Thromboprophylaxis: nursing measures

The frame: medical order, nursing delivery

The professional basis is the S3 guideline “Prophylaxis of venous thromboembolism (VTE)” (AWMF 003-001), version 4.1. It is a medical document: it orders risk, indication and method. How the measure is delivered, observed and documented is not in it — and there is no German nursing expert standard for it, as set out under Is there an expert standard on thromboprophylaxis?.

In practice: the guideline supplies the what, nursing owns the how. What follows is ordered along the nursing process.

1. Risk assessment

What comes first is not a measure but an appraisal. Recommendation 5.1 (new in 2025): before the indication for VTE prophylaxis is made, both the VTE and the bleeding risk shall be evaluated. The two belong together — bleeding risk co-determines which measure is available at all.

The guideline distinguishes two kinds of risk factor:

• Exposure-related — arising from the situation: type and extent of the procedure, injury, immobilisation, acute illness.
• Patient-related — previous venous thromboembolism, age, obesity, cancer, thrombophilia and others.

One finding matters particularly in practice: in 70 to 80 per cent of cases at least one patient-related factor is present in addition to the exposure-related one. The guideline therefore explicitly requires checking whether the combination places the patient in a higher risk category. Looking only at the procedure means systematically underestimating.

Recommendation 5.2: the assessment should lead to one of three risk groups — low, moderate, high. Recommendation 5.3: type and extent of prophylaxis shall follow that classification, with contraindications and bleeding risk taken into account.

Risk group	Distal DVT	Proximal DVT	Fatal PE
Low	< 10 %	< 1 %	< 0.1 %
Moderate	10–40 %	1–10 %	0.1–1 %
High	40–80 %	10–30 %	> 1 %

Frequencies of venous thromboembolism without thromboprophylaxis, per the S3 guideline on VTE prophylaxis, version 4.1. The figures are why risk assessment comes first, not last.

Two qualifications: risk assessment models such as the Caprini score may help — the guideline rates this as an open recommendation at grade 0 with low evidence (5.4). And extended laboratory screening, including thrombophilia testing, is not recommended for risk classification.

2. The measures

The guideline groups three (statement 6.1):

Basic measures — the nursing core

Early mobilisation, movement exercises and instruction in self-directed exercises. They should be applied regularly in all patients (recommendation 3.1, grade B); at low VTE risk the recommendation carries grade A (6.2). Adequate hydration belongs with them. What works and what does not is covered under movement exercises for thromboprophylaxis.

Physical measures

Medical thromboprophylaxis stockings and intermittent pneumatic compression (IPC). Version 4.1 sharpened this: at moderate or high VTE risk with contraindications to pharmacological prophylaxis, physical measures shall be applied, preferably IPC — recommendation 7.3, grade A. In addition to pharmacological prophylaxis they may be applied (7.4, grade 0). What they must not do: replace an indicated pharmacological prophylaxis (7.2).

Pharmacological measures

Order and selection are medical decisions. What is relevant for nursing is administration, observation and passing on anything unusual. The comparison of methods is under mechanical vs. pharmacological.

3. Goals in care planning

The guideline formulates no nursing goals. Anyone who needs them faces the question of what a goal can attach to — and “the patient does not develop a thrombosis” is unsuitable: not steerable, not verifiable during the stay, and in effect a promise of success no one can give.

Goals that attach to the measure and its delivery hold better — that movement exercises take place at the planned frequency, that the compression garment fits correctly over the ordered wear time, that the patient knows and performs the self-directed exercises, that the skin under the garment stays unremarkable. These are observable, documentable and assessable over time.

4. Delivery, observation, documentation

The effect of physical measures depends on consistent application. For IPC in stroke, efficacy is documented from at least 18 hours of application per day — a measure running only for a few hours is not the one that was studied.

The guideline also names IPC-related adverse events: disturbed sleep patterns, skin injuries and an increased risk of falls, with an incidence of 2.89 per cent versus 1.29 per cent in the control group. That defines the nursing observation task concretely: skin checks, fit of the garment, sleep quality, mobility at the bedside.

Where devices are used, documented instruction under Section 4 (3) MPBetreibV applies — person-specific and verifiable. The recognised limits of the method are under IPC contraindications.

What does not sit with nursing

The indication. Whether and which prophylaxis is appropriate is decided by the treating medical staff on the basis of VTE and bleeding risk. Routine screening is not a ward task either — the guideline explicitly advises against it in asymptomatic patients.

What does sit with nursing is the feedback: when an ordered measure cannot be delivered, when the fit does not hold, when the skin reacts, when the patient declines. That information belongs back in the indication decision, where it is needed.

This article addresses medical professionals. It replaces neither a medical order nor an in-house procedure.