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
Risk For Bleeding
Risk for Bleeding: At risk for a decrease in blood volume that may compromise health.
May be related to
- Abnormal blood profiles
- Anticoagulation therapy for deep vein thrombosis (DVT)
Possibly evidenced by
- [not applicable]
- Client will maintain a therapeutic blood level of anticoagulant, s evidenced by prothrombin time (PT), international normalized ratio (INR), and partial thromboplastin time (PTT) within desired range.
- Client will not experience bleeding.
|Assess for the signs and symptoms of bleeding.||Bruises, epistaxis, and gum bleeding are early signs of spontaneous bleeding.|
|Monitor platelet counts and coagulation test results (INR, PT, PTT).||The effects of anticoagulation therapy must be closely monitored to reduce the risk of bleeding.|
|Monitor platelets and the heparin-induced platelet aggregation (HIPA) status.||Sudden decrease in the platelet count can occur with heparin use and is known as heparin-induced thrombocytopenia (HIT). HIT is less commonly seen with the use of low-molecular-weight heparin.|
|Administer anticoagulant therapy as prescribed (continuous IV heparin/subcutaneous low-molecular-weight heparin; oral warfarin).||Anticoagulants are given to prevent further clot formation. The type of medication varies per protocol and severity of the clot.|
|If bleeding occurs while on IV heparin:||Laboratory data guide further treatment. The guide for the PTT level is 1.5 to 2 times normal.|
|Convert from IV anticoagulation to oral anticoagulation after the appropriate length of therapy. Monitor INR, PT, and PTT levels.||PT or INR levels should be in a therapeutic range for anticoagulation before discontinuing heparin.|
|If HIPA is positive, stop all heparin products and anticipate a hematology consult.||Continuation of heparin products further complicates the situation. Specialty expertise is needed.|
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