Risk for thrombosis

Risk for thrombosis

Domain 4. Activity-rest
Class 4. Cardiovascular-pulmonary responses
Diagnostic Code: 00291
Nanda label: Risk for thrombosis
Diagnostic focus: Thrombosis

Introduction to Nursing Diagnosis Risk for Thrombosis

The health discipline of nursing is inextricably linked to the myriad of components of patient care, and one of its essential missions is to detect and prevent conditions that threaten health. Therefore, it is essential for nurses to be clear on the concept of Nursing Diagnosis (ND) and to be able to recognize NDs that represent risk factors for patients. Nursing diagnosis risk for thrombosis is a condition in which tiny microscopic blood clots can form in arteries or veins, leading to a variety of health complications. This article examines the characteristics of this ND and discusses an array of risk factors and associated conditions.

NANDA Nursing Diagnosis Definition

Nursing diagnosis risk for thrombosis has been defined by NANDA International (the National Association of Nurses with Disabilities) as ‘a state in which a person is at increased risk for developing a clot in a vein or artery’.

Risk Factors

Inability to move about freely: Those who are bed-ridden for prolonged periods are more likely to develop deep vein thrombosis; this is known as immobility-related thrombosis.

Being overweight or obese: People who are obese are more likely to develop blood clots due to their increased risk of high blood pressure, insulin resistance, and plaque buildup in their arteries.

Family history of thrombosis: Following investigations into the occurrence of thrombosis, it has been observed that members of the same family are more vulnerable to the condition due its genetic component.

Smoking: Studies have shown that smokers are more likely to be affected by thrombosis due to chemical components in cigarettes which decrease oxygen levels in the blood and so increase the risk of clotting.

Antiphospholipid Syndrome: This disorder is caused by an abnormal immune response to the mutations of antiphospholipid antibodies. It significantly increases the risk of a variety of clotting disorders including thrombosis.

At Risk Population

Those people at an increased risk of thrombosis include:

Patients undergoing surgery: During any surgery, blood flow to the blood vessels accessible to the surgeon is restricted, leading to an increased risk of thrombosis.

Pregnant women: It is thought that changes in the shape and size of the uterus during pregnancy reduces return to the heart and this, combined with pregnancy hormones, leads to an increased risk of clot formation.

Those with certain cancers: Those receiving chemotherapy are particularly susceptible to thrombosis, either through direct damage to the cells lining the blood vessels or because of the drugs used for treatment.

People using certain contraceptives: Women using oral contraceptives, certain intrauterine devices, or hormone replacement therapy are more prone to thrombosis.

Associated Conditions

The following conditions are encountered most often in patients with thrombosis:

Venous Thromboembolism (VTE): VTE refers to blood clots that form in the legs or lungs. It results in serious health issues such as pulmonary embolism, deep vein thrombosis, and stroke.

Myocardial Infarction: Also known as a heart attack, this occurs when a blood clot blocks the flow of blood to the heart muscle, resulting in tissue damage and likely to be fatal if left untreated.

Peripheral Artery Disease (PAD): PAD is caused by deposits of fatty substances blocking the arteries and reducing the flow of oxygenated blood around the body, ultimately leading to tissue death.

Stroke: Occurs when a blood clot blocks the flow of oxygenated blood and nutrients to the brain. Symptoms such as loss of vision and paralysis can result.

Suggestions of Use

Nurses should promote preventative methods to reduce the risk of thrombosis, and these include ensuring correct foot and leg posture while sitting, getting up and carrying out light activity, and healthy eating habits such as avoiding processed and high sugar foods. Where applicable, treatments should be discussed such as anticoagulant medications and lifestyle changes.

Suggested Alternative NANDA Nursing Diagnoses

In cases where thrombosis cannot be prevented there may be alternative diagnoses that can be made:

Risk for Pulmonary Embolism: Pulmonary embolism occurs when a clot from a vein enters the lung, obstructing oxygenated blood from reaching the pulmonary bed.

Impaired Gas Exchange: This diagnosis is centred on the disruption of the respiratory process due to occlusion in an airway or respiratory equipment.

Impaired Mobility: This can be caused by immobility, muscle weakness, pain, and other conditions criteria.

Ineffective Circulation: Reduced circulation can be a result of a thrombus.

Usage Tips

When recognising a nursing diagnosis such as risk for thrombosis it is important to note the associated signs and symptoms, including pain and swelling in limbs, heavy feeling in the legs, discolouration, inflammation, and tenderness around the appropriate area, chest pain or difficulty breathing, headache, blurred vision, confusion and fatigue.

NOC Outcomes

In order to assess the effectiveness of patient care, NOC (Nursing Outcomes Classification) is employed to measure outcomes in relation to nursing interventions. The NOC outcomes for Risk for Thrombosis are grouped under the category Falling Risk. This includes:

•Health Perceptions/Health Management: Understanding of options for medical care and health promotion.

•Mobility: Patients ability to engage in moving from one place to another.

•Self-Care: Patient’s abilities to carry out activities of daily living.

•Risk Control: Minimizing the chance of harm or injury due to risk presenting behaviors or situations.

Evaluation Objectives and Criteria

Objectives: To evaluate knowledge regarding thrombosis and to ensure that preventive measures are being taken by the patient.

Criteria: It is expected that the patient will be knowledgeable of the risks factors and maintain a healthy lifestyle to reduce the risk of thrombosis.

NIC Interventions

The NIC (Nursing Interventions Classification) specifies a range of interventions that are related to thrombosis. These include:

•Early Mobilization: Encouraging mobility to reduce the risk of blood stasis.

•Exercise/Therapeutic Activity: Promoting gentle activity and exercise.

•Leg Care Instructions: Teaching correct foot and leg positioning while sitting.

•Thromboembolic Deterrence: Discussing and implementing preventive strategies, such as anticoagulant medications such as Warfarin, Heparin, and Aspirin.

•Nutrition Monitoring: Ensuring appropriate nutrition levels to meet daily needs.

•Pain Management: Administering appropriate pain relief.

Nursing Activities

Nurses should employ the following activities with patients at risk of thrombosis:

•Assess patient risk factors, health perception and history

•Educate on relevant lifestyle changes such as reducing smoking, eating a healthy diet, and avoiding sitting for long periods

•Develop and implement a plan of care based on individualized goals

•Monitor vital signs, oxygen saturation, activity level, and skin integrity regularly

•Document progress decisions, and any side effects

Conclusion

Risk for thrombosis is a condition which could have serious consequences if not addressed in a timely manner. As part of their duty, nurses should have an understanding of the condition and be able to recognize the associated signs and symptoms as well as the risk factors and associated conditions which predispose patients to the occurrence of a thrombus. Furthermore, they should employ relevant NANDA and NIC frameworks to ensure best practice and implement a range of nursing interventions and activities for the patient.

5 FAQs

How is thrombosis defined?

Thrombosis is a condition in which a clot forms in a vein or artery, disrupting normal blood flow.

Who is at risk of developing thrombosis?

Anyone who is bed-ridden for prolonged periods, overweight/obese, has a family history of thrombosis, smokes, or has Antiphospholipid Syndrome (APS) are all at a higher risk of developing thrombosis. Women using oral contraceptives, certain intrauterine devices, or hormone replacement therapy are also more likely to be affected.

What are some of the associated conditions related to thrombosis?

The conditions most commonly linked to thrombosis are Venous Thromboembolism, Myocardial Infarction, Peripheral Artery Disease, and Stroke.

What preventive measures can be done to reduce one’s risk of thrombosis?

Preventative measures that could help reduce the risk of thrombosis include maintaining correct foot and leg posture when sitting, practising light activities, undertaking regular exercise, and eating a healthy balanced diet.

What kind of interventions and activities should nurses perform with thrombosis patients?

Nurses should assess the patient’s risk factors, provide education on lifestyle changes, develop and implement a personalized plan of care, monitor vital signs, administer analgesia, and document progress and decisions. Moreover, they should employ NANDA and NIC frameworks to ensure best practice.