Nursing Care Plan | NCP Thrombophlebitis

Thrombophlebitis, inflammation of a vein with an associated blood clot (thrombus), typically occurs in the veins of the lower extremities when fibrin and platelets accumulate at areas of stasis or turbulence near venous valves. Deep vein thrombophlebitis (deep vein thrombosis [DVT]) occurs more than 90% of the time in small veins, such as the lesser saphenous, or in large veins, such as the femoral and popliteal. DVT and its possible consequence, pulmonary embolism, are the leading causes of preventable mortality in hospitalized patients in the United States. DVT occurs in approximately 1 person in 20 over her/his lifetime, but in hospitalized patients, the incidence of DVT ranges from 20% to 70%.

DVT is potentially more serious than that of the superficial veins because the deep veins carry approximately 90% of the blood flow as it leaves the lower extremities. Once a thrombus begins to move, it becomes an embolus (a detached intravascular mass carried by the blood). If it reaches the lungs, a pulmonary embolus, it is potentially fatal.

Venous stasis, hypercoagulability, and vascular injury are major causes of thrombophlebitis. Venous stasis results from prolonged immobility, pregnancy, obesity, chronic heart disease such as congestive heart failure (CHF) or myocardial infarction, recovery from major surgery (surgical procedures lasting more than 30 minutes), cerebrovascular accidents, and advanced age. Hypercoagulability is associated with pregnancy, cigarette smoking, dehydration, deficiencies of substances involved in clot breakdown, disseminated intravascular coagulation, estrogen supplements and oral contraceptives, and sepsis. Vascular injury can occur with lower extremity fractures, surgery, burns, multiple trauma, childbirth, infections, irritating intravenous (IV) solutions, venipuncture, and venulitis. Other diseases that may lead to thrombus formation are cancer of the lung, gastrointestinal tract, and genitourinary tract and also atrial fibrillation; individuals older than 55 years are also particularly susceptible to thrombophlebitis.

Nursing care plan assessment and physical examination

Although almost half of the patients with deep and superficial thrombophlebitis are asymptomatic, patients with DVT may have complaints of calf muscle or groin tenderness, pain, fever (rarely above 101°F), chills, general weakness, and lethargy.

Observe both legs, noting alterations in symmetry, color, and temperature of one leg compared with the other. In DVT, the affected limb may reveal redness, warmth, swelling, and discoloration when compared with the contralateral limb. In addition, superficial veins over the area may be distended. Note the presence of calf pain with dorsiflexion of the foot of the affected extremity, which is a positive Homans’ sign. This positive finding occurs in 33% of patients with DVT and is considered an inconsistent and unreliable physical sign. Superficial vein thrombosis may be asymptomatic or may lead to pain, redness, induration, and swelling in the local area of the thrombus. Note the presence of local redness and nodules on the skin or extremity edema, which is rare. Palpate over the suspected vein involved. It may feel like a cord or thickness that extends upward along the entire length of the vein.

The patient has not only an unexpected, sudden illness but also an increased risk for life-threatening complications such as pulmonary embolism. Assess the patient’s ability to cope. In addition, assess the patient’s degree of anxiety about the illness and potential complications.

Nursing care plan primary nursing diagnosis: Altered peripheral tissue perfusion related to obstructed venous blood flow.

Nursing care plan intervention and treatment plan

To prevent thrombus formation, most physicians prescribe compression of the legs by graduated compression stockings to reduce venous stasis in low-risk general surgical patients. In higherrisk patients, intermittent pneumatic compression boots prevent venous stasis and increase the normal breakdown of fibrin in the body with increased fibrinolytic activity.

Most patients who develop thrombophlebitis are placed on bedrest with extremity elevation to avoid dislodging the thrombus. Local heat with warm soaks may also be used to reduce venospasm and decrease inflammation. Generally, the patient is given analgesics for pain control and anticoagulant therapy, initially with heparin, to prevent further clot formation. From 1 to 3 days later, warfarin (Coumadin) therapy is started. Heparin is usually discontinued 48 hours after the patient’s prothrombin time (PT) reaches a therapeutic value (Box 1). Some patients may continue heparin subcutaneously for several weeks before changing to warfarin. Because prothrombin assays are performed in various ways, PT results are now also reported as an International Normalized Ratio (INR). The target INR for oral anticoagulation is at least 2.0; current recommendations are to stop heparin therapy after 5 to 7 days of joint therapy when the INR is 2.0 to 3.0 with the patient off heparin. For patients with massive DVT in proximal veins, thrombolytic therapy may be considered. Before initiating therapy, the risk that the clot presents to the patient is compared with the risk of bleeding from thrombolytic agents.

Other treatments that may be used for severe, obstructive DVT are thrombectomy (surgical clot removal) and surgical prophylaxis against pulmonary embolism (implantation of a Greenfield filter or an umbrella filter in the inferior vena cava). If a filter device cannot be placed, the inferior vena cava may be tied off (ligated) or stitched (plicated) to limit movement of emboli.

The most important nursing interventions focus on prevention. Decrease the risk of venous stasis in a bedridden patient by performing early ambulation and active or passive range-of-motion exercises several times a day. Avoid using the knee gatch because of the risk of popliteal pressure and venous stasis; encourage patients not to cross their legs, especially when sitting. If pillows are needed to elevate extremities, position them along the entire length of the extremity to prevent additional pressure on veins and to allow for adequate venous drainage. If the patient is immobile and not on fluid restriction, encourage the patient to drink at least 3 L of fluid a day to prevent dehydration and venous stasis. To prevent injury to vessel walls, monitor IV cannulas to prevent infiltration. If IV medications are irritating to the vein, IV cannulas should be changed and rotated to new sites more often than the standard procedure.

Discuss activity restrictions with the patient and family. The patient usually feels confined and may become resentful because of the need for absolute bedrest. To increase mobility in bed, install an orthoframe and trapeze system to the bed. A sheepskin, air mattress, foam pad, foot cradle, or heel pads can reduce the risk of skin breakdown while the person is on bedrest. Provide diversional activities to reduce anxiety.

Nursing care plan discharge and home health care guidelines

Teach the patient preventive strategies. Demonstrate how to apply compression stockings correctly, if they have been prescribed. Be sure the patient understands all medications, including the dosage, route, action, adverse effects, and need for routine laboratory monitoring for anticoagulants. If the patient is being discharged on subcutaneous heparin, the patient or family needs to demonstrate the injection technique. The patient also needs to know to avoid over-the-counter medications, particularly those that contain aspirin. Explain the need to avoid activities that could cause bumping or injury and predispose the patient to excessive bleeding. Instruct the patient to notify the physician if abdominal or flank pain, heavy bleeding during menstruation, and bloody urine or stool occurs.

Recommend using a soft toothbrush and an electric razor to limit injury. Remind the patient to notify the physician or dentist of anticoagulant use before any invasive procedure. Instruct the patient to report leg pain or swelling, skin discoloration, or decreases in peripheral skin temperature to the physician. In addition, if the patient experiences signs of possible pulmonary embolism (anxiety, shortness of breath, pleuritic pain, hemoptysis), he or she should go to the emergency department immediately.