Nursing Diagnosis for Thrombophlebitis | Ineffective Peripheral Tissue Perfusion

Nursing diagnosis: ineffective peripheral tissue Perfusion related to decreased blood flow and venous stasis (partial or complete venous obstruction)

Possibly evidenced by

Tissue edema, pain

Diminished peripheral pulses, slow or diminished capillary refill

Skin color changes—pallor, erythema

Desired Outcomes/Evaluation Criteria—Client Will

Tissue Perfusion: Peripheral

Demonstrate improved perfusion as evidenced by peripheral pulses present, equal skin color, and temperature normal and absence of edema.

Engage in behaviors or actions to enhance tissue perfusion.

Display increasing tolerance to activity.

Nursing care plan intervention with rationale:

1. Evaluate circulatory and neurological studies of involved extremity, both sensory and motor. Inspect legs from groin to foot for skin color and temperature changes as well as edema. Note symmetry of calves; measure and record calf circumference. Report proximal progression of inflammatory process and traveling pain.

Rationale: Symptoms help distinguish between thrombophlebitis and DVT. Redness, heat, tenderness, and localized edema are characteristic of superficial involvement. Note: Unilateral edema is one of the most reliable physical findings in DVT. Calf vein involvement is associated with absence of edema; femoral vein involvement is associated with mild to moderate

edema; and iliofemoral vein thrombosis is characterized by severe edema.

2. Examine extremity for obviously prominent veins. Palpate gently for local tissue tension, stretched skin, and knots or bumps along course of vein.

Rationale: Distention of superficial veins can occur in DVT because of backflow through communicating veins. Thrombophlebitis in superficial veins may be visible or palpable.

3. Assess capillary refill and check for Homans’ sign.

Rationale: Diminished capillary refill usually present in DVT. Note: Homans’ sign is unreliable because it is not present in many clients with DVT.

4. Promote early ambulation.

Rationale: Short, frequent walks are better for extremities and prevention of pulmonary complications than one long walk. If client is confined to bed, ensure range-of-motion exercises.

5. Elevate legs when in bed or chair, as indicated.

Rationale: Reduces tissue swelling and rapidly empties superficial and tibial veins, preventing overdistention and thereby increasing venous return. Note: Some physicians believe that elevation may potentiate release of thrombus, thus increasing risk of embolization and decreasing circulation to the most distal portion of the extremity.

6. Initiate active or passive exercises while in bed, for example, flex, extend, and rotate feet periodically. Assist with gradual resumption of ambulation as soon as client is permitted out

of bed.

Rationale: These measures are designed to increase venous return from lower extremities and reduce venous stasis as well as improve general muscle tone and strength. They also promote

normal organ function and enhance general wellbeing.

7. Caution client to avoid crossing legs or hyperflex at knee, such as seated position with legs dangling or lying in jackknife position.

Rationale: Physical restriction of circulation impairs blood flow and increases venous stasis in pelvic, popliteal, and leg vessels, thus increasing swelling and discomfort.

8. Instruct client to avoid rubbing or massaging the affected extremity.

Rationale: This activity potentiates risk of fragmenting and dislodging thrombus, causing embolization, and increasing risk of complications.

9. Encourage deep-breathing exercises.

Rationale: Increases negative pressure in thorax, which assists in emptying large veins.

10. Increase fluid intake to at least 1,500 to 2,000 mL/day, within cardiac tolerance.

Rationale: Dehydration increases blood viscosity and venous stasis, predisposing to thrombus formation.