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
Deficient Knowledge: Absence or deficiency of cognitive information related to a specific topic.
May be related to
- Unfamiliarity with the disease, management, and prevention
Possibly evidenced by
- Inaccurate information
- Inaccurate follow-through
- Multiple questions to health care team
- Client and/or significant others will verbalize understanding of the disease, treatment, and prevention.
|Assess the client’s understanding of the causes, treatment, and prevention plan for deep vein thrombosis.||This information gives an important starting point in education. DVT requires preventive effort to reduce the risk of reoccurrence.|
|For clients with DVT, instruct in the following signs of pulmonary embolus:||These symptoms can be caused by a blood clot that breaks off from the original clot in the leg and travels to the lung.|
|Instruct the client to take medications as indicated, explaining their actions, dosages, and side effects.||Correct knowledge decreases future complications. Analgesics and anti-inflammatory medications are indicatedfor short-term symptom relief. Clients may require anticoagulation for weeks or long term, depending on the risks.|
|Inform the client of the need for regular laboratory testing while on oral anticoagulation.||Routine coagulation monitoring is necessary to ensure that a therapeutic response is obtained and prevent reoccurrences of clots.|
|Discuss and give the client a list of signs and symptoms of excessive anticoagulation.||Clients need to self-manage their condition. Early assessment facilitates prompt treatment.|
|Provide teaching regarding the safety measures while on anticoagulant therapy such as the use of an electric razor, the use of a soft toothbrush.||These precautionary measures help reduce the risk of bleeding.|
|Instruct the client to avoid rubbing or massaging the calf.||This will prevent breaking off the clot, which may travel into the circulation as an embolus.|
|Instruct the client in the correct application of compression stockings.||Stockings applied inaccurately can serve as a tourniquet and promote clot formation.|
|Educate the client about the following measures to prevent reoccurrence:|
|Wearing constricting clothing decreases normal blood flow and promotes clotting.|
|This will avoid the occurrence of venous stasis.|
|Sufficient hydration prevents hypercoagulability.|
|Obesity contributes to venous insufficiency and venous hypertension through the compression of the main veins in the pelvic region.|
|The client should refrain from any position that promotes vein compression.|
|Walking, swimming, and cycling help promote venous return through the contraction of the calf and thigh muscles. These muscles act as a pump to compress veins and support the column of blood returning to the heart.|
|Cigarretes contain nicotine which is a vasoconstrictor that affects blood clotting and circulation.|
|Clients with DVT are at high risk for redevelopment and may need to wear stockings over the long term.|
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