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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):
1. Impaired Gas Exchange
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. |
2. 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:
- - Asymptomatic
- - Increased leg warmth
- - Edema (Unilateral)
- - Pain during palpation of calf muscle
- - Tenderness
Desired Outcomes
- - 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.
| Nursing Interventions | Rationale |
|---|---|
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). |
3. Acute Pain
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
- - Restlessness
- - Reports of pain, tenderness, aching or burning
Desired Outcomes
- - 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.
| Nursing Interventions | Rationale |
|---|---|
| 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. |
4. Deficient Knowledge
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
Desired Outcomes
- - Client and/or significant others will verbalize understanding of the disease, treatment, and prevention.
| Nursing Interventions | Rationale |
|---|---|
| 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. |
5. 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]
Desired Outcomes
- - 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.
| Nursing Interventions | Rationale |
|---|---|
| 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. |
References and Sources : nurseslabs.com
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