Superficial thrombophlebitis is commonly prevalent during the postpartum period than during pregnancy and is seen more in women experiencing varices. Postpartum deep vein thrombosis (DVT) and superficial thrombophlebitis have been attributed to trauma to pelvic veins from the pressure exerted by the presenting fetal part, impaired circulation caused by mechanical edema, and changes in coagulation related to the high amount of estrogens produced during pregnancy. Thrombosis that involves only the superficial veins of the leg or thigh is unlikely to result in pulmonary emboli (PE). While approximately 50% of clients with DVT are asymptomatic, DVT is more serious in terms of potential complications, such as pulmonary embolism, post-thrombotic syndrome, chronic venous insufficiency, and vein valve destruction.
Nursing care plan goals for a client with postpartum thrombophlebitis include enhance tissue perfusion, facilitate resolution of thrombus, promote optimal comfort, prevent complications and provide information and emotional support.
Here are four (4) nursing care plans (NCP) for postpartum thrombophlebitis:
Altered Peripheral Tissue Perfusion
Ineffective Tissue Perfusion: Decreased in the oxygen resulting in the failure to nourish the tissues at the capillary level.
May be related to
- Venous blood flow interruption
Possibly evidenced by
- Pallor and cyanosis (DVT)
- Prolonged capillary refill time
- Weak peripheral pulses
- Swelling of affected extremity
- Redness/erythema (superficial thrombophlebitis)
- Client will demonstrate improved circulation of affected extremity as evidenced by palpable and equal peripheral pulses, adequate capillary refill, reduced edema, and erythema.
|Monitor capillary refill time; Assess for positive Homans’ sign (calf pain at dorsiflexion of the foot).||DVT may prolonged capillary refill time. Positive Homans’ sign is not a reliable indicator of DVT.|
|Assess circulation, asymmetry, sensory and motor function of extremity; Observe edema from groin to foot; Measure and record calf/thigh circumference of both legs as appropriate. Report proximal progression of inflammation, traveling pain.||Symptoms help differentiate between superficial thrombophlebitis and DVT. Localized edema, redness, warmth, and tenderness are indicative of superficial involvement. Pallor and coolness of extremity are more characteristic of DVT. Calf vein involvement of DVT is usually associated with the absence of edema; mild to moderate edema suggests femoral vein involvement, and severe edema is characteristic of ileofemoral vein thrombosis.|
|Assess respiration and auscultate for lung sounds, noting crackles or friction rub. Investigate reports of chest pain or feelings of anxiety.||Pulmonary congestion, sudden sharp substernal chest pain, anxiety, shortness of breath, rapid heart rate, and hemoptysis are characteristic of pulmonary emboli, especially in DVT.|
|Instruct client to avoid massaging or rubbing the affected extremity.||Massaging the extremity increases the risk of dislodging the thrombus that can turn into emboli.|
|Maintain bed rest with elevation of feet and lower legs in above heart level during the acute phase.||Decreases the possibility of dislodging thrombus and creating emboli. Rapidly empties superficial and tibial veins and keeps veins collapsed, thereby increasing venous return.|
|Elevate client’s legs when resting or sitting in a chair.||Reduces tissue swelling and rapidly empties superficial and tibial veins, preventing overdistension and, thereby, increasing venous return.|
|Instruct client to avoid crossing the legs or wear constrictive clothing.||Promotes restriction in circulation that impairs blood flow, thus increasing venous stasis, pain, and trauma.|
|Encourage increased fluid intake of 2500 ml/day unless contraindicated||Reduces blood viscosity and minimizes the possibility of a thrombus formation.|
|Emphasize the importance of deep-breathing exercises.||Increase negative pressure in the thorax which aids in emptying large veins.|
|Facilitate and assist with active or passive ROM while on bedrest; Assist with gradual resumption of ambulation as advised.||Enhances increased venous return, decreases venous stasis, and maintains muscle strength.|
|Apply warm, moist compresses or heating pad to affected extremity as ordered.||Promotes circulation, reduces swelling and improves venous return.|
|Apply elastic support hose. Caution is advised to prevent a tourniquet effect.||Useful during the acute phase of superficial thrombosis since they exert a sustained, evenly distributed pressure over the entire surface of calves and thighs, decreasing caliber of superficial veins, enhancing blood flow to deep veins, and reducing stasis|
|Apply mechanical devices such as sequential compression stockings, thromboembolic (TED) stockings as indicated.||Reduces venous stasis in the lower extremities and increases blood flow to the large leg veins which are prone to thrombus formation.|
|Monitor laboratory studies:|
|Increased levels may indicate a thrombi formation.|
|Measures the efficacy of the anticoagulant therapy. Hemoconcentration and dehydration increases blood viscosity and venous stasis, which promotes thrombus formation.|
|Administer medication as indicated:|
|Reproductive tract infection may result in septic pelvic thrombophlebitis.|
|May be used for the treatment of acute or massive DVT to prevent valvular damage and development of chronic venous insufficiency. Heparin is usually begun several hours after the completion of thrombolytic therapy.|
|Heparin is usually preferred initially, owing to its prompt and predictable antagonistic action toward thrombin formation and prevention of further clot formation. Because of its large molecular size, heparin does not pass through to breast milk as coumarin derivatives do; however, coumarin, which blocks the formation of prothrombin from vitamin K, may be used for long-term therapy following discharge.|
|Prepare client for surgical intervention as indicated.||Thrombectomy (excision of thrombus) is usually done if inflammation extends proximally or circulation is severely compromised. Recurrent thrombotic episodes that are unresponsive/ contraindicated to anticoagulant therapy may require insertion of an inferior vena cava (IVC) filter.|
Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end and a duration of <6 months.
May be related to
- Presence of inflammatory process
- Vascular spasms
- Accumulation of lactic acid
Possibly evidenced by
- Verbalizations of pain, tenderness, or burning
- Guarding behavior
- Autonomic responses
- Client will report pain is relieved/controlled.
- Client will participate in behaviors/techniques to promote comfort.
|Assess degree and characteristic of discomfort or pain using 0–10 scale; palpate leg with caution. Note guarding of extremity.||Degree of pain is directly related to extent of arterial involvement, degree of hypoxia, and extent of edema associated with thrombus development in inflamed venous wall. Client may guard or immobilize affected extremity to decrease painful sensations associated with muscle movement.Changes in characteristics of pain may indicate progression of problem/development of complications|
|Monitor vital signs, noting elevated temperature or pulse.||Elevation of vital signs may indicate increasing pain, or occur in response to fever and inflammatory process. Fever may contribute to general discomfort.|
|Observe for reports of sudden or sharp chest pain, dyspnea, tachycardia, or apprehension.||These signs and symptoms indicate pulmonary embolism as a complication of DVT.|
|Encourage change of position, keeping extremity elevated.||Promotes increases venous return; Decreases fatigue and muscle spasm.|
|Elevate affected extremity; provide foot cradle.||Encourages venous return, facilitates circulation. Foot cradle keeps pressure of bedclothes off the affected leg, thereby reducing pressure discomfort|
|Maintain bedrest during the acute phase.||Reduces discomfort associated with muscle contraction and movement. Minimizes the possibility of dislodging thrombus.|
|Explain procedures, treatments, and nursing interventions.||Involving the client in the nursing care increases her sense of control and decreases her level of anxiety.|
|Apply moist heat to extremity.||Causes vasodilation, which increases circulation, relaxes muscles and may stimulate the release of endorphins.|
|Administer medications as indicated:|
|Reduces fever and inflammation.|
|Relieves pain and decreases muscle tension, promoting relaxation/rest|
Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.
May be related to
- Lack of exposure/recall, misinterpretation
Possibly evidenced by
- Inaccurate follow-through of instructions
- Development of preventable complications
- Client will verbalize understanding of condition, treatment, and restrictions
- Client will initiate necessary behavioral changes/correctly perform therapeutic procedures.
- Client will identify signs/symptoms requiring medical evaluation.
|Assess client’s knowledge and understanding of disease process. Correct misconceptions as needed.||Helps in determining specific needs and clarifying previous information.|
|Provide information about management and diagnostic tests. Identify signs and symptoms requiring notification of healthcare provider; e.g., pain, swelling and tenderness in one of the legs.||Can increase understanding and decrease anxiety associated with the condition and home management. Progression of condition and/or development of bleeding requires prompt evaluation and possible changes in therapy to prevent serious complications.|
|Demonstrate the use of anti-embolic stocking. Encourage removal of elastic stockings for brief intervals at least twice daily.||Continuous constriction may alter or reduce surface perfusion, leading to muscle fatigue. Removal of elastic stockings allows for detection of further vascular involvement or inflammation.|
|Explain the purpose of bedrest or activity restrictions needs for adequate rest.||Rest reduces oxygen and nutrient needs of compromised tissues and decreases the risk of fragmentation of thrombosis. Balancing rest with activity prevents exhaustion and further impairment of cellular perfusion.|
|Educate on safety measures to avoid bleeding, such as the use of an electric razor for shaving, use of soft toothbrush, avoiding barefoot walking.||Alterations in coagulation process may result in increased tendency to bleed, which may indicate a need to alter anticoagulant therapy.|
|Discuss purpose, dosage of anticoagulant. Emphasize the importance of taking the drug as prescribed.||Promotes client safety by reducing risk of inadequate therapeutic response/deleterious side effects.|
|Identify possible interactions between oral other medications (e.g., antibiotics, NSAIDs, barbiturates, diuretics, and vitamins). Stress need to read ingredient labels of over-the-counter (OTC) drugs.||Oral anticoagulant therapy may last 3–4 mo and anticoagulant therapy and may cause problems or require alterations in drug dosage if it is allowed to interact with other medications. Salicylates and excess alcohol decrease prothrombin activity; vitamin K in multivitamins increases prothrombin activity; antibiotics alter intestinal flora and may interfere with vitamin K synthesis; barbiturates increase metabolism of coumarin drugs.|
|Identify untoward anticoagulant effects requiring medical attention, e.g., bleeding from mucous membranes, continued oozing from cuts/punctures, severe bruising after minimal trauma, development of petechiae||Early detection of deleterious effects of therapy (prolongation of clotting time) allows for timely interventions and may prevent serious complications.|
|Stress importance of medical follow-up/ laboratory testing.||Understanding that close supervision of anticoagulant/therapy is necessary (therapeutic dosage range is narrow and complications may be deadly) promotes client participation/adherence to the therapeutic regimen.|
Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response.
May be related to
- Change in health status
- Interpersonal transmission of anxiety from family members
- Perceived or actual threat to self
- Situational crisis
Possibly evidenced by
- Increased tension
- Sympathetic stimulation
- Client will verbalize awareness of feelings of anxiety.
- Client will report anxiety reduced to a manageable level.
- Client will exhibit a decrease in behavioral signs, such as restlessness and irritability
|Explain disease condition, diagnostic procedures and treatment regimen.||Promotes client’s learning and involvement in the care; Decreases the fear of the unknown.|
|Monitor vital signs and behavioral signs such as restlessness, irritability, and crying.||May reveals a change in the level of anxiety and reflects decreasing ability to cope up with events.|
|Involve client and family members in the development of a plan of care; review instructions and restrictions.||Allows them to have a sense of control over the situation; Provides information and enable the client and significant other understand the purpose of interventions and restrictions.|
|Assist client in caring for herself and infant.||Client’s anxiety may minimize when needs are met and that she is able to adjust and engage in self-care and infant care tasks.|
|Encourage use of relaxation techniques. Provide an opportunity to verbalize concerns.||Relaxation prevents muscle fatigue and allows the client to rest; Expression of concerns reduce emotional tension, lessening anxiety.|
|Encourage frequent contact, in person or by telephone, with spouse and children if the client is hospitalized. Encourage regular ”rooming in” with the newborn as condition allows.||Helps to reduce feelings of separation and isolation. Facilitates transition to home.|
|Determine anticipated availability/ effectiveness of supports following discharge. Prioritize responsibilities/ household tasks.||Help identify specific needs, encourages problem-solving to meet needs of client/family before the client is discharged.|
|Refer to social services, visiting nurse, homecare agency, as appropriate.||May require additional support to facilitate recovery/meet needs of the family.|
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Maternal and Newborn Care Plans
Nursing care plans related to the care of the pregnant mother and her infant. See care plans for maternity and obstetric nursing:
- Abruptio Placenta| 3 Care Plan
- Cesarean Birth | 10 Care Plans
- Cleft Palate and Cleft Lip | 6 Care Plans
- Dysfunctional Labor (Dystocia) | 4 Care Plans
- Elective Termination | 6 Care Plans
- Gestational Diabetes Mellitus | 4 Care Plans
- Hyperbilirubinemia | 4 Care Plans
- Labor Stages, Induced and Augmented Labor | 36 Care Plans
- Neonatal Sepsis | 5 Care Plans
- Perinatal Loss | 5 Care Plans
- Placenta Previa | 3 Care Plans
- Postpartum Hemorrhage | 8 Care Plans
- Postpartum Thrombophlebitis | 4 Care Plans
- Prenatal Hemorrhage | 7 Care Plans
- Prenatal Substance Dependence/Abuse | 6 Care Plans
- Precipitous Labor | 3 Care Plans
- Pregnancy Induced Hypertension | 6 Care Plans
- Premature Dilation of the Cervix | 3 Care Plans
- Prenatal Infection | 3 Care Plans
- Preterm Labor | 6 Care Plans
- Puerperal Infection | 4 Care Plans