Nursing Diagnosis for Thrombophlebitis | Knowledge Deficit

Nursing diagnosis: deficient Knowledge [Learning Need] regarding condition, treatment program, self-care, and discharge needs related to lack of exposure or recall; misinterpretation of information; unfamiliarity with information resources

Possibly evidenced by

Request for information, statement of misconception

Inaccurate follow-through of instructions

Development of preventable complications

Desired Outcomes/Evaluation Criteria—Client Will

Knowledge: Disease Process

Verbalize understanding of disease process, treatment regimen, and limitations.

Participate in learning process.

Identify signs and symptoms requiring medical evaluation.

Knowledge: Treatment Regimen

Correctly perform therapeutic actions and explain reasons for actions.

Nursing care plan intervention with rationale:

1. Review pathophysiology of condition and signs and symptoms of possible complications, such as PE, chronic venous insufficiency, and venous stasis ulcers (postphlebitic syndrome).

Rationale: Provides a knowledge base from which client can make informed choices and understand and identify healthcare needs. A significant number of clients experience a recurrence of DVT. Note: Genetic blood testing may help identify inherited thrombotic disorders. Screening tests should be done when venous thrombosis occurs in those aged 45 years or younger; when a thrombus occurs at an unusual location such as in gastrointestinal tract, brain, or arm; and when there is an immediate family history of DVT.

2. Explain purpose of activity restrictions and need for balance between activity and rest.

Rationale: Rest reduces oxygen and nutrient needs of compromised tissues and decreases risk of fragmentation of thrombosis. Balancing rest with activity prevents exhaustion and further

impairment of cellular perfusion.

3. Establish appropriate exercise and activity program.

Rationale: Aids in developing collateral circulation, enhances venous return, and prevents recurrence.

4. Problem-solve solutions to predisposing factors that may be present, such as employment that requires prolonged standing or sitting, wearing restrictive clothing, use of oral contraceptives, obesity, prolonged immobility, and dehydration.

Rationale: Actively involves client in identifying and initiating lifestyle and behavior changes to promote health and prevent recurrence of condition or development of complications.

5. Recommend sitting with feet touching the floor, avoiding crossing of legs.

Rationale: Prevents excess pressure on the popliteal space.

6. Review purpose and demonstrate correct application and removal of antiembolic hose.

Rationale: Understanding may enhance cooperation with prescribed therapy and prevent improper or ineffective use.

7. Instruct in meticulous skin care of lower extremities, such as prevent or promptly treat breaks in skin and report development of ulcers or changes in skin color.

Rationale: Chronic venous congestion and postphlebitic syndrome may develop, especially in presence of severe vascular involvement and recurrent DVT, potentiating risk of stasis ulcers.

8. Discuss purpose and dosage of anticoagulant. Emphasize importance of taking drug as prescribed.

Rationale: Promotes client safety by reducing risk of inadequate therapeutic response and deleterious side effects.

9. Identify safety precautions, such as use of soft toothbrush, electric razor for shaving, gloves for gardening, avoiding sharp objects (including toothpicks), walking barefoot, engaging in rough sports and activities, or forceful blowing of nose.

Rationale: Reduces the risk of traumatic injury, which potentiates bleeding or clot formation.

10. Review client’s usual medications and foods when on oral anticoagulants, stress need to read ingredient labels of over-the-counter (OTC) drugs and herbal supplements, and discuss use with healthcare provider prior to starting new medications.

Rationale: Warfarin (Coumadin) interacts with many foods and drugs, either increasing or decreasing the anticoagulant effect. Salicylates and excess alcohol decrease prothrombin activity, whereas vitamin K (multivitamins, bananas, leafy green vegetables) increases prothrombin activity and can cause a higher or lower INR, possibly outside the therapeutic range. Barbiturates increase metabolism of coumarin drugs; antibiotics alter intestinal flora and may interfere with vitamin K synthesis.