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
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
- Diminished arterial circulation and oxygenation of tissues with production and accumulation of lactic acid in tissues
- Inflammatory response in affected vein
Possibly evidenced by
- Distraction behaviors
- Guarding of affected limb
- Reports of pain, tenderness, aching or burning
- Client will report that pain or discomfort is alleviated or controlled.
- Client will verbalize methods that provide relief.
- Client will display relaxed manner; be able to sleep or rest and engage in desired activity.
|Assess degree and characteristics of discomfort and pain.||Degree of pain depends on the extent of circulatory deficit, inflammatory process, the degree of tissue ischemia, and extent of edema associated with thrombus development. Changes in characteristics of pain may indicate the development of complications.|
|Investigate reports of sudden or sharp chest pain, accompanied by dyspnea, tachycardia, and apprehension, or development of a new pain with signs of another site of vascular involvement.||These signs and symptoms suggest the presence of pulmonary embolism as a complication of DVT or peripheral arterial occlusion associated with heparin‐induced thrombocytopenia with thrombosis syndrome (HITT). Both conditions require immediate medical treatment.|
|Monitor vital signs, noting increased temperature.||Elevations in heart rate may indicate increased discomfort or may occur in response to fever and inflammatory process. Fever can also increase client’s discomfort.|
|Maintain bed rest during the acute phase.||Decreases discomfort associated with muscle contraction and movement.|
|Encourage client to change position frequently.||Reduces muscle fatigue, helps minimize muscle spasm and maximizes circulation to tissues.|
|Provide foot cradle.||Cradle keeps the pressure of bedclothes off the affected leg, thereby reducing pressure discomfort.|
|Elevate affected extremity.||Encourages venous return to facilitate circulation, reducing stasis and edema formation.|
|Apply a warm compress to the affected leg using a 2-hour-on, 2-hour-off schedule around the clock.||Moist heat may be applied to the affected region to relieve pain and improve circulation through vasodilation.|
|Administer medications, as indicated:|
|Relieves pain and decreases muscle tension.|
|Reduces fever and inflammation.|
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