NSG210 DVT Simulation Prep

This prep sheet turns the DVT student-copy handout into a practical study and simulation plan. Source: raw/nsg210_sim_DVT_student_copy.md. Status: Med-Surg simulation completed October 8, 2026 (moved from the Oct 1-2 clinical week). Related course topics include alterations in perfusion, DVT/PE, atrial fibrillation, heparin protocol, PTT monitoring, anticoagulation safety, and patient education.

Patient snapshot

Patient: Jorge Simpson
Age: 70
Sex: Male
Background: retired bus driver, married, Baptist, smokes 1/2 pack per day
PMH: DVT, atrial fibrillation
Current diagnosis: right leg DVT
Current treatment: heparin protocol after 5000-unit bolus; heparin drip at 10 mL/hr; next PTT pending
Main symptoms: severe right-leg pain, swelling that progressed from lower leg to groin, tiredness, foot/ankle swelling
Important history: shortness of breath on exertion for two months

What to know before simulation

1. What is DVT?

Deep vein thrombosis is a clot in a deep vein, most often in the lower extremity. The main dangers are:

clot extension;
impaired venous return and swelling/pain;
pulmonary embolism if part of the clot breaks off and travels to the lungs;
post-thrombotic syndrome.

2. Virchow triad

DVT risk is usually explained by Virchow triad:

Component	Meaning	Patient connection
Venous stasis	Slow blood flow	retired bus driver, possible immobility/sitting
Vessel injury	Endothelial injury	may be absent or not provided
Hypercoagulability	Blood more likely to clot	older age, smoking, prior DVT, possible A-fib/anticoagulation history

3. Signs and symptoms of DVT

Expected findings may include:

unilateral leg swelling;
pain or tenderness;
warmth;
redness or discoloration;
edema of foot/ankle/calf/thigh;
increased circumference compared with other leg;
visible superficial veins;
sometimes low-grade fever;
sometimes asymptomatic.

Do not rely on Homans sign as a diagnostic test.

4. Pulmonary embolism red flags

Because DVT can embolize, always watch for PE:

sudden or worsening shortness of breath;
chest pain, especially pleuritic chest pain;
tachycardia;
tachypnea;
low SpO2;
hemoptysis;
syncope/lightheadedness;
anxiety/restlessness;
new hypotension.

Simulation move: if the patient reports chest pain, shortness of breath, or SpO2 drops, stop routine care and escalate immediately.

Focused assessment plan

Initial safety and orientation

Introduce self, identify patient with two identifiers.
Hand hygiene.
Ask about pain, shortness of breath, chest pain, dizziness, bleeding.
Confirm allergies: NKDA.
Check current orders: heparin protocol, PTT due, activity orders, vitals frequency.
Check IV pump/rate against order and facility heparin protocol.

Vital signs and cardiopulmonary

BP, HR, RR, SpO2, temperature, pain score.
Cardiac rhythm if monitored, especially because of A-fib history.
Lung sounds.
Work of breathing.
Ask directly: “Are you short of breath right now?” and “Any chest pain?”

Right-leg DVT assessment

Assess both legs for comparison:

location and severity of pain;
swelling/edema;
warmth;
color;
pulses distal to clot if allowed/appropriate;
capillary refill;
sensation and movement;
skin integrity;
calf/thigh circumference if ordered or expected.

Avoid unnecessary deep massage or vigorous manipulation of the affected extremity.

Bleeding assessment on heparin

Check for:

bleeding gums;
nosebleeds;
bruising/ecchymosis;
hematuria;
black/tarry stool;
oozing from IV sites;
new headache or neuro changes;
hypotension/tachycardia suggesting bleeding.

Labs and diagnostics to expect

D-dimer

Elevated in the scenario.
Supports clotting activity but is not specific.

aPTT / PTT

Used to monitor IV unfractionated heparin.
Therapeutic range depends on facility protocol.
Course pharma notes list aPTT reference range around 25-40 seconds and therapeutic target often 1.5-2 times control, but follow the actual heparin protocol.

Platelets

Monitor for heparin-induced thrombocytopenia (HIT/HITT).
Concerning drop in platelets, especially after several days of heparin exposure, must be reported.

CBC/Hgb/Hct

Monitor for bleeding.

Duplex ultrasound

Common diagnostic test for DVT.

PT/INR

More relevant to warfarin if bridging to oral anticoagulation.

Medication focus

Heparin

Purpose: immediate anticoagulation to prevent clot extension and reduce risk of PE. It does not dissolve the clot directly; the body breaks down clot over time.

Mechanism: enhances antithrombin activity, inhibits thrombin/factor Xa activity, prevents fibrin clot formation.

Nursing priorities:

verify order, concentration, pump rate, and line;
monitor PTT/aPTT or anti-Xa per protocol;
monitor for bleeding;
monitor platelets for HIT;
avoid IM injections when possible;
use soft toothbrush/electric razor teaching;
fall precautions and bleeding precautions;
know antidote: protamine sulfate.

Warfarin / DOAC transition

If the case moves toward discharge teaching:

Warfarin requires PT/INR monitoring and consistent vitamin K intake.
Warfarin often given in evening so same-day INR results can guide dosing.
DOACs such as rivaroxaban/apixaban/dabigatran have less routine lab monitoring but still carry bleeding risk and require adherence.
Renal function matters for some anticoagulants.

Priority nursing diagnoses / problems

Use whichever fits the assignment language:

Acute pain related to venous obstruction/inflammation as evidenced by severe right-leg pain.
Ineffective peripheral tissue perfusion related to venous thrombus as evidenced by unilateral swelling and pain.
Risk for bleeding related to heparin therapy.
Risk for impaired gas exchange related to possible pulmonary embolism.
Deficient knowledge related to DVT, anticoagulation, bleeding precautions, and PE warning signs.
Risk for falls/injury related to anticoagulation and older age.

Nursing plan of care

Top priorities

Assess for PE symptoms.
Maintain safety while on heparin.
Monitor PTT/aPTT and follow heparin protocol.
Manage pain and affected extremity safely.
Teach anticoagulation precautions and when to seek help.

Interventions and rationales

Intervention	Rationale
Assess respiratory status, SpO2, chest pain, and sudden dyspnea	Detect possible PE early
Monitor affected leg for pain, swelling, warmth, pulses, sensation, skin	Tracks DVT status and perfusion/safety
Keep patient safe on anticoagulation	Reduces bleeding/fall injury risk
Monitor PTT/aPTT per protocol	Ensures heparin is therapeutic, not subtherapeutic or excessive
Monitor CBC, Hgb/Hct, platelets	Detects bleeding and HIT risk
Use infusion pump and verify heparin concentration/rate	Heparin is high-alert; dosing errors can be serious
Avoid massage of affected leg	Reduces risk of clot dislodgement
Provide pain management as ordered	Improves comfort and mobility tolerance
Teach PE warning signs	Supports rapid response after discharge
Teach bleeding precautions	Reduces anticoagulation complications

What to say in simulation

Opening assessment

“Mr. Simpson, I’m going to check your vital signs, pain level, breathing, and right leg because with a DVT we want to watch both the clot symptoms and any signs that the clot could be affecting your lungs.”

Heparin explanation

“You’re receiving heparin to keep the clot from getting bigger and to help prevent part of it from traveling to your lungs. We monitor your blood work closely so the medication is strong enough to work but not so strong that it causes bleeding.”

PE screening questions

“Are you having any shortness of breath right now?”
“Any chest pain or pain when you take a deep breath?”
“Any coughing up blood, dizziness, or feeling like you might pass out?”

Bleeding screening questions

“Have you noticed bleeding from your gums or nose?”
“Any blood in your urine?”
“Any black or tarry stools?”
“Any unusual bruising?”

Patient education

“Call for help before getting up. Because you are on a blood thinner, a fall or injury can cause more serious bleeding. Also report any chest pain, shortness of breath, sudden dizziness, or bleeding right away.”

SBAR practice

Situation

Mr. Simpson is a 70-year-old male admitted with right-leg DVT on a heparin drip after a 5000-unit bolus. He continues to report severe right-leg pain and swelling.

Background

Past history includes DVT and A-fib. D-dimer is elevated. Heparin protocol was started, PTT was drawn, and the next PTT result is pending. He reports prior shortness of breath on exertion and swelling progressing up to the groin.

Assessment

Focused assessment should include vital signs, oxygen saturation, cardiopulmonary status, PE symptoms, right-leg neurovascular/skin assessment, pain score, bleeding assessment, IV site, and heparin infusion verification.

Recommendation

Request review of the pending PTT and heparin protocol adjustment if needed. Escalate immediately for new shortness of breath, chest pain, hypoxia, hypotension, altered mental status, signs of PE, active bleeding, or major platelet drop.

Likely instructor questions

What is DVT?

A thrombus in a deep vein, usually the lower extremity, that can impair venous return and create risk for pulmonary embolism.

What are signs and symptoms?

Unilateral leg swelling, pain/tenderness, warmth, erythema/discoloration, edema, and sometimes dilated superficial veins. It may also be asymptomatic.

What are treatments?

Anticoagulation with heparin/LMWH/warfarin/DOACs, monitoring labs as indicated, bleeding precautions, pain management, compression/mobility plan as ordered, and PE monitoring. Thrombolysis, thrombectomy, or IVC filter may be used in selected cases.

Why heparin first?

IV unfractionated heparin works immediately and can be titrated based on PTT/aPTT. It prevents clot extension and embolization while longer-term therapy is planned.

What is the antidote for heparin?

Protamine sulfate.

What lab monitors heparin?

Usually aPTT/PTT for IV unfractionated heparin, or anti-Xa depending on facility protocol.

What is HIT?

Heparin-induced thrombocytopenia: immune-mediated platelet drop with paradoxical increased thrombosis risk. Watch for falling platelets and new thrombosis.

Mini checklist for clinical/sim day

Identify patient and allergies.
Full vitals including SpO2.
Pain score and location.
Ask PE questions before focusing only on the leg.
Compare both legs.
Check heparin infusion order/rate/site.
Look for bleeding.
Ask for/interpret pending PTT within protocol.
Use fall/bleeding precautions.
Teach: DVT, PE warning signs, bleeding precautions, medication purpose.
Escalate changes promptly with SBAR.

Connection to next-week perfusion content

The weekly NSG210 map places DVT/PE under alterations in perfusion/PVD content. This simulation connects peripheral venous clotting to systemic safety risks: pulmonary embolism, anticoagulation bleeding risk, A-fib-related thromboembolism, and prioritization of assessment findings.