Dvt Mylab.docx

DEEP VENOUS THROMBOSIS: LESSON INTRODUCTION In venous thrombosis (also termed thrombophlebitis), a blood clot forms on the wall of a vein, resulting in inflammation and some obstruction of blood flow back to the heart for reoxygenation. Deep venous thrombosis (DVT) is thrombosis in one of the body's deep veins. Prevention of venous thrombosis is particularly important in caring for the patient who is immobilized, postoperative, or postpartum. This lesson covers: • Pathophysiology and Etiology • Risk Factors • Clinical Manifestations • Diagnostic Tests • Prophylaxis • Pharmacologic Therapies • Surgeries • Clinical Therapies • Assessment • Diagnosis • Planning • Implementation • Evaluation.

TEST: 16.5 PRETEST DEEP VENOUS THROMBOSIS 1.

A client is scheduled for a duplex venous ultrasonography to assist in the diagnosis of a DVT. What should the nurse instruct the client about this diagnostic test? A. "Duplex venous ultrasonography removes thrombi to improve venous circulation and prevent pulmonary embolism or gangrene." B. "Duplex venous ultrasonography uses an injected contrast medium to assess venous thrombosis." C. "Duplex venous ultrasonography passes a balloon catheter through the skin, into the vessel, and through the vessel to the site of the lesion." D. "Duplex venous ultrasonography measures changes in blood flow through the veins."

D. Duplex venous ultrasonography is a noninvasive test used to visualize the vein and measure the velocity of blood flow in the veins; although the clot often cannot be visualized directly, its presence can be inferred by an inability to compress the vein during the examination. Ascending contrast venography uses an injected contrast medium to assess venous thrombosis. Percutaneous transluminal angioplasty passes a balloon catheter through the skin, into the vessel, and through the vessel to the site of a lesion, where the tip of the catheter is inflated to expand the lumen of the vessel. Venous thrombectomy is a surgical procedure that removes thrombi to improve venous circulation and prevent pulmonary embolism or gangrene.

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The nurse is caring for a postoperative client who has limited mobility. Which assessment finding should the nurse report as a possible sign of a pending DVT? (Select all that apply.) A. Area of redness along a left lower leg vein B. Aching of the left calf C. Pale skin color of the left lower leg D. Swelling of the left lower leg E. Muscle twitching of the left thigh Before receiving the morning report, the nurse makes rounds on assigned clients. At the bedside of one client, the nurse notes an ampule of vitamin K. What should the presence of this medication indicate to the nurse? A. The client is receiving low-molecular-weight heparin injections. B. The client is receiving high-dose aspirin therapy. C. The client is receiving intravenous heparin. D. The client is receiving warfarin. The nurse is reviewing assigned clients to determine which are at risk for developing a DVT. Which client should the nurse identify as a candidate for DVT preventivetherapy? A. The client with elevated cholesterol levels B. The client with a recently fractured femur C. The client with a history of diabetes mellitus D. The client with a history of hypertension

A,B,C,D. Manifestations of DVT include calf pain/tightness or dull, aching pain in the affected extremity that gets worse with walking; possible tenderness, swelling, warmth, and erythema along the affected vein; and edema and cyanosis of the affected extremity. Muscle twitching is not a manifestation of DVT.

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D. Vitamin K is the antagonist for warfarin; as a safety feature in the event of bleeding, vitamin K should be at the bedside of any client prescribed warfarin. Protamine sulfate is the antagonist for heparin. The risk of bleeding is reduced with low-molecular-weight heparin injections. Vitamin K is not an antagonist for aspirin therapy.

B. Along with the expected immobilization associated with this injury, recent fracture of the femur places a client at high risk for DVT. Hypertension is not considered a direct risk factor for DVT. Diabetes mellitus and elevated cholesterol levels are risk factors for peripheral arterial disease.

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The nurse is planning care for a client with a DVT of the right calf. What should the nurse include in this client's plan of care? (Select all that apply.) A. Coaching to perform deep breathing and coughing every 2 hours B. Applying warm, moist heat to the affected area every 6 hours C. Measuring the calf and thigh diameter of the right leg every shift D. Encouraging range-of-motion exercises every 2 to 4 hours E. Assisting to a sitting position with the legs dependent every 4 hours During a health history interview, the nurse is concerned that a client is experiencing signs of a developing DVT. Which information should cause this concern? A. Osteoarthritis of both wrists B. Total hip replacement 5 years ago C. Current calf pain with walking D. History of hypertension

A,B,C,D. Interventions that may be appropriate for inclusion in the plan of care for the client with DVT include measuring the calf and thigh diameter of the affected leg everyshift; applying warm, moist heat to the affected extremity at least four times a day; encouraging range-of-motion exercises; and assisting with deep breathing and coughing. The legs should be elevated, not dependent.

C. Considerations related to the development of DVT include complaints of leg or calf pain. A history of hypertension, joint replacement 5 years ago, and current diagnosis of osteoarthritis of the wrists do not increase the client's risk for developing a DVT.

OVERVIEW Overview: Pathophysiology and Etiology Trauma to a blood vessel stimulates the clotting cascade, causing platelet aggregation at the site of trauma. An initial clot is formed from platelets and fibrin. Red blood cells are trapped in the fibrin meshwork, causing the thrombus to grow in the direction of blood flow. The inflammatory response that is triggered leads to tenderness, swelling, and erythema in the area of the thrombus. The thrombus floats within the vein at first. Pieces may break loose and move through the circulatory system as emboli. Fibroblasts invade the thrombus, causing vein wall scarring and destroying venous valves. This valve damage may be permanent and affects directional blood flow. The three pathological factors, known as the Virchow triad, associated with thrombophlebitis are: • Blood stasis • Vessel damage • Increased blood coagulability. Venous thrombi are more common than arterial thrombi. Venous thrombi often occur where the vein is normal but blood flow is low. The most common type of venous thrombosis is deep venous thrombosis (DVT), which occurs in a deep vein that leads to the vena cava. DVT occurs most often in the deep veins of the legs (particularly the calf) and the pelvis. DVT less frequently occurs in the arm, chest, or other location. About half of DVTs are asymptomatic. Symptoms depend on the location and size of the thrombus.

Overview: Risk Factors The incidence of DVT is highest in individuals who are immobilized or who have had recent surgery, particularly abdominal or thoracic surgery. Trauma and certain cancers may also increase the risk of DVT. Women of childbearing age have a higher risk of DVT than men. The risk of DVT is high during pregnancy and the first few months postpartum. Clients with DVT are at risk for chronic venous and pulmonary embolism. The following table provides more information about risks for DVT. Characteristics Risk Factor Atrial fibrillation Acute myocardial infarction Ischemic stroke Orthopedic procedures Coagulation disorders

• Thrombi form within the atria and can enter general circulation. Transesophageal echocardiography can identify clients at risk of thromboembolism. • Risk of DVT is almost 20% for clients who had an MI. Older adults at risk include those with recurrent angina, heat failure, and ventricular arrhythmias. • Risk of DVT is 40% for clients with stroke and paralyzed extremities. • Risk of DVT is 25% in clients with total hip replacement without prophylaxis, about 50% in clients with traumatic hip fracture, and up to 60% in clients with total knee replacement. • These disorders promote clotting.

Cancer

• High incidence of DVT in clients with pancreatic, lung, ovary, testes, urinary tract, breast, and stomach cancers. • Oral contraceptives increase risk. • Hormone replacement therapy increases risk. • Recovery from myocardial infarction, heart failure, stroke, and surgical procedures involving immobility increases risk. • Pregnancy increases blood volume and stresses blood vessels. • During pregnancy and the first few months postpartum, risk is 4 times greater than that for nonpregnant women. • Orthopedic, thoracic, abdominal, or genitourinary surgery involves more risk. • Fracture of the spine, pelvis, femur, or tibia increases risk. • Spinal cord injury increases risk.

Hormone therapy Immobilization Pregnancy and delivery Surgery Trauma

Overview: Clinical Manifestations DVT is usually asymptomatic. Clinical manifestations are primarily the result of the inflammatory process that accompanies the thrombus and may include: • Calf pain/tightness or dull aching pain in the affected extremity that gets worse with walking • Possible tenderness, swelling, warmth, and erythema along the affected vein • Cyanosis of the affected extremity • Edema of the affected extremity • Chronic venous and pulmonary emboli.

COLLABORATION Collaboration: Diagnostic Tests Diagnostic Test Duplex venous ultrasonography

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Plethysmography

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Magnetic resonance imaging

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Ascending contrast venography

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Purpose To visualize the vein and measure the velocity of blood flow To measure changes in blood flow through the veins Often used in combination with Doppler ultrasonography Important in diagnosing thromboses of larger or more superficial veins To diagnose a thrombus in the vena cava or pelvic veins To assess the location and extent of venous thrombosis Contrast medium injected to assess venous thrombosis Expensive, invasive, and uncomfortable but the most accurate diagnostic test for a DVT Used when less invasive tests give an unclear diagnosis1

Diagnostic tests make it possible to differentiate venous thrombosis from other causes of extremity pain, such as lymphedema, contusion, muscle strain, and cellulitis. Tests used to diagnose DVT are detailed in the table to the left.

Collaboration: Prophylaxis

Some clients need extra prophylactic measures to avoid the occurrence of DVT. These include clients who are immobilized, postoperative, and postpartum. Prophylactic measures that may prevent a DVT include: • • Administering low-molecular-weight heparin injections • Elevating the client's feet with the knees slightly bent • Avoiding pillows under the client's knees • Encouraging the client to use a recliner or footstool • when sitting • Encouraging early ambulation after surgery • Teaching ankle flexion and extension exercises • Instructing the client to wear elastic stockings, use pneumatic compression devices, or both • Instructing the client to avoid crossing the legs in bed or when sitting •

Collaboration: Pharmacologic Therapies Pharmacologic therapies used in treatment of DVT include the following: • Anticoagulant medications prevent clot formation or growth and allow the body's lytic system to dissolve existing clots. • Fibrinolytic medications speed up clot lysis and prevent damage to venous valves. • Thrombolytic medications dissolve clots. • Nonsteroidal anti-inflammatory drugs (NSAIDs) reduce inflammation and relieve client symptoms. Drugs used to treat peripheral vascular disease are detailed in the following table. Medication Aspirin Clopidogrel bisulfate (Plavix) Cilostazol (Pletal) Pentoxifylline (Trental) Prostaglandins

Indications • • • • • • • •

Inhibits platelet aggregation Inhibits platelet aggregation Inhibits platelets to improve claudication Decreases blood viscosity Increases red blood cell flexibility Decrease pain Facilitate healing in severe limb ischemia Used long term

Medications specifically used to treat DVT include: • Intravenous heparin • Oral anticoagulation for at least 3 months • NSAIDs for pain. Heparin dosage is calculated to maintain the activated partial thromboplastin time (aPTT) at approximately twice the control of normal value. Warfarin (Coumadin) doses are adjusted to maintain the International Normalized Ratio (INR) at 2.0 to 3.0.3

Collaboration: Surgeries Venous thrombosis is usually treated with anticoagulation and conservative measures. However, surgery is sometimes required to treat venous thrombosis. The purpose of surgery is to remove the thrombus, prevent it from entering deep veins, or prevent embolization. Surgical options include: • Venous thrombectomy, which removes thrombi from the femoral vein to improve venous circulation and prevent pulmonary embolism or gangrene. • Insertion of a filter in the vena cava to capture emboli from the pelvis and lower extremities. This procedure is used when venous thrombosis is recurrent and anticoagulant therapy is contraindicated. Two types of filters are the Greenfield filter and the Nitinol filter. • Ligation and division of the saphenous vein where it joins the femoral vein. The vein that is affected by a septic venous thrombosis is excised to control infection. This procedure prevents clots from entering the deep venous system. The surgical procedure is accompanied by antibiotic therapy.

Collaboration: Clinical Therapies Clinical therapies for DVT are instituted to relieve symptoms and reduce inflammation. Treatments for DVT include: • Application of warm, moist compresses over the affected vein • Bed rest: The degree of leg edema determines how much time the client should spend in bed. • Elevation of the legs at a 15- to 20-degree angle with the knees slightly flexed above the level of the heart. This aids venous return and inhibits venous pooling. • Use of elastic antiembolism stockings, which aid the return of blood to the heart by stimulating the muscle-pumping mechanism • Use of pneumatic compression devices • Walking when able • Avoidance of prolonged standing or sitting • Avoidance of leg crossing • Avoidance of tight-fitting or binding garments and stockings

NURSING PROCESS Nursing Process: Assessment During the assessment phase of the nursing process, the nurse collects and documents data related to the client's health history, medication regimen, and current health status. These data are used to identify actual and potential health alterations, to promote wellness, and to target client-specific outcomes. Selected considerations related to focused assessment of the client with DVT are outlined in the following table. Assessment Health history

Physical examination

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Considerations Related to Clients with Deep Venous Thrombosis History of venous thrombosis or other clotting disorders Complaints of leg or calf pain Duration of leg or calf pain Characteristics of the pain Effect of the pain on walking Current medications Body temperature Redness of the affected extremity Edema of the affected extremity Tenderness on palpation Warmth on palpation Cord-like structures rare on palpation

Nursing Process: Diagnosis During the diagnosis phase of the nursing process, the nurse analyzes and synthesizes assessment data to formulate client-specific nursing diagnoses. The nurse also identifies emergent and urgent problems that require immediate attention and provides prompt client care as indicated. Nursing diagnoses that are reflective of safety risks or infectious disease transmission should be addressed immediately. Nursing diagnoses may address actual problems, potential problems (risks), or opportunities to enhance the client's wellness. Nursing diagnoses that may be appropriate for inclusion in the plan of care for the client with DVT address a variety of problems, including: • Impaired tissue perfusion • Alterations in comfort • Potential for ineffective protection • Increased risk for impaired physical mobility.

Nursing Process: Planning The planning phase of the nursing process includes formulating client goals and outcomes as well as selecting evidence-based nursing interventions that support the client's achievement of the identified goals and outcomes. Client goals and outcomes should be measurable. In addition, client goals and outcomes should be client-specific and tailored to meet the client's needs. General examples of client goals and outcomes that may be appropriate for inclusion in the plan of care for the client with DVT include: • The client will demonstrate increased tissue perfusion. • The client will not have complications from thrombus embolization. • The client will rate pain at ≤3 on a 1–10 pain scale. Nursing interventions include independent and collaborative interventions. Independent interventions may be performed by the nurse, as needed. Collaborative interventions, such as medication administration, require a primary care provider's order. Nursing interventions are chosen during the planning phase and carried out during the implementation phase of the nursing process. Nursing interventions related to the care of the client with DVT are discussed in the following section.

Nursing Process: Implementation During the implementation phase of the nursing process, the nurse carries out independent and collaborative nursing interventions that support the client's achievement of the identified client goals and outcomes. For the client with DVT, nursing interventions are aimed at increasing tissue perfusion, improving patient comfort, maintaining circulation, and other considerations. Interventions that may be appropriate for inclusion in the plan of care for the client with DVT include:

• • • • • • • • • • • • •

Assessing pain location and characteristics and reporting increasing pain or changes in pain location Measuring calf and thigh diameter of the affected extremity and reporting any increases Applying warm, moist heat to the affected extremity at least four times a day Maintaining the client on bed rest as ordered, with the leg elevated and an egg-crate mattress or sheepskin as needed Assessing peripheral pulses, skin integrity, capillary refill, and color of extremities at least every 8 hours Encouraging frequent position changes Assessing respiratory status frequently and initiating oxygen therapy as needed Monitoring laboratory results and reporting values outside the desired range Assisting with deep breathing and coughing Encouraging range-of-motion (ROM) exercises and providing passive ROM as needed Assisting with ambulation as needed Performing daily hygiene on the affected leg using mild soaps and a non-alcohol-based moisturizer Encouraging diversional activities to help the client avoid inertia.

Nursing Process: Evaluation During the evaluation phase, the nurse evaluates: • The client's response to all nursing interventions • The degree to which the client goals and outcomes were achieved • The need for revising the client's plan of care, including modifying, adding, or discontinuing nursing diagnoses and interventions. For the client with a DVT who successfully achieves the identified client goals and outcomes, examples of nursing observations during the evaluation phase may include: • The client demonstrated increased tissue perfusion. • The client did not have complications from thrombus embolization. • The client rated pain at ≤3 on a 1–10 pain scale. The nursing process operates as a feedback loop. That is, each step is influenced by the preceding and following step. Although the nursing process is presented as a linear, five-step process, in practice it is dynamic and multidirectional. As such, the nurse is continually assessing the client and evaluating the client's response to nursing interventions.

HOMEWORK: 16.5 REMEMBER 1.

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Which is a risk factor for development of a DVT? (Select all that apply.) A. Immobilization B. Lung cancer C. Hypercholesterolemia D. Diabetes mellitus E. Hormone therapy Which pathological factors, or parts of the Virchow triad, are associated with thrombophlebitis? (Select all that apply.) A. Stasis of blood B. Lysis C. Embolism D. Vessel damage E. Increased blood coagulability Which action helps prevent development of a DVT? (Select all that apply.) A. Avoiding crossing the legs B. Avoiding prolonged standing C. Avoiding prolonged sitting D. Avoiding extreme exercise E. Avoiding tight-fitting clothing or stockings Which test is used to diagnose a DVT? (Select all that apply.) A. Plethysmography B. Duplex venous ultrasonography C. Color-flow Doppler ultrasound D. Magnetic resonance angiography E. Magnetic resonance imaging

A,B,D. Hormone therapy, lung cancer, and immobilization are all risk factors for the development of DVT. Hypercholesterolemia and diabetes mellitus are risk factors for peripheral vascular disease, not DVT.

A,D,E. The Virchow triad involves blood stasis, increased blood coagulability, and vessel damage. An embolism is a vascular occlusion. Lysis is the dissolution or destruction of cells, the opposite of what happens when thrombi form.

A,B,C,E. Actions to prevent development of a DVT include avoiding prolonged standing orsitting, avoiding leg crossing, and avoiding tight-fitting or binding garments and stockings. Avoiding extreme exercise does not prevent development of a DVT. A,B,E. Duplex venous ultrasonography, magnetic resonance imaging, and plethysmography are used to diagnose a DVT. Color-flow Doppler ultrasound and magnetic resonance angiography are used to diagnose peripheral vascular disease.

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What is assessed during the physical examination of a client with a DVT? (Select all that apply.) A. Muscle atrophy of the affected extremity B. Edema of the affected extremity C. Redness of the affected extremity D. Body temperature E. Warmth on palpation Which nursing diagnosis is used to guide the care for a client with a DVT? (Select all that apply.) A. Impaired tissue perfusion B. Increased risk for impaired physical mobility C. Alterations in comfort D. Potential for ineffective protection E. Ineffective oxygenation

B,C,D,E. When conducting the physical examination of a client with a DVT, assess bodytemperature, redness of the affected extremity, edema of the affected extremity, and the presence of warmth on palpation. Muscle atrophy is not a manifestation associated with a DVT.

A,B,C,D. Nursing diagnoses that may be appropriate for inclusion in the plan of care for a client with a DVT include impaired tissue perfusion, alterations in comfort, potential for ineffective protection, and Increased risk for impaired physical mobility. A DVT does not affect oxygenation.

HOMEWORK: 16.5 APPLY 1.

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Mrs. Kim, a 58-year-old client, is hospitalized with symptoms of DVT. The latest test results indicate stasis of blood, and the healthcare provider suspects that Mrs. Kim has developed venous thrombi. What other pathological factor should the nurse use to determine whether Mrs. Kim has a DVT? A. Increased blood coagulability B. Tissue hypoxia C. Increased blood pressure D. Tissue anoxia Samuel Lewis, an 84-year-old client, is admitted for testing to rule out a DVT. While the nurse prepares an injection oflow-molecular-weight heparin, Mr. Lewis asks why he needs injections in his stomach if the problem is in his leg. How should the nurse respond? A. "Didn't your doctor tell you that you need to take these shots in your stomach for the rest of your life?" B. "This medication dissolves any clots in your legs but must be given in your stomach." C. "Low-molecular weight heparin prevents blood clots from forming in your leg but must be given in yourstomach." D. "People over the age of 80 should be receiving this medication in their stomach so that blood doesn't pool in the legs." Janice Jaworski, a 50-year-old client, is being discharged after treatment for a DVT. Ms. Jaworski is a freelance writer and spends prolonged periods of time working at a computer. What instruction should the nurse provide to Ms. Jaworski to reduce the risk of future DVT development? A. "Standing is preferred over sitting, so think about altering your work environment." B. "Sitting is permitted as long as the legs are not crossed." C. "Take frequent breaks to prevent sitting for prolonged periods of time at the computer." D. "It is best to stand and wear tight-fitting hose when working."

A. Mrs. Kim already shows two of the three pathological factors, known as the Virchow triad, associated with venous thrombi: stasis of blood and symptoms of blood vessel damage. Increased blood coagulability is the third pathological factor associated with venous thrombi. Tissue hypoxia and anoxia are not pathological factors of DVT, and DVT does not affect blood pressure.

C. Low-molecular-weight heparin, administered in the fatty tissue of the abdomen, is used as a prophylactic measure to prevent the formation of blood clots in those who are at risk for developing deep venous thrombosis. It does not dissolve any currently formed clots. People over the age of 80 do not need to receivelow-molecular-weight heparin, nor does this medication prevent pooling of blood in the lower extremities. These injections do not need to be provided to the client for the rest of his life.

C. The client should take frequent breaks to prevent long periods of uninterrupted sitting. Standing for long periods is not advised because this can potentiate the development of future DVT. The client should also avoid crossing the legs and wearing tight-fitting clothing and stockings.

TEST: 16.5 POSTTEST DEEP VENOUS THROMBOSIS 1.

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The nurse is planning care for a client who has been prescribed bed rest after abdominal surgery. Which action by the nurse helps to prevent development of a DVT in this client? (Select all that apply.) A. Limiting fluids and restricting caloric intake B. Elevating the client's feet with the knees slightly bent C. Teaching the proper way to cross the legs D. Reviewing ankle extension and flexion exercises E. Placing a pillow under the client's knees During a home visit, the nurse evaluates care provided to a client recovering from a DVT. Which observation indicates that additional teaching is required? A. The client is sitting with the legs elevated. B. The client has removed the antiembolism stockings. C. The client is taking warfarin as prescribed. D. The client frequently changes position. A client with a history of DVT reports a sudden onset of severe pain in the pelvis. Which diagnostic test should the nurse expect to be prescribed for this client? A. Magnetic resonance imaging B. Ascending contrast venography C. Plethysmography D. Duplex venous ultrasonography The nurse is preparing discharge instructions for a client prescribed warfarin (Coumadin) for a DVT. What should the nurse include in this teaching? A. "Take the warfarin at bedtime each day." B. "Omit warfarin on the days when laboratory tests are ordered." C. "Use a hard-bristled toothbrush." D. "Notify the healthcare provider of bleeding or bruising." The nurse is teaching a 25-year-old female client who is taking oral contraceptives. Which instruction should the nurse include to minimize the risk for developing aDVT? A. "Include periods of activity when traveling." B. "Decrease your alcohol consumption." C. "Consume a low-fat diet." D. "Avoid high-sodium foods." While conducting an assessment, the nurse determines that a client is at risk for developing a DVT. What did the nurse assess to make this conclusion? (Select all that apply.) A. The client is taking over-the-counter medication for arthritis. B. The client controls type 2 diabetes mellitus with dietary intake and exercise. C. The client has a history of atrial fibrillation. D. The client is being treated for bladder cancer. E. The client experienced a myocardial infarction 2 years ago.

B,D. Prophylactic measures that may prevent a DVT include elevating the feet with the knees slightly bent and practicing ankle flexion and extension exercises. Avoid pillows under the knees and crossing the legs. Limiting fluids and restricting caloric intake do not prevent development of a DVT.

B. The client should be wearing antiembolism stockings as prescribed; this observation indicates that additional teaching is required. Taking warfarin as prescribed, elevating the legs, and frequent position changes indicate that teaching has been effective. A. With this client's history of venous thrombosis, the healthcare provider would order an MRI to diagnose a thrombus in a pelvic vein. Ascending contrast venography assesses the location and extent of venous thrombosis. Plethysmography measures changes in blood flow through the veins. Duplex venous ultrasonography visualizes the vein and measures the velocity of blood flow. D. Warfarin (Coumadin) can cause bleeding even if the laboratory tests used to measure the effectiveness are in the therapeutic range; the healthcare provider must be notified of any bleeding so that the dosage can be adjusted. The client should use a soft-bristled toothbrush to prevent gum injury and bleeding. Warfarin can be taken at any time of day; however, it must be taken at the same time each day. Clients taking warfarin should not omit a dose without the healthcare provider's knowledge. A. Use of oral contraceptives places the client at increased risk for DVT. Being sedentary also increases the risk for DVT. There is no link between alcohol consumption and thrombosis in women who take oral contraceptives. A low-fat diet will not directly minimize the risk for DVT, and a high sodium intake is associated with hypertension in those taking oral contraceptives.