Nursing Diagnosis for Thrombophlebitis | Acute Pain

Nursing diagnosis: acute pain related to diminished arterial circulation and oxygenation of tissues with production and accumulation of lactic acid in tissues; inflammatory process

Possibly evidenced by

Reports of pain, tenderness, aching or burning

Guarding of affected limb

Restlessness, distraction behaviors

Desired Outcomes/Evaluation Criteria—Client Will

Pain Control

Report that pain or discomfort is alleviated or controlled.

Verbalize methods that provide relief.

Display relaxed manner; be able to sleep or rest and engage in desired activity.

Nursing intervention with rationale:

1. Assess degree and characteristics of discomfort and pain. Note guarding of extremity. Palpate leg with caution.

Rationale: Degree of pain is directly related to extent of circulatory deficit, inflammatory process, degree of tissue ischemia, and extent of edema associated with thrombus development.

Changes in characteristics of pain may indicate development of complications.

2. Maintain bedrest during acute phase.

Rationale: Reduces discomfort associated with muscle contraction and movement.

3. Elevate affected extremity.

Rationale: Encourages venous return to facilitate circulation, reducing stasis and edema formation.

4. Provide foot cradle.

Rationale: Cradle keeps pressure of bedclothes off the affected leg, thereby reducing pressure discomfort.

5. Encourage client to change position frequently.

Rationale: Reduces muscle fatigue, helps minimize muscle spasm, and maximizes circulation to tissues.

6. Monitor vital signs, noting elevated temperature.

Rationale: 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.

7. 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.

Rationale: These signs and symptoms suggest the presence of PE as a complication of DVT or peripheral arterial occlusion associated with HITT. Both conditions require prompt

medical evaluation and treatment.

8. Administer medications, as indicated, for example, analgesics (opioid and nonopioid) and antipyretics, such as acetaminophen (Tylenol).

Rationale: Relieves pain and decreases muscle tension. Reduces fever and inflammation. Note: Risk of bleeding may be increased by concurrent use of drugs that affect platelet function,

such as aspirin and NSAIDs.

9. Apply moist heat to extremity if indicated.

Rationale: Causes vasodilation, which increases circulation, relaxes muscles, and may stimulate release of natural endorphins.