NCP Postpartal Thrombophlebitis

Superficial thrombophlebitis is seen more often during the postpartal period than during pregnancy and is more common in women with preexisting varices. Postpartal deep vein thrombosis (DVT) and superficial thrombophlebitis have been attributed to trauma to pelvic veins from pressure of the presenting fetal part, sluggish circulation caused by mechanical edema, and alterations in coagulation related to the large amounts of estrogens produced during pregnancy. Thrombosis that involves only the superficial veins of the leg or thigh is unlikely to generate pulmonary emboli (PE). While approximately 50% of clients with DVT are asymptomatic, DVT is more serious in terms of potential complications, including PE, postphlebotic syndrome, chronic venous insufficiency, and vein valve destruction.
(This plan of care is an adjunct to the regular postpartal plans of care.)

CLIENT ASSESSMENT DATA BASE

Activity/Rest

History of prolonged sitting, either work-related or as a result of activity restrictions
Current immobility associated with bedrest and anesthesia
Activity/prolonged standing limited by pain
Fatigue/weakness of affected extremity, general malaise

Circulation

Varicose veins; thrombosis may be palpable, bumpy/knotty.
Slight elevation of pulse rate (superficial).
History of previous venous thrombosis, heart disease, hemorrhage, PIH, diabetes mellitus, hypercoagulability in early puerperium.
Peripheral pulses diminished, positive Homans’ sign may or may not be noted (indicators of DVT).
Lower extremity (calf/thigh) may be warm and pinkish-red in color, or affected limb may be cool, pale, edematous.

Food/Fluid

Excessive weight gain/obesity.
Poor skin turgor, dry mucous membranes (dehydration predisposes to hypercoagulability).
Milk supply may occasionally be reduced in lactating client.
Edema of affected extremity (dependent on location of thrombus).

Pain/Discomfort

Throbbing, tenderness, aching pain in affected area (e.g., calf or thigh) aggravated by standing or movement
Lower abdominal pain (involvement of ovarian vein)
Guarding of affected extremity

Safety

Presence of postpartal endometritis or pelvic cellulitis.
Temperature may be slightly elevated; progression to marked elevation and chills (signs of DVT); high fever (septic pelvic thrombophlebitis).

Sexuality

Multiparity; hydramnios
Prolonged labor associated with fetal head pressure on pelvic veins, use of stirrups or faulty positioning of extremities during intrapartal phase/operative delivery

Teaching/Learning

Use of oral contraceptives
Use of estrogen for suppression of lactation

DIAGNOSTIC STUDIES

Hematocrit (Hct): Identify hemoconcentration.
Coagulation Studies: Reveals hypercoagulability.
Noninvasive Vascular Studies (Doppler Oscillometry, Exercise Tolerance, Impedance Plethysmography, and Real-Time [duplex] Ultrasonography): Changes in blood flow and volume identify venous occlusion, vascular damage, and vascular insufficiency. Ultrasonography appears to be most accurate noninvasive method for diagnosing multiple proximal DVT (iliac, popliteal) but is less reliable in detecting isolated calf vein thrombi.
Trendelenburg Test: May demonstrate vessel valve incompetence.
Contrast Venography: Confirms diagnosis of DVT through changes in blood flow and/or size of channels.

NURSING PRIORITIES

1. Maintain/enhance tissue perfusion, facilitate resolution of thrombus.
2. Promote optimal comfort.
3. Prevent complications.
4. Provide information and emotional support.

DISCHARGE GOALS

1. Tissue perfusion improved in affected limb/area
2. Pain/discomfort relieved
3. Complications prevented/resolved
4. Disease process/prognosis and therapeutic needs understood
5. Plan in place to meet needs after discharge