Effect of Implementing Nursing Guidelines on Occurrence of Deep Venous Thrombosis for Critically Ill Patients

Deep venous thrombosis (DVT) is a major health problem that results in significant morbidity and mortality for the critically ill patients in the critical care units. It was documented that DVT occurs in about two million Americans each year, whereas pulmonary embolism (PE) as a complication of DVT causes approximately 50.000 to 60.000 deaths. Moreover, it was revealed by a study done in Assuit University Hospital that out of 220 surgical patients, 12 (5%) died with pulmonary embolism as a complication of DVT. Other research done at Alexandria University in El-Hadra Hospital on 50 orthopedic patients revealed that seven patients were detected with DVT. The critical care nurses are the key players in the prevention of DVT and its complications. They are in the ideal position to asses' patient risk factors early and ask for DVT prophylaxis. Objective: the current study was carried out to evaluate the effect of implementing nursing guidelines on the occurrence of DVT for critically ill patients. Methods: Four critical care unites were used to collect the data for this study at Assuit University Hospital, sixty critically ill patients were included in this study, they were divided into two groups G1 (control group) and G2 (interventional group) 30 patients each. Two tools were used to collect the data of this study. Tool one: "Patient’s assessment for DVT, and Tool two: the "DVT evaluation sheet". Results and conclusion: Findings of the current study revealed low incidence of DVT for the global sample, only two patients experienced DVT in the control group, and none of the interventional group experienced DVT. Moreover, it was observed that the preventive measures of DVT done by the critical care nurses for the control group using non-pharmacological and mechanical methods were not adequately performed. In addition, it was found that all the studied patients of control group did not wear the elastic stocking, while small proportion of this group performed leg exercises, changed their position, did deep breathing, and coughing exercises, and transfer on the chair. It was observed that most of the studied patients experienced low percent of DVT manifestations with no statistically significant difference between the both groups. The present study revealed also that nearly half of the studied patients were in moderate & high risk grades for DVT in the both groups. Recommendations: based on the current study findings it can be recommended that this research should be repeated on a large sample size and in multi centers for generalization. Moreover, training programs should be established to update critical care nurses' knowledge and skills about DVT preventive measures, and how to use the technical skills to assess the occurrence of DVT using the evidence base nursing and medicine. INTRODUCTION Deep venous thrombosis (DVT) is particularly important to the critical care practitioner; it can be a primary reason for admission to the critical care unit or 201 Bull High Inst Public Health Vol.38 No.1 [2008] complication of other critical illness(1). Critically ill patients are at great risk for developing DVT due to their premorbid condition, admitting diagnosis in the critical care units such as sepsis and trauma; and exposure to invasive procedure such as central and peripheral venous catheterization and certain medications as sedative, narcotic, and analgesic. DVT occurs also in critically ill patients who have immobility for an extended period of time(2) . Most of the clinical studies of DVT in the critically ill patients estimated that 90% of cases of pulmonary embolism (PE) originated in the deep venous system of the lower limb(3,4). It was documented that DVT and Pulmonary embolism (PE) constitute a major health problem that result in significant morbidity and mortality for critically ill in the critical care units. DVT occurs in about two million Americans each year, where as PE causes, approximately 50.000 to 60.000 deaths each year in the United States(2,5). A study done in Assuit University Hospital revealed that out of 220 surgical patients, 12 (5%) died with PE as a complication of DVT(6). Other research was done at Alexandria University in El-Hadra Hospital (2004) on 50 orthopedic patients revealed that seven patient only were detected with DVT(3). Previous research has shown that DVT of the lower limbs is primarily responsible for the vast majority of cases of pulmonary embolus in hospitalized patients(7). Recent studies have shown that despite prophylaxis, DVT occurs in approximately 11% of intensive care patients. A number of reviews have been undertaken in recent years to examine the development and prevention of DVT in intensive care patients(8). Critical care nurses are the key players in the prevention of DVT and its complications. They are in the ideal position to assess patient risk factors early and ask for DVT prophylaxis. Admission assessments are an opportune time to El-Rashedy et al., 202 evaluate patient risk factors such as immobility, age, previous history of DVT, and medical conditions that increase the risk of developing DVT in hospitalized patients. Patient risk assessment should be ongoing throughout hospitalization but especially with condition changes(9,10). Once a patient is considered at risk for developing DVT, critical care nurses must advocate for timely prevention mechanisms. This can be done by notifying physicians about the risk factors and asking for orders to initiate prophylaxis early or following an established hospital protocols and guidelines(11). Once prophylaxis orders are obtained, they need to be initiated as soon as acute care. Critical care nurses should be well-acquainted with the two forms of the disease (DVT and its dreaded sequel, pulmonary embolism). Preventing and detecting these two conditions have long been essential components of quality nursing. It was documented that PE is the most common undiagnosed cause of death in hospitalized patients(12). Even with best efforts in the critical care unit, it might never be able to eliminate all cases of venous thromboembolism, but it should be equipped with nursing expertise and the latest tools for dealing with this potential killer. Critical care nurses can help reduce its incidence and save lives(12). Hence this study was carried out to evaluate the effect of implementing nursing guidelines on the occurrence of DVT in critically ill patients. MATERIAL AND METHOF Material Design: A quasi experimental research design was adopted to conduct this study. Setting: This study was carried out in 4 intensive care units (ICUs) namely, stroke, general, trauma, and post operative ICUs, at Assuit university Hospitals. Subject: The sample of this study comprised of 203 Bull High Inst Public Health Vol.38 No.1 [2008] 60 adult patients including both sex, their age ranged from 20-60 years old, and admitted to the previously mentioned settings. They were selected by convenience and randomly assigned to two equal groups, control (G1) and interventional group (G2) (30 patients each). Exclusion Criteria: Any patients with the following conditions were excluded from the study: Coronary artery diseases in acute stage. Fluid restriction. Exercises contraindication. Tools: Two tools were used to collect the data in this study and developed by the researcher based on the related literatures (10,14,15). Tool one: "Patient's assessment for DVT", this tool was developed to assess the patient's risk factors, it included four parts: Part I: "patients profile" to document the patient's name, age, sex, diagnosis, date of admission, and type of ICU. Part II: "DVT risk factors scale", this part was initially developed by Autar (1996)(16), then it was modified by Abd Elmanam (2004)(3), and further modification was done by the researcher based on the literature review(17-19) to suit the critically ill patients. It included nine items as age of the specific group, weight, mobility level, special risk category, site of trauma, surgical operations, high risk diseases, family history of DVT, and type of anesthesia. Part III: "the special biological factors and therapeutic modalities in the ICU": This part was developed by the researcher based on the literature review(7,20) it included assessment of the hydration status as (skin turgor, mucous membrane, central venous catheter and intake and out put data), mechanical ventilator connection, and medications. Part IV: "DVT preventive measures" this part was used to assess the preventive measures that were done by the critical El-Rashedy et al., 204 care nurses for the control group (nursing procedures that are considered to be effective in prevention of DVT), These measures included: Applying elastic stocking & leg elevation (check list ten Items). Changing position in bed (check list nineteen Items). Deep breathing and coughing exercise (check list ten Items). Range of motion of lower limb (check list twelve Items). Transferring patient from bed to chair (check list twenty one Items). Tool two: "DVT evaluation sheet", this tool was developed by the researcher based on the extensive review of related literatures)(21-22), it was used to assess the occurrence of DVT, and to evaluate the effect of nursing guidelines, it included three parts: Part I: "DVT manifestations", this part was used to assess DVT manifestations as the presence of six items (calf pain, calf tenderness, calf circumference, skin color and distension of superficial vein, and warm calf). Part II: "Laboratory tests findings" , this part was used to interpret the data related to the laboratory testes findings to determine coagulation status of the patient, as partial thromboplastin time (PTT), prothrambin time (PT), hemoglobin (HB), platelets and, fibrinogen level. Part III: "Doppler findings", this part was used to assess the blood supply in the veins in the lower limbs, that indicate the occurrence of DVT. Method Permission to conduct the stu


Deep venous thrombosis (DVT) is
particularly important to the critical care practitioner; it can be a primary reason for admission to the critical care unit or Bull High Inst Public Health Vol.38 No. 1 [2008]   complication of other critical illness (1) .
Critically ill patients are at great risk for developing DVT due to their premorbid condition, admitting diagnosis in the critical care units such as sepsis and trauma; and exposure to invasive procedure such as central and peripheral venous catheterization and certain medications as sedative, narcotic, and analgesic.DVT occurs also in critically ill patients who have immobility for an extended period of time (2) .
Most of the clinical studies of DVT in the critically ill patients estimated that 90% of cases of pulmonary embolism (PE) originated in the deep venous system of the lower limb (3,4) .
It was documented that DVT and Pulmonary embolism (PE) constitute a major health problem that result in significant morbidity and mortality for critically ill in the critical care units.DVT occurs in about two million Americans each year, where as PE causes, approximately 50.000 to 60.000 deaths each year in the United States (2,5) .A study done in Assuit University Hospital revealed that out of 220 surgical patients, 12 (5%) died with PE as a complication of DVT (6) .Other research was done at Alexandria University in El-Hadra Hospital (2004) on 50 orthopedic patients revealed that seven patient only were detected with DVT (3) .Previous research has shown that DVT of the lower limbs is primarily responsible for the vast majority of cases of pulmonary embolus in hospitalized patients (7) .Recent studies have shown that despite prophylaxis, DVT occurs in approximately 11% of intensive care patients.A number of reviews have been undertaken in recent years to examine the development and prevention of DVT in intensive care patients (8) .
Critical care nurses are the key players in the prevention of DVT and its especially with condition changes (9,10) .
Once a patient is considered at risk for developing DVT, critical care nurses must advocate for timely prevention mechanisms.
This can be done by notifying physicians about the risk factors and asking for orders to initiate prophylaxis early or following an established hospital protocols and guidelines (11) .Once prophylaxis orders are obtained, they need to be initiated as soon as acute care.Critical care nurses should be well-acquainted with the two forms of the disease (DVT and its dreaded sequel, pulmonary embolism).Preventing and detecting these two conditions have long been essential components of quality nursing.It was documented that PE is the most common undiagnosed cause of death in hospitalized patients (12) .Even with best efforts in the critical care unit, it might never be able to eliminate all cases of venous thromboembolism, but it should be equipped with nursing expertise and the latest tools for dealing with this potential killer.Critical care nurses can help reduce its incidence and save lives (12) .Hence this study was carried out to evaluate the effect of implementing nursing guidelines on the occurrence of DVT in critically ill patients.

Design:
A quasi experimental research design was adopted to conduct this study.

Setting:
This study was carried out in 4 intensive care units (ICUs) namely, stroke, general, trauma, and post operative ICUs, at Assuit university Hospitals.

Subject:
The sample of this study comprised of

Exclusion Criteria:
Any patients with the following conditions were excluded from the study: -Coronary artery diseases in acute stage.

Tools:
Two tools were used to collect the data in this study and developed by the researcher based on the related literatures (10,14,15) .
Tool one: "Patient's assessment for DVT", this tool was developed to assess the patient's risk factors, it included four parts: Part I: -"patients profile" to document the patient's name, age, sex, diagnosis, date of admission, and type of ICU.
Part II: "DVT risk factors scale", this part was initially developed by Autar (1996) (16) , then it was modified by Abd Elmanam (2004) (3) , and further modification was done by the researcher based on the literature review (17)(18)(19) to suit the critically ill patients.This part was developed by the researcher based on the literature review (7,20) it included assessment of the hydration status as (skin turgor, mucous membrane, central venous catheter and intake and out put data), mechanical ventilator connection, and medications.
Part IV: "DVT preventive measures" this part was used to assess the preventive measures that were done by the critical care nurses for the control group (nursing procedures that are considered to be effective in prevention of DVT), These measures included: -Applying elastic stocking & leg elevation (check list ten Items).
-Changing position in bed (check list nineteen Items).
-Deep breathing and coughing exercise (check list ten Items).
-Range of motion of lower limb (check list twelve Items).
-Transferring patient from bed to chair (check list twenty one Items).
Tool two: "DVT evaluation sheet", this tool was developed by the researcher based on the extensive review of related literatures) (21)(22) , it was used to assess the

Method
-Permission to conduct the study was obtained from the responsible authorities of all the selected ICUs after explanation of the aim of the study.
-Development of the tools after reviewing the related literature was done.
-Informed consent was obtained from each patient or from the responsible person for the unconscious patients.
-A pilot study was conducted on 5 patients who met the predetermined selection criteria to test the applicability of the tools.Appropriate study modifications were done prior to data collection.

Data collection:
The data were collected from the first day of admission after stabilization of the patient's condition and for ten consecutive days, every day and every shift then the data were recorded in the developed tools.
Data were collected on three phases.
-Anesthesia: if spinal scored---0, if general---1 then the entire patient's data were marked in the scale to collect number.
-The total score of the risk factors -Changing position in bed (check list nineteen Items).
-Deep breathing and coughing exercise (check list ten Items).
-Range of motion of lower limb (check list twelve Items).
-Transferring patient from bed to chair (check list twenty one Items).

Evaluation of clinical outcomes for the patients in the control group (GI):
Data for this group were collected from 30 -Doppler ultrasound was done to evaluate the blood supply flow in the veins of the lower limbs to detect the presence or absence of DVT.This was done in the first day, third day, fifth day, seventh day, and tenth day.

Implementation phase of the DVT preventive nursing guidelines:
-During this phase, the developed DVT preventive guidelines were implemented for the intervention group which consisted of 30 patients who met the predetermined criteria.
The following steps were followed during its implementation:

Assessment phase:
Assessment phase was conducted as previously done with the control group.

Implementation phase for the interventional group (G2):
-This phase was begun from first day of admission for ten consecutive days every day and every shift.
-During this phase the developed nursing guidelines performed to all the studied patients (intervention group). -

Evaluation phase:
-This phase was done to evaluate the effect of the nursing guidelines on the occurrence of DVT by comparing the results of outcomes of the both groups by using tool two part I, II, III.

Statistical analysis:
The collected data were coded, analyzed using Statistical Package for Social Sciences (SPSS/ version 13) software, and tabulated.
-Descriptive statistics as number and percent, mean and standard deviation were used.
-Z-test was used.(This test was used to compare between the both groups in relation to sign and symptoms.
-Fisher exact test was used to identify the relationship between DVT manifestations, also the relationship between the level of risk grade and the special risk factors that may have effect on the occurrence of DVT.
-The level of Qui square is significance at <0.05.
-Cronbach`s Alpha was done to test reliability of the tools.to make or confirm.The usual method of treatment with anticoagulation is hazardous and may be contraindicated in some of these patients.Therefore, there is increased emphasis on the prevention of deep venous thrombosis and pulmonary thromboembolism in ICU patients given to that they have multiple risk factors for this disease (11,13,14) .Abd Elmanam (2004) (3) indicated that less than one quarter of the studied patients experienced DVT, which is considered to be low percent in relation to the orthopedic patients.Moreover, Gamal Eldeen (1999) (4) reported that none of her studied abdominal surgical patients developed DVT.

DVT risk factors:
Wendy et al., (2004) (24) reported that the Findings of the current study revealed apparently that with increasing age there was increase in the risk of DVT in the both groups.Abd Elmonam (2004) (3) , and Ebell (2001) (25) reported that the patent's age was found to be a significant factor in the development of DVT in the studied patients.
Moreover, Autar (1996) (16) proved that there was a linear relationship between advanced age and the incidence of DVT.It was documented that the incidence of DVT increases linearly with increasing age, three factors have been proposed to explain this increase.First: as the increased vein age, they lose their elasticity, and the resulting dilatation and tortuosity contributes to an increase in the stasis of blood.Second: the decrease in muscle mass of the venous pump effectiveness add additional venous stasis.Third: there is an increased incidence with associated conditions and diseases, as malignancy, heart disease which predisposes older patients to thromboembolic complications (22) .
Gender was documented also to be another factor for DVT development.The gender in the current study sample was found to be equal in G1, while more than half of the studied patients in G2 were males.Abd Elmonam (2004) (3) pointed out that sex was found to be a significant variable in DVT development.Snow et al., (2007) (26) reported that females were generally at increased risk for DVT.They indicated that it could be related to the pregnancy and using contraceptives.On the other hand, Criner , et al., (2002) (27) identified that the incidence of DVT in hospitalized patients appear to be equal in males and female.
Concerning the body weight, it was found that forty four percent of the studied patients in G1 and 66% in G2 in the present study were overweight and obese.Haines and Stuart (2003) (28) recorded that obese Bull High Inst Public Health Vol.38 No. 1 [2008]   patients were found to be high risk for DVT development, due to impaired fibrinolytic system in the obese patients that related to impaired hyper-coagulable state.In contrast, Abd Elmonam (2004) (3) and Anderson et al., (2003) (29) found that obesity was not a statistical significant factor in the development of DVT.Furthermore, the immobility level is considered risk factor, it was observed that most of the studied patients in the current study were immobile.
Geerts et al., (2003) (9) emphasized that immobility is a major risk factor that also affects most of the studied critically ill patients.DVT development was higher in critically ill patients because of bed rest is frequently ordered for monitoring equipment, intravenous lines, drainage tubes, catheters, and other necessary medical equipment.
Regarding the hydration status, it was observed that patients with negative balance were in the moderate and high risk grade of DVT in both groups of the current study.It was documented that the critical care nurses should check skin turgor and the mucous membrane daily, and those who are found to be in need for more fluid should be reported to the physician for proper hydration.Gamal Eldeen (1999) (4) , indicated that the critical care nurse should advice the patients to receive at least two liters of fluids per day to prevent increase viscosity of the blood if not contraindicated.
As for the connection to the mechanical ventilator, results of the current study revealed that Fifty percent of the studied patients in G1 and 33% in G2 were connected with mechanical ventilator.
A previous research done by the Martinelli et al., (2004) (31) strongly recommended the use of mechanical  (9) indicated that the prevention of DVT  (34) stated that the use of this exercises is safe for all patients except those with bone injures.Early ambulation is another useful technique, it was recommended for decreasing venous thromboembolism.In addition Khan and Ginsberg (2004) (35) reported that the role of elastic stocking was based on the presence of symptoms.On the other hand, Kucher and Coldhaber (2005) (36) reported that anti-embolic stocking is widely advocated in the prevention of DVT, but it may do more harm, it may cause heal pressure ulceration if not used correctly.
Dean et al., (1999) (37) recommended that the critical care nurses should ensure that small designed and well fitting stocking is applied and fitted according to calf size and leg length.If stocking is misused it leads to an inverse gradient and decrease venous emptying.

DVT manifestations:
The signs and symptoms of DVT may include pain, swelling, erythema, and warmth in the affected extremities.Many clinicians still check homen's sign, the presence of calf pain with dorsiflexion of the foot.However, this is no longer considered available indicator of DVT.About half of the patients will have no symptoms, and the first indication may be signs or symptoms associated with PE or even sudden death.
That is why preventive intervention and treatment in patients at risk are so imperative (38) .Findings of the current study revealed that most of the studied patients experienced low percent of DVT manifestations with no statistical significant difference between the both groups related to rare signs & symptoms.Moreover, Qaseem et al., (2007) (39) found that pain & swelling resolve more quickly and there is no risk for PE.On the other hand, Kahn (1998) (40)  high risk groups so that prophylaxis could be tailored to the element of risk that the critically ill patient is facing (15) .
DVT is generally a disorder of critically ill patients, with PE being one of the top preventable killers in these patients.A variety of measures are available to reduce the risk of DVT, these measures include careful risk assessment of the patients and the use of thrombo-prophylactic measures in patients at risk of an event.The introduction of a validated simple bed side tool to estimate the risk of DVT in patients could refine the decision-making process.In view of the thromboembolism event, there is a need for extended prophylaxis in the critical care unit setting to further reduce the incidence of DVT (36) .
The critical care nurses play an -The CC nurses should be provided with posters of DVT nursing guidelines and handout of the procedures of DVT preventive measures.
-Providing the CC nurses with the DVT preventive devices like elastic stocking, talcum powder, and measuring tape to perform the preventive measures.
-Focused attention to documentation should be done for all procedures for DVT prevention, because of documentation serves to promote the continuity of care given by nurses and other health-care providers.
-Further research is recommended on regular scale in multi certain Egyptian complications.They are in the ideal position to assess patient risk factors early and ask for DVT prophylaxis.Admission assessments are an opportune time to El-Rashedy et al., 202 evaluate patient risk factors such as immobility, age, previous history of DVT, and medical conditions that increase the risk of developing DVT in hospitalized patients.Patient risk assessment should be ongoing throughout hospitalization but occurrence of DVT, and to evaluate the effect of nursing guidelines, it included three parts: Part I: "DVT manifestations", this part was used to assess DVT manifestations as the presence of six items (calf pain, calf tenderness, calf circumference, skin color and distension of superficial vein, and warm calf).Part II: "Laboratory tests findings" , this part was used to interpret the data related to the laboratory testes findings to determine coagulation status of the patient, as partial thromboplastin time (PTT), prothrambin time (PT), hemoglobin (HB), platelets and, fibrinogen level.Part III: "Doppler findings", this part was used to assess the blood supply in the veins in the lower limbs, that indicate the occurrence of DVT.

-
The patients profile was collected from the patient or from nurses if the patient was comatose, and recorded in part I, tool one.-then assessment of the risk factors of DVT was done by the assessment scale using Part II in tool one as the following:-For the age: 20 < 30 years scored --0, if 30 <40 years scored --1, if 40 <50 years scored ---2.

-
was measured by centimeter tap and recorded in equation to determine the body weight, and then divided the weight (kg) on the height (m 2 ) to determine the body mass index.The body mass index: by using Chumlea equation and classify the weight as the following: if (20 <25) → ideal weight and scored ---o, (25 <30) → over weight---1 and (≥ 30) → obese ---2.

ranged from 1 -
as minimum to 28 as a maximum.The increased number was considered as high risk for development of DVT.-After that assessment of the hydration status was done by observation of the skin turgor and the mucous membrane, then central venous pressure and intake and output was measured and documented in the patient's chart every day and every shift.Bull High Inst Public Health Vol.38 No.1 [2008] were assessed every day and every shift (as mechanical ventilator connection, and the medications that the patients received) and recorded in tool one part II.Assessment of the nursing performance for DVT preventive measures for the control group using check lists.The actual nursing practices related to DVT preventive measures for the patients were observed by the researcher, using DVT prevention check lists that included the following check lists: Applying elastic stocking & leg elevation (check list ten Items).

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patients who met the predetermined criteria in the control group who received the routine unit care, using tool two part I (manifestations of DVT), part II (the laboratory tests) and part III (Doppler ultrasound) findings.-The patient's legs were assessed for DVT manifestations.The assessment included six items, which were scored as follows, calf pain scored as absent (0) or present 1, calf tenderness absent (0), present (1), calf edema skin color, and, distension of superficial vein and skin temperature of legs (warm calf).All data were recorded in the tool two parts I.The total score of manifestations scale To determine the grade of high risk for DVT if <9---No risk, low risk (9 <14), moderate risk (14 <21) and high risk ≥21-40.After that the laboratory data of the patients (prothrombin, time, hemoglobin, haematocrite, platelets, and fibrinogen level were recorded.These laboratory tests were done routinely, these data were recorded in the first day, fifth day, seventh day, and tenth days to determine coagulation status and compare patient's value with normal value. These preventive measures were performed by the researcher with assistance of the physiotherapist and the critical care nurses that involved in providing direct patient's care after training on the guidelines.Measuring the outcome of using DVT nursing guidelines: Bull High Inst Public Health Vol.38 No.1 [2008] -To evaluate the effect of the nursing guidelines on the occurrence of DVT for the interventional groups, tool two was used part I (manifestations of DVT), part II laboratory tests, and part III Doppler ultrasound findings.As previously done for the control group.

Table ( 3 )
indicates the mean and standard deviation of the DVT preventive measures done by the nurses for the control group.It was observed that no body was found in the control group to wear the elastic stocking.The mean number of the studied patients that changed their position in G1 was found to be 57.03±17.4Themean number of the studied patients in G1 was 2.22±10.27that performed deep breathing and coughing exercises.While the mean number of the patients that performed range of motion for the lower limbs was found to be 10.00±30.51.The mean number of the studied patients was found to be 3±10.0that were transferred to

FIGURE ( 1 )FIGURE ( 3 )FIGURE ( 4 )
FIGURE (1) THE MEAN PERCENT OF AGE IN THE BOTH GROUPS

Findings
of the current study revealed low incidence of DVT in the global sample, only two patients experienced DVT in the control group, and none of the interventional group experienced DVT.This result may be attributed to the small sample size, short period of observation and follow up individual risk factors are important in considering the need for DVT prophylaxis, multiple risk factors lead to an ever greater risk, therefore, the critically ill patients should be screened for DVT risk upon admission; and DVT prevention techniques should be initiated based on the risk assessment.
reported that occurrence of DVT is common among critically ill patients requiring prolonged mechanical ventilation more than 7 days in the critical care unit, despite the use of prophylaxis measures.Therefore, they documented that the critical care nurses should monitor the air way, breathing pattern, nutritional status, and psychological status for the patients who were connected to the mechanical ventilator.Moreover, the critical care nurses should change the patient's position, perform range of motion exercises for the lower limbs, and monitor of the hydration status to prevent dehydration Cook and co workers (2001) (1) pointed out that critically ill patients with high risk of DVT and PE and its potential morbidity and mortality, need accurate diagnosis and effective prevention.Therefore, critical care nurses need to understand approaches used for diagnosis, and to understand national interest in DVT research program.The present study shows that preventive measures of DVT done by the critical care nurses for the control group using nonpharmacological and mechanical methods were not adequately performed.It was observed that all the studied patients did not wear the elastic stocking.While small proportion of the studied patients performed leg exercises, and changed their position, did deep breathing exercises and coughing exercises, and transfer on the chair.This inadequacy of DVT preventive measures may be related to the lack of supplies and equipment, lack of in-services training programme about DVT preventive measures, lack of supervision and evaluation.This finding in line with Abd

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important role in DVT prevention.She must cooperate with other health professionals to develop system and quality improvement processes which are effective in terms of providing quality, and cost effective management for DVT prevention to critically ill patients.She must use keen judgment to detect patients at risk for DVT and to select appropriate interventions to defend against the onset of this problem.CONCLUSION Based on the findings of the current study, it can be concluded that: Findings of the current study revealed low incidence of DVT in the global sample, It was observed that the incidence of DVT in the control group was found to be two patients, while none of the interventional group experienced DVT.Furthermore, it can be concluded that DVT preventive measures done by the nurses for the control group were not adequate.No body was found in the control group wear the elastic stocking, and the mean percent of the studied patients that changed their position in G1 was found to be 57.03 ± 17.4.While the mean percent of the studied patients that performed deep breathing and cough exercises in G1 was 2.22 ±10.27.In addition, the mean percent of the patients that performed range of motion for the lower limbs was found to be 10.00 ±30.51, and the mean percent of the studied patients that were Transferred the patient on the chair were found to be 3±10.0.Concerning the DVT manifestations, it was observed that 43% of the studied patients in the control group experienced DVT manifestations, while in the interventional group was found to be 28%.Furthermore, it was found that most of the studied patients were in the moderate and high risk for DVT (14<21), they constituted about 47% of the studied patients in G1, and 53% in G2, with no statistical significant difference between of them.Procession of training programmes for critical care nurses.Training program should be established to update critical care nurses' knowledge and skills about DVT preventive measures.

Characteristics of the both groups in relation to their profile and DVT risk factors (figure1, 2, 3, 4, table 1, table 2):
of this study regarding the effect of implementing nursing guidelines on the occurrence of DVT for critically ill patients presented in four parts:-Part I: