eclampsia finds that women who have >8 proteinuria in a 24-hour urine are at greater risk of developing DVTs postpartum, and that current recommendation is to have them on subcut heparin during their hospital stay. I had questioned the doctor because I had a s/p MgSO4 pt secondary to pre-eclampsia, and I was wondering why she was on heparin, as when I questioned her, she didn't have any risk factors that I could determine.

Could you tell me more about this for curiosity's sake? My drug book indicates that subcut heparin duration is 8-12 hrs, while IV duration is 2-6 hrs. What happens if the patient has to go in for an emergency C-section?

Practically speaking, it seems that IV heparin should be stopped 3 hours prior to invasive medical procedures. (A recent patient I had went to the OR, and the doctors were asking when the heparin drip was stopped. One of them murmured, "I hope it's been at least 3 hours!") But, if subcut is of longer duration, wouldn't the risk of bleeding be greater than the risk of a DVT? I mean, that baby *is* coming out, and she *will* bleed. The chance of DVT is just a "maybe".

Thanks in advance.

[klone, MSN, RN]

Could you tell me more about this for curiosity's sake? My drug book indicates that subcut heparin duration is 8-12 hrs, while IV duration is 2-6 hrs. What happens if the patient has to go in for an emergency C-section?

Sorry for the ambiguity, this is for postpartum patients. From after delivery until time of discharge from the hospital.

[dudette10, MSN, RN]

Sorry for the ambiguity, this is for postpartum patients. From after delivery until time of discharge from the hospital.

Oh, duh! I completely missed that in your previous post.

[SaltyNurse]

Homans' sign is of little practical value these days. Off the top of my head I recall the predictability being on the order of 30%. When faced with the non-zero risk of throwing a clot, what's the value given that the D-dimer and ultrasound are how it's diagnosed.[/quote']

D-dimer and US are not ordered for surveillance as is the (theoretical) purpose for assessing for Homans' sign. Granted, assessing for Homans' is neither sensitive (my old Jarvis text cites 35%) nor specific. I'd be curious to now if the risk for dislodging a clot is based in evidence or just one of those nursing myths that float around. I tend to think the risk is more theoretical than actual. After all we don't restrict a patient from dorsi/plantarflexing nor crossing one calf over the other leg, or bending their knees, or walking for some unfounded fear of dislodging a clot. In fact, such restrictions predispose a patient to forming a clot. Now if you're looking at a leg, or an arm for that matter and you notice that the circumference is asymmetrical and/or the color is different and/or the temperature is different and/or there is pain/tenderness present, then naturally you would avoid compressing the suspicious extremity with your hands, or a blood pressure cuff, or sequential compression wraps, etc. It would be at that finding that a D-dimer and/or US would be appropriate.

[Spacklehead, MSN, NP]

In primary care, we use the Wells Prediction Rule to help determine if a patient was low-mod-high risk for a DVT and then would send for d-dimer or Doppler studies depending on the risk I don't know if it could be used in the post-partum patient, however.

This is how we did it:

http://www.aafp.org/afp/2004/0615/p2829.html

[Nascar nurse, ASN, RN]

She said if there are no obvious signs and symptoms of a DVT such as the warmth, redness and swelling of the calf we can perform it, but if there are obvious s/sx of a possible DVT then don't perform it because that can cause the clot to dislodge.

Here's a first hand reason this is probably still the wrong answer..

10 years ago I had horrible leg pain..very similar to having a leg cramp, but the cramp would not quit. My leg was NEVER red, NEVER warm and NEVER swollen. Because I never developed the "obvious" symptoms I waited 3 days (non stop pain to the point eventually I could only limp) before I went to the hospital. I did have a DVT and by then had PE as well! My point being, never assume because someone doesn't have textbook symptoms that they will not have a DVT.

By the way..while driving to the hospital, I decided I did have a positive Homans sign. Imagine the foot movement of going from the gas peddle to the brake peddle (dorsiflexion of the foot - repeatedly).