Dvt

[PHTLS]

QUESTION:

If the patient already has a blood clot forming on his/her calf (warm to the touch and + Homan's), would you put on SCD's and potentially cause that clot to dislodge or do you wait for Heparin to take affect before putting on SCD's?

:uhoh21:

[VivaLasViejas, ASN, RN]

We used to keep pt's with DVT on strict bedrest until PTT's had been within therapeutic levels for 24 hours. Nowadays, we just have the pt. keep the affected limb elevated as much as possible, because unless we have orders for a Foley (which is never the case with a normally active, independent patient), they're going to have to use the bathroom sometime, and that means getting them OOB! Most doctors where I work don't order bedrest anymore anyway, even for pt's who haven't ambulated in years........it's always "up ad lib as tolerated" or, for the worst cases, "Chair w/ assist TID". Only pts. with fractured hips and joint replacements are ordered to bedrest, and only on the day of surgery. Which could be why we haven't seen as many DVTs in recent years?? :)

How times change.......we used to admit people for heparin infusions all the time, and now there are nurses on our floor who have never done one, mostly due to the fact that most of our docs have switched to sub-Q Fragmin to treat DVT, thus saving pts. lengthy hospitalizations (and us the trouble of dealing with labor-intensive heparin protocols).

I do wonder at the 'logic' of a nurse who would put SCDs on someone with DVT, however........that's just downright scary. :uhoh21:

[CritterLover, BSN, RN]

i thought heparin did not dissolve clots but just prevented new ones from forming? i never did understand how that works. . . any thoughts?

correct. heparin does not dissovle the clot. it prevents the original clot from growing and new clots from forming. the body will eventually break down the original clot.

i've always seen a "no scd" policy until a follow up doppler shows the clot to be gone. waiting just until the heparin is theapeutic is not enough, since the clot is most likely still there. its been a long time since i've seen a dvt on a patient that was able to ambulate, so i really can't comment on the bed rest status, but that particular patient was on bedrest, with use of the bedpan/urinal. that would make sense to me, since any contraction of the particular muscle could dislodge the clot. are they now having them use crutches or somehow making that extremity nwb?

one unit i worked on even went as far as to order a doppler study before replacing the scds if scds were left off for >24 hours, just in case a clot had formed.

interestingly, the last few dvts that i have seen have been in the subclavian, rather than a lower extremity (usually line related).

[VivaLasViejas, ASN, RN]

its been a long time since i've seen a dvt on a patient that was able to ambulate, so i really can't comment on the bed rest status, but that particular patient was on bedrest, with use of the bedpan/urinal. that would make sense to me, since any contraction of the particular muscle could dislodge the clot. are they now having them use crutches or somehow making that extremity nwb?

i think bedrest orders have pretty much gone the way of the dinosaur at our facility because it's basically unenforceable. we caution patients not to bear weight on the affected extremity, and they are encouraged to keep it elevated at all times, but many patients insist that they can't use a bedpan (i have to admit, i myself am in that category, so i can empathize ), and you can't make someone who's aa&ox3 stay in bed.

that said, we often see dvt among our super-obese population, many of whom are frequent flyers because of their co-morbidities, e.g. diabetes and circulation problems. we also see it in ivdus, and occasionally even in a new mom who didn't walk around enough after her c-section (i developed it after i had my last child 13 1/2 years ago.....oh, if i'd known then what i know now!). with the drug users, it's usually in an arm rather than the legs, but we also deal with a lot of lower-extremity dvt in middle-aged, ambulatory patients, and it rarely has anything to do with surgery since we use scd's on just about everyone, including outpatients, who have any procedure that requires general anesthesia.