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.
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 (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
Ineffective Peripheral Tissue Perfusion
Ineffective Tissue Perfusion: Decrease in oxygen, resulting in failure to nourish tissues at the capillary level.
May be related to
- Increased coagulability of blood
- Venous stasis
- Vessel wall injury
Possibly evidenced by
- Usually involves changes in femoral, popliteal, or small calf veins:
- Increased leg warmth
- Edema (Unilateral)
- Pain during palpation of calf muscle
- Client will maintain optimal peripheral tissue perfusion in the affected extremity, as evidenced by strong palpable pulses, reduction in and/or absence of pain, warm, and dry extremities, and adequate capillary refill.
- Client will not experience pulmonary embolism, as evidenced by normal breathing, normal heart rate, and absence of dyspnea and chest pain.
|Assess for contributing factors:||Most clients with DVT are asymptomatic. Knowledge of high-risk situations helps in early detection.|
|Assess for the signs and symptoms of deep vein thrombosis (DVT).||The signs and symptoms occur in the leg affected by the deep vein clot which includes swelling, pain or tenderness, increased warmth, and changes in skin color (redness).|
|Measure the circumference of the affected leg with a tape measure.||Unilateral leg and thigh swelling can be assessed by measuring the circumference of the affected leg 10 cm below the tibial tuberosity and 10 cm to 15 cm above the upper edge of the patella. Deep vein thrombosis is suspected if there is a difference of >3 cm between the extremities.|
|Monitor the results of diagnostic tests:||These tests are used to document the location of a clot and the status of the affected vein.|
|Ultrasound uses sound waves to create pictures of blood flowing through the arteries and veins in the affected leg.|
|D-dimer is a marker for clot lysis. This test can also be used to check the effectivity of the treatment.|
|This test uses an inflated cuff for blocking the venous flow and monitoring the blood volume increase in the limb.|
|This test uses radiopaque contrast media injected through a foot vein to localize thrombi in the deep venous system.|
|Monitor the following coagulation profile:||These are used to measure the effectiveness of anticoagulant therapy. The PT/INR is used for clients receiving warfarin. Baseline values are obtained before the first dose of anticoagulant is administered. Repeated tests are done at prescribed intervals to adjust drug dosages to achieved desired changes in coagulation.|
|Maintain adequate hydration.||Hydration prevents an increased viscosity of blood, which contributes to venous stasis and clotting.|
|Encourage bedrest and keep the affected leg elevated (depending on size and location of the clot) as indicated.||Clients usually require bed rest until symptoms are relieved. The affected leg should be elevated to a position above the heart to decrease swelling.|
|Provide warm, moist heat to the affected site.||Heat promotes comfort and reduces inflammation.|
|Apply below-knee compression stockings as prescribed. Ensure that the stockings are the correct size and are applied correctly.||Compression stockings enhance circulation by providing a graduated pressure on the affected leg to help return the venous blood to the heart. Inaccurately applied stockings can serve as a tourniquet and can promote clot formation.|
|Administer analgesics as prescribed.||Analgesics relieve pain and promote comfort.|
|Administer anticoagulants as (heparin/warfarin [Coumadin]) as prescribed.||Treatment with anticoagulant is used primarily to prevent the formation of new clots by decreasing the normal activity of the clotting mechanism. Heparin IV or subcutaneous low-molecular-weight heparin is started initially. Oral anticoagulant therapy (warfarin) will be initiated while the client is still receiving heparin because the onset of action for warfarin can be up to 72 hours. Heparin will be discontinued once the warfarin reaches therapeutic levels.|
|With a massive DVT severely comprising tissue perfusion, anticipate thrombolytic therapy.||Thrombolytic therapy is used only in severe embolism that significantly comprises blood flow to the tissues since they can cause can cause sudden bleeding. For the maximum effectiveness, therapy must be started soon after the onset of symptoms (within 5 days).|
|For clients who are unresponsive to the anticoagulant therapy, anticipate the following surgical treatment:|
|The filter is inserted inside the vena cava. The filter catches blood clots before they travel to the lungs, which prevents pulmonary embolism. It is recommended for clients who cannot take anticoagulants or those with recurrent DVT despite anticoagulant therapy.|
|The most severe cases of DVT may require the surgical removal of the blood clot from the vein (thrombectomy).|
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