NCP Thrombophlebitis: Deep Vein Thrombosis (Including Pulmonary Emboli Considerations)

Thrombophlebitis is a condition in which a clot forms in a vein, associated with inflammation/trauma of the vein wall or a partial obstruction of the vein. Clot formation is related to (1) stasis of blood flow, (2) abnormalities in the vessel walls, and (3) alterations in the clotting mechanism (Virchow’s triad). Young women and the elderly are at greatest risk.
Thrombophlebitis can affect superficial or deep veins. Although both conditions can cause symptoms, deep vein thrombosis (DVT) is more serious in terms of potential complications, including pulmonary embolism, postphlebotic syndrome, chronic venous insufficiency, and vein valve destruction. Note: Approximately 50% of patients with DVT are asymptomatic.

CARE SETTING

Primarily treated at the community level, with short inpatient stay generally indicated in the presence of embolization.

RELATED CONCERNS

Surgical intervention
Ventilatory assistance (mechanical)
Fractures
Psychosocial aspects of care

Patient Assessment Database

ACTIVITY/REST
May report: Occupation that requires sitting or standing for long periods of time
Prolonged immobility (e.g., fractured hip/orthopedic trauma, long hospitalization/bedrest, prolonged sitting or travel without adequate exercise, complicated pregnancy); spinal cord injury/paralysis; progressive debilitating condition
Pain with activity/prolonged standing
Fatigue/weakness of affected extremity, general malaise
May exhibit: Generalized or extremity weakness

CIRCULATION
May report: History of previous peripheral vascular disease, venous thrombosis, varicose veins
Presence of other predisposing factors, e.g., hypertension (pregnancy-induced), diabetes mellitus, MI/valvular heart disease, thrombotic cerebrovascular accident, blood dyscrasias
May exhibit: Tachycardia
Peripheral pulse may be diminished in the affected extremity (DVT)
Varicosities and/or hardened, bumpy/knotty vein (thrombus)
Skin color/temperature in affected extremity (calf/thigh): pale, cool, edematous (DVT); pinkish red, warm along the course of the vein (superficial)
Positive Homans’ sign (absence does not rule out DVT, because only about 33% of patients have a positive sign)

FOOD/FLUID
May exhibit: Poor skin turgor, dry mucous membranes (dehydration predisposes to hypercoagulability)
Obesity (predisposes to stasis and pelvic vein pressure)
Edema of affected extremity (present with thrombus in small veins or major venous trunks)

PAIN/DISCOMFORT
May report: Throbbing, tenderness, aching pain aggravated by standing or movement of affected
extremity, groin tenderness
May exhibit: Guarding of affected extremity

SAFETY
May report: History of direct or indirect injury to extremity or vein (e.g., major trauma/fractures,
orthopedic/pelvic surgery, prolonged labor with fetal head pressure on pelvic
veins, venous cannulation or catheterization/intravenous therapy)
Presence of malignancy (particularly neoplasms of the pancreas, lung, GI system, prostate); sepsis
May exhibit: Fever, chills

TEACHING/LEARNING
May report: Use of oral contraceptives/estrogens; recent anticoagulant therapy (predisposes to hypercoagulability)
Recurrence/lack of resolution of previous thrombophlebotic episode

Discharge plan
DRG projected mean length of inpatient stay: 5.8 days
Temporary assistance with shopping, transportation, and homemaker/maintenance tasks Properly fitted antiembolic hose

DIAGNOSTIC STUDIES

Hematocrit: Hemoconcentration (elevated Hct) potentiates risk of thrombus formation.
Coagulation profile: Levels of PT, PTT, and platelets may reveal hypercoagulability.
Antithrombin: Useful in determining cause of impaired coagulation/hypercoagulation and in the management of venous thrombotic disease. Elevated in DVT.
Noninvasive vascular studies (Doppler ultrasound, compression ultrasonography, impedance plethysmography, and duplex venous scanning): 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, femoral, popliteal) but is less reliable in detecting isolated calf vein thrombi.
Trendelenburg test: May demonstrate vessel valve incompetence.
Venography: Radiographically confirms diagnosis through changes in blood flow and/or size of channels. Note: This study carries a risk of inducing DVT and therefore is reserved for patients with negative or difficult-to-interpret noninvasive studies in the presence of high clinical suspicion.
MRI: May be useful in assessing blood flow turbulence and movement, venous valvular competence.

NURSING PRIORITIES

1. Maintain/enhance tissue perfusion, facilitate resolution of thrombus.
2. Promote optimal comfort.
3. Prevent complications.
4. Provide information about disease process/prognosis and treatment regimen.

DISCHARGE GOALS

1. Tissue perfusion improved in affected limb.
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.