19 terms

Thrombophlebitis

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Overview
Development of a thrombus that may cause vessel occlusion or embolization
Acute condition characterized by inflammation and thrombus formation
Possibly occurring in deep or superficial veins (see Major venous pathways of the leg)
Typically occurring at the valve cusps because venous stasis encourages accumulation and adherence of platelet and fibrin
Overview-Pathophysiology
Alterations in the epithelial lining cause platelet aggregation and fibrin entrapment of red blood cells, white blood cells, and additional platelets.
The thrombus initiates a chemical inflammatory process in the vessel epithelium that leads to fibrosis, which may occlude the vessel lumen or embolize.
Overview-Causes
Fracture of the spine, pelvis, femur, or tibia
Hormonal contraceptives such as estrogens
Idiopathic
Neoplasms
Pregnancy and childbirth
Prolonged bed rest
Surgery
Trauma, including internal trauma to a vein from an indwelling catheter
Venous stasis
Venulitis
Overview-Incidence
The incidence of superficial thrombophlebitis ranges from 3% to 11% of the general population.
The risk of developing deep vein thrombophlebitis dramatically rises with increased age.
Deep vein thrombosis typically occurs in patients older than age 40.
Overview-Complications
Pulmonary embolism
Chronic venous insufficiency
Hemorrhage
Assessment-History
Asymptomatic in up to 50% of patients with deep vein thrombophlebitis
Possible tenderness, aching, or severe pain in the affected leg or arm; fever, chills, and malaise
Assessment-Physical Findings
Redness, swelling, and tenderness of the affected leg or arm
Possible positive Homans' sign (not a reliable indicator)
Positive cuff sign
Possible warm feeling in affected leg or arm
Lymphadenitis in the case of extensive vein involvement
Palpable, indurated, cordlike, tender venous segment (superficial)
Reddish purple discoloration of the lower extremity
Diagnostic Test Results-Imaging
Doppler ultrasonography may show reduced blood flow to a specific area and any obstruction to the venous flow, particularly in iliofemoral deep vein thrombophlebitis.
Plethysmography may show decreased circulation distal to the affected area; this test is more sensitive than ultrasonography in detecting deep vein thrombophlebitis.
Phlebography confirms the diagnosis and may show filling defects and a diverted blood flow.
Treatment-General
Application of warm or cool moist compresses to the affected area
Antiembolism stockings, compression stockings, or pneumatic compression devices
Treatment-Activity
Bed rest, with elevation of the affected extremity
Early ambulation when symptoms are controlled and anticoagulation has been started
Treatment-Medications
Low-molecular-weight heparin, such as enoxaparin sodium, dalteparin sodium, tinzaparin sodium, or fondaparinux sodium
I.V. heparin bolus followed by continuous infusion
Warfarin
Nonsteroidal anti-inflammatory agents, such as ibuprofen, for pain relief.
Treatment-Surgery
Simple ligation to vein plication or clipping
Embolectomy
Caval interruption with transvenous placement of a vena cava filter
Nursing Considerations-Nursing Diagnoses
Activity intolerance
Acute pain
Impaired skin integrity
Ineffective peripheral tissue perfusion
Risk for decreased cardiac perfusion
Risk for infection
Risk for injury
Nursing Considerations-Expected Outcomes
participate in energy conservation measures to reduce metabolic demands
express feelings of increased comfort and decreased pain
maintain normal skin integrity
exhibit adequate peripheral tissue perfusion
maintain hemodynamic stability and cardiac function
develop no signs or symptoms of infection
remain free from complications.
Nursing Considerations-Nursing Interventions
Enforce bed rest and elevate the patient's affected arm or leg, but avoid compressing the popliteal space. Encourage ambulation as soon as possible.
Apply moist cool or warm compresses or use a covered aquathermia pad; ensure that the compresses or pad is covered and not in direct contact with the skin.
Mark, measure, and record the circumference of the affected arm or leg daily, and compare this measurement with that of the other arm or leg; also compare pulses in the affected and unaffected extremities.
Give prescribed anticoagulants. Administer low-molecular-weight heparin by deep subcutaneous injection into the anterolateral and posterolateral abdominal wall sites.
Institute bleeding precautions and protect the patient from injury. Check stools, emesis, and urine for possible occult blood.
Obtain specimens for laboratory testing as ordered, especially platelet levels and coagulation studies (activated partial thromboplastin time [aPTT], prothrombin time [PT], and International Normalized Ratio [INR]) to evaluate the effectiveness of heparin and warfarin therapy.
Expect to begin warfarin therapy approximately 3 days before discontinuing heparin therapy.
Perform or encourage range-of-motion exercises as appropriate.
Encourage frequent rest periods and measures to conserve energy.
Use pneumatic compression devices.
Apply antiembolism stockings.
Nursing Considerations-Monitoring
Affected extremity for size, swelling, warmth, and erythema
Signs and symptoms of bleeding
Vital signs
Laboratory test results, such as platelet levels, aPTT for a patient on heparin therapy, and PT and INR for a patient on warfarin
Signs and symptoms of heparin-induced thrombocytopenia
Signs and symptoms of pulmonary embolism
Skin integrity
Peripheral pulses and tissue perfusion
Response to treatment
Nursing Considerations-Associated Nursing Procedures
Antiembolism stocking application, knee-length
Antiembolism stocking application, thigh-length
Antiembolism stocking application, waist-length
Blood pressure assessment
Heat application
IV bag preparation
IV bolus injection
IV catheter insertion
IV heparin administration
Oral drug administration
Pain management
Passive range-of-motion exercises
Postoperative care
Preoperative care
Pulse assessment
Respiration assessment
Subcutaneous injection
Venipuncture
Patient Teaching-General
disorder, diagnosis, possible underlying causes, and treatments, including anticoagulant therapy, antiembolism stockings, extremity elevation, and application of cool or warm moist compresses
importance of follow-up blood studies to monitor anticoagulant therapy
prescribed medication therapy regimen, including drug names, dosages, frequency and routes of administration, and duration of therapy
technique for administering subcutaneous anticoagulant injections, if necessary
possible adverse effects of anticoagulant therapy, such as bleeding and associated signs and symptoms, along with the need to notify a health care provider if any occur
foods that are high in vitamin K and the need to maintain a consistent intake of such foods to prevent interaction with warfarin therapy
importance of maintaining activity, especially ambulation, and the need to avoid prolonged sitting or standing, and strategies for risk reduction if traveling for long periods while sitting (such as long airline flights), including:
getting up and walking around every 1 to 2 hours

avoiding smoking

wearing loose-fitting, comfortable clothing

avoiding crossing the legs

flexing and extending the ankles and knees periodically

drinking plenty of fluids and avoiding alcoholic beverages
getting up and walking around every 1 to 2 hours
avoiding smoking
wearing loose-fitting, comfortable clothing
avoiding crossing the legs
flexing and extending the ankles and knees periodically
drinking plenty of fluids and avoiding alcoholic beverages
proper application and use of antiembolism stockings
importance of adequate hydration
bleeding precautions, including use of an electric razor and avoidance of products that contain aspirin
importance of smoking cessation
use of low-estrogen oral contraceptives as appropriate
need to wear medical alert identification noting the use of anticoagulant therapy.
Patient Teaching-Discharge Planning
Refer the patient for home health care services as appropriate to assist with home anticoagulant therapy.
Refer the patient to social services to help with financial concerns and prescribed therapy as indicated.