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.
Here are five (5) nursing care plans for Deep Vein Thrombosis (DVT):
- Impaired Gas Exchange
- Ineffective Peripheral Tissue Perfusion
- Acute Pain
- Deficient Knowledge
- Risk For Bleeding
Impaired Gas Exchange: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.
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
- 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. |
See Also
You may also like the following posts and care plans:
Hematologic and Lymphatic Care Plans
Care plans related to the hematologic and lymphatic system:
- Anaphylactic Shock | 4 Care Plans
- Anemia | 4 Care Plans
- Aortic Aneurysm | 4 Care Plans
- Deep Vein Thrombosis | 5 Care Plans
- Disseminated Intravascular Coagulation | 4 Care Plans
- 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
Further Reading
Recommended books and resources:
- Nursing Care Plans: Diagnoses, Interventions, and Outcomes
- Nurse's Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
- Nursing Diagnoses 2015-17: Definitions and Classification
- Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TR)
- Manual of Psychiatric Nursing Care Planning
- Maternal Newborn Nursing Care Plans
- Delmar's Maternal-Infant Nursing Care Plans, 2nd Edition
- Maternal Newborn Nursing Care Plans
