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Thrombophlebitis is the inflammation of the vein wall resulting in the formation of a thrombosis (blood clot) that may interfere the normal blood flow through the vessel.
Typically, venous thrombophlebitis occurs in the lower extremities. It may also occur in superficial veins such as cephalic, basilic, and greater saphenous veins, which usually is not life threatening and does not necessitate hospitalization, or it may happen in a deep vein, which can be life-threatening because clots may travel to the bloodstream and cause a pulmonary embolism.
Three contributing factors (known as Virchow’s triad) can lead to the development of deep vein thrombosis (DVT) which includes venous stasis, hypercoagulability, and a vessel wall injury.
Venous stasis occurs when blood flow is decreased, as in immobility, medication therapies and in heart failure. Hypercoagulability occurs most commonly in clients with deficient fluid volume, pregnancy, oral contraceptive use, smoking, and some blood dyscrasias. Venous wall damage may occur secondary to venipuncture, certain medications, trauma, and surgery. The objective of treatment of DVT involves preventing the clot from dislodgement (risking pulmonary embolism) and reducing the risk of post-thrombotic syndrome.
Nursing Care Plans
The nursing care plan for the client with deep vein thrombosis include: providing information regarding disease condition, treatment, and prevention; assessing and monitoring anticoagulant therapy; providing comfort measures; positioning the body and encouraging exercise; maintaining adequate tissue perfusion; and preventing complications.
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Here are five (5) nursing care plans (NCP) and nursing diagnosis for patients with deep vein thrombosis (DVT):
- Impaired Gas Exchange
- Ineffective Peripheral Tissue Perfusion
- Acute Pain
- Deficient Knowledge
- Risk For Bleeding
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Impaired Gas Exchange
Nursing Diagnosis
- Impaired Gas Exchange
May be related to
- Altered blood flow to alveoli or to major portions of the lung
- Alveolar-capillary membrane changes–active bleeding, airway or alveolar collapse, atelectasis, excessive secretions, or pulmonary effusion/edema
Possibly evidenced by
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- Apprehension
- Cyanosis
- Dyspnea
- Hypercapnia
- Hypoxemia
- Restlessness
- Somnolence
Desired Outcomes
- Client will demonstrate adequate ventilation and oxygenation by ABGs within client’s normal range.
- Client will report or display resolution or absence of symptoms of respiratory distress.
| Nursing Interventions | Rationale |
|---|---|
| Assess level of consciousness and changes in mentation. | Initial signs of systemic hypoxemia include restlessness and irritability, followed by progressively decreased mentation. |
| Auscultate lungs for areas of decreased and absent breath sounds and the presence of adventitious sounds (crackles). | Non-ventilated areas may be identified by the absence of breath sounds. Crackles may be seen in fluid-filled tissues and airway or may indicate cardiac decompensation. |
| Monitor vital signs. Observe changes in cardiac rhythm. | Tachycardia, tachypnea, and BP changes are associated with progressing hypoxemia and acidosis. Alterations in heart rhythm and extra heart sounds may indicate increased cardiac workload related to worsening ventilation imbalance. |
| Assess respiratory rate and rhythm. Observe for use of accessory muscles, nasal flaring, and pursed lip breathing. | Tachypnea and dyspnea indicative of pulmonary obstruction. Dyspnea and increased work of breathing may be first or only sign of subacute pulmonary embolism. Severe respiratory distress and failure accompany moderate to severe loss of functional lung units. |
| Observe for generalized duskiness and cyanosis in the earlobes, lips, tongue, and buccal membranes. | Suggestive of systemic hypoxemia. |
| Assess activity tolerance, such as reports of weakness and fatigue, vital sign changes, or increased dyspnea during exertion. Encourage rest periods, and limit activities to client tolerance. | These guidelines help in determining the response of the client to resume activities and ability to engage in self-care. |
| Monitor the client frequently and arrange for someone to stay with the client, as indicated. | Provides assurance that changes in condition will be noted and that assistance is readily available. |
| Provide brief explanations of what is happening and expected effects of an intervention. | Relieves anxiety related to unknown and may help decrease fears regarding personal safety. |
| Encourage expression of feelings and inform the client and significant others of normalcy of anxious feelings and sense of impending doom. | Understanding basis of feelings may help the client regain some sense of control over emotions. |
| Assist with frequent changes of position, and encourage ambulation as tolerated. | Turning and ambulation enhance aeration of different lung segments, thereby improving oxygenation. |
| Encourage coughing, deep breathing exercises, and suctioning as indicated. | Increases oxygen delivery to the lungs by mobilizing secretions and enhancing ventilation. |
| Assist client to deal with the fear and anxiety that may be present. | Inability to breathe properly increases oxygen consumption and demand, therefore, worsening the anxiety level. |
| Keep the head of bed elevated. | Promotes maximal chest expansion, making it easier to breathe and enhancing physiological and psychological comfort. |
| Monitor ABGs or pulse oximetry. | Hypoxemia is present in varying degrees, depending on the degree of airway obstruction, cardiopulmonary status, and presence and degree of shock. Respiratory alkalosis and metabolic acidosis may also be present. |
| Prepare the client for a lung scan. | May reveal the pattern of abnormal perfusion in areas of ventilation, reflecting ventilation and perfusion mismatch, confirming the diagnosis of pulmonary embolism and degree of obstruction. Absence of both ventilation and perfusion reflects alveolar congestion or airway obstruction. |
| Assist with chest physiotherapy, such as postural drainage and percussion of the non-affected area and incentive spirometer. | Facilitates deeper respiratory effort and promotes drainage of secretions from lung segments into bronchi, where they may more readily be removed by coughing or suctioning. |
| Provide supplemental humidification, such as ultrasonic nebulizers. | Nebulization gives moisture to mucous membranes and helps liquefy secretions to facilitate airway clearance. |
| Provide oxygen therapy with an appropriate method as ordered. | Maximizes available oxygen for gas exchange, reducing work of breathing. |
| Provide adequate hydration either oral (PO) or IV as indicated. | Increased fluids may be given to decrease hyperviscosity of blood, which can potentiate thrombus formation, or support circulating volume and tissue perfusion. |
| Administer medications, as indicated: | |
| These agents intended to bring about clot lysis (breakdown of the clot) and immediate normalization of venous blood flow. |
| These are given to decrease pain or anxiety and improve work of breathing., maximizing gas exchange. |
| Prepare for and assist with bronchoscopy. | The purpose of this procedure is to remove blood clots and clear the airway. |
| Prepare for surgical intervention, if indicated. | Vena caval ligation or insertion of an intracaval umbrella is intended for clients with recurrent emboli despite adequate anticoagulation, when anticoagulation is contraindicated, or when septic emboli arising from below the renal veins unresponsive to treatment; Pulmonary embolectomy is often done as a last resort treatment of PE. |
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Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.
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- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use. - Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively. - NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales. - Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates. - Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing. - Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans. - Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you. - Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023. - All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
See also
Other recommended site resources for this nursing care plan:
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- Nursing Care Plans (NCP): Ultimate Guide and Database
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch. - Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
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- Hemophilia | 5 Care Plans
- Leukemia | 5 Care Plans
- Lymphoma | 3 Care Plans
- Sepsis and Septicemia | 6 Care Plans
- Sickle Cell Anemia Crisis | 6 Care Plans
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