Last updated on August 22nd, 2022 at 11:43 am
Thrombophlebitis Nursing Care Plans Diagnosis and Interventions
Thrombophlebitis NCLEX Review and Nursing Care Plans
Thrombophlebitis is a condition where in the inflammatory process results to blood clot formation, and the blood clot blocks the veins.
Limbs, particularly the legs, are the usual sites of thrombophlebitis. It can be superficial, as the blood clot can block the veins near the surface of the skin.
However, it can also be found in a vein located deep within a muscle, which makes it a deep vein thrombosis or DVT. Prolonged inactivity, trauma, or surgical procedures may cause thrombophlebitis.
The first line of treatment is to prescribed blood-thinning medications called anticoagulants to the patient.
Signs and Symptoms of Thrombophlebitis
- Redness (erythema)
- Swelling (edema)
- Pain on the affected area
- Warmth on the affected area
Causes and Risk Factors of Thrombophlebitis
A blood clot can block a vein and cause thrombophlebitis. Some of the most common causes of blood clot formation include immobility for long periods (such as during very long flights, a hospital stay or an injury), genetic blood-clotting disorders, or injury to a vein (as in surgery or trauma).
The risk factors that may increase the chance of developing thrombophlebitis include varicose veins, having a pacemaker, pregnancy, use of hormone replacement therapy (HRT) or birth control pills, genetic predisposition or having a blood-clotting disorder, had a stroke, age of over 60, have cancer, smoking, or over-weight/obese.
Complications of Thrombophlebitis
Superficial thrombophlebitis may not develop in serious complications. However, if the patient develops DVT, pulmonary embolism and post-thrombotic syndrome may occur.
- Pulmonary embolism. The dislodgement of a deep vein blood clot, or even just a part of it, may result to it traveling to the lungs. The blood clot, now called an embolus, can cause blockage of a lung artery. This medical condition called pulmonary embolism, is life-threatening and requires immediate treatment.
- Post-thrombotic syndrome. Also called post-phlebetic syndrome, this condition may happen after DVT. It may take months or years to actually occur in some patients. The symptoms of this syndrome include a heavy feeling in the affected limb, swelling or edema, and disabling chronic pain.
Diagnosis of Thrombophlebitis
- Physical examination and history taking – to check for the signs and symptoms and for any risk factors for thrombophlebitis
- Blood test – to check for D-dimer levels, which are elevated in this condition
- Imaging – ultrasound is used to diagnose whether the patient has superficial thrombophlebitis or deep vein thrombosis
Treatment for Thrombophlebitis
- Anti-coagulants. These blood-thinning medications are used to increase the clotting time of the blood, reducing the risk for blood clot formation. They usually come in two forms, such as subcutaneous injections (e.g. low molecular weight heparin, apixaban, or fondaparinux or oral tablets (e.g. warfarin and rivaroxaban). The patient needs to be educated of the signs of excessive bleeding while on anticoagulant therapy, so that they can notify the physician immediately and be subjected to a lowered dose or a change of treatment.
- Thrombolytics. These medications are clot-dissolving, a process also known as thrombolysis. Extensive DVT such as people who develop pulmonary embolism, may be treated with alteplase (Activase).
- Compression stockings. The doctor may prescribe compression stockings to lower the risk of developing thrombophlebitis and its complications, as well as to reduce the risk of swelling.
- Varicose vein stripping. This surgery involves the removal of varicose veins that may result to recurrent thrombophlebitis.
- Vena cava filter. The surgeon may insert a temporary filter into the vena cava or main vein of the abdomen to reduce the risk of clots travelling from the affected leg vein to the lungs. This is usually done when the patient is unable to take anticoagulants.
Thrombophlebitis Nursing Diagnosis
Thrombophlebitis Nursing Care Plan 1
Nursing Diagnosis: Deficient Knowledge related to new diagnosis of thrombophlebitis as evidenced by patient’s verbalization of “I want to know more about my diagnosis and care”
Desired Outcome: At the end of the health teaching session, the patient will be able to demonstrate sufficient knowledge of thrombophlebitis and its management.
|Thrombophlebitis Nursing Interventions
|Assess the patient’s readiness to learn, misconceptions, and blocks to learning (e.g. acute pain that distracts the patient)
|To address the patient’s cognition and mental status towards the new diagnosis of thrombophlebitis and to help the patient overcome blocks to learning.
|Explain what thrombophlebitis is, and how it can develop into complications such as DVT and pulmonary embolism if left untreated. Avoid using medical jargons and explain in layman’s terms.
|To provide information on thrombophlebitis and its pathophysiology in the simplest way possible.
|Educate the patient about anticoagulation therapy. Inform him/her the target therapeutic range. Instruct the patient regarding routine coagulation testing/monitoring.
|To give the patient enough information on anticoagulation therapy and its role in the management of thrombophlebitis. Routine coagulation blood tests are needed to check if the anticoagulant is taken within the therapeutic range, or whether the dose needs to be amended.
|Teach the patient on how to identify signs of excessive anticoagulation.
|Anticoagulation therapy is usually done over weeks or even long-term. The patient needs to know the signs of too much anticoagulant therapy to alert him/her to inform the doctor.
|Inform the patient the details about the prescribed medications (e.g. drug class, use, benefits, side effects, and risks) involved in anticoagulation therapy, and explain how to properly self-administer each of them. Ask the patient to repeat or demonstrate the self-administration details to you.
|To inform the patient of each prescribed drug and to ensure that the patient fully understands the purpose, possible side effects, adverse events, and self-administration details.
Thrombophlebitis Nursing Care Plan 2
2. Nursing Diagnosis: Risk for Bleeding related to anticoagulant therapy for thrombophlebitis
Desired Outcome: To prevent any bleeding episode while the patient is on anticoagulant therapy.
|Thrombophlebitis Nursing Interventions
|Assess the patient’s vital signs and perform a focused physical assessment, looking for any signs of bleeding.
|Anticoagulants put the patient at risk for bleeding. Early signs of bleeding include gum bleeding, epistaxis, and unexplained bruises. Low blood pressure, low temperature, and dizziness may result from excessive bleeding.
|Obtain blood samples and monitor platelet counts as well as coagulation levels (INR, PT, and PTT).
|To ensure that the anticoagulant dosing is in line with the target therapeutic range, thus reducing the risk of bleeding.
|Administer the anticoagulant as prescribed.
|There are different anticoagulants in different forms. The most common ones are IV heparin, subcutaneous low-molecular weight heparin (LMWH), and oral warfarin.
|Recommend to switch from IV anticoagulant to subcutaneous or oral anticoagulant to the doctor when the therapeutic range has been reached.
|To facilitate safe transition of anticoagulation therapy from clinical management to patient self-management before discharge.
Thrombophlebitis Nursing Care Plan 3
Impaired Gas Exchange
Nursing Diagnosis: Impaired Gas Exchange related to impaired blood flow to the alveoli and main lung parts and alveolar-capillary membrane changes secondary to thrombophlebitis as possibly evidenced by dyspnea, cyanosis, hypoxemia, hypercapnia, apprehension, restlessness, and somnolence.
- The patient will demonstrate adequate ventilation and perfusion as evidenced by arterial blood gas results within the normal range.
- The patient will verbalize or demonstrate the absence of respiratory distress symptoms
|Thrombophlebitis Nursing Interventions
|Evaluate the patient’s level of consciousness and changes in mental status, if any.
|Restlessness and irritability followed by progressively diminished mental status are initial signs of systemic hypoxemia.
|Auscultate the lungs and examine areas with diminished or absent breath sounds. Examine also for the presence of adventitious sounds such as crackles.
|Absent breath sounds are an indication that an area of the lung is poorly or not ventilated at all. Crackles are indicative of cardiac decompensation and are observed in tissues and airways.
|Monitor the patient’s vital signs and observe changes in heart rhythm.
|Progressive hypoxemia and acidosis are marked by an increased heart rate, increased respiratory rate, and changes in blood pressure. Changes in the cardiac rhythm are indicative of increase in the heart’s workload associated with a deteriorating imbalance in ventilation.
|Evaluate the patient’s respiratory rate. Observe for signs of respiratory distress such as the use of accessory muscles of respiration (sternocleidomastoid, scalene, intercostal muscles), pursed-lip breathing, and nasal flaring.
|Shortness of breath (dyspnea) and an increased respiratory rate (tachypnea) indicate that there is an obstruction in the airways of the lungs. It is pivotal to observe these signs because it can help in narrowing down possible diagnoses. In pulmonary embolism, increased work of breathing and dyspnea may be the first or only sign. A moderate to severe loss of functional lung units is associated with severe respiratory distress, and eventually failure.
|Observe for signs of cyanosis in the lips, tongue, earlobe, and buccal membranes.
|Cyanosis is a condition described as bluish discoloration of the skin or mucous membranes. The presence of cyanosis suggests that the patient is experiencing systemic hypoxemia.
|Monitor the patient’s condition regularly and make arrangements with the patient’s relatives or hospital staff to accompany the patient, as indicated.
|This ensures that changes in the patient’s condition will be identified abruptly. This also provides assurance that patient needs are met and assistance readily available.
|Evaluate the patient’s activity tolerance. Note for signs of weakness and fatigue, changes in vital signs, and worsening shortness of breath on exertion. Promote rest periods and limit the activities in accordance with the patient’s exercise tolerance.
|Watching out for these signs will aid in the determination of the patient’s response to activities and evaluate the ability of the patient to transition and resume usual daily activities. This will also help in identifying the patient’s ability to engage in self-care practices.
|Establish patient rapport and give understandable explanations about the patient’s condition and disclose the expected effects of disease interventions.
|This will help in putting the patient at ease. This will aid in alleviating the patient’s anxiety associated with the unknown and may decrease fears associated with personal safety.
|Encourage the patient to express and verbalize their feelings. Also inform the patient’s relatives that feelings of anxiety and sense of impending doom is normal.
|Understanding the root cause of these feelings will help the patient restore some sense of control over his or her emotions.
|Urge the patient to cough and practice deep breathing exercises, and suctioning, as indicated.
|These methods will help increase oxygen delivery to the lungs by getting rid of secretions and improving ventilation.
|Ensure that the head of the bed is raised or elevated.
|This will encourage maximal chest expansion and will make it easier for the patient to breathe. This will also improve physiological and psychological comfort.
|Assist with regular position changes and promote ambulation, as indicated.
|Frequent position changes and ambulation will improve lung aeration across different lung segments, thereby enhancing overall ventilation.
|Monitor the patient’s arterial blood gases and pulse oximetry.
|Arterial blood gases (ABGs) test measures the patient’s pH as well as their oxygen and carbon dioxide levels in their arterial blood. This can help identify if the patient is experiencing conditions related to pH imbalances such as respiratory alkalosis and metabolic acidosis. This may also help in detecting hypoxemia. Hypoxemia may present in different settings depending on the cardiopulmonary status, degree of airway obstruction, and presence and extent of shock.
|Prepare the patient for a chest x-ray as ordered.
|Chest radiography allows the clinicians to identify patterns of ventilation-perfusion (V/Q) mismatch as reflected by abnormal perfusion in ventilated lung areas. This can confirm the diagnosis of pulmonary embolism and the presence of airway obstruction. The absence of both ventilation and perfusion is indicative of alveolar congestion or airway obstruction.
|Provide oxygen therapy as indicated. Make sure to employ the appropriate method of administration as ordered by the physician.
|Oxygen therapy can reduce the work of breathing by maximizing the available oxygen which can be used for gas exchange.
Thrombophlebitis Nursing Care Plan 4
Ineffective Peripheral Tissue Perfusion
Nursing Diagnosis: Ineffective Tissue Perfusion (Peripheral) related to venous stasis, vessel wall injury, and increased blood coagulability secondary to thrombophlebitis as possibly evidenced by changes in femoral, popliteal, or small calf veins such as increased leg warmth, tenderness, pain during palpation of the calf muscle, and edema.
- The patient will maintain optimal peripheral tissue perfusion in the affected extremity as evidenced by adequate capillary refill time, strong palpable pulses, reduced pain level and warmth on the affected area, and dry extremities.
- The patient will not to demonstrate symptoms of pulmonary embolism such as dyspnea, chest pain, and abnormal respiratory and cardiac rates.
|Thrombophlebitis Nursing Interventions
|Evaluate for signs and symptoms of thrombophlebitis.
|Signs and symptoms of thrombophlebitis occur in the leg due to a deep vein clot. This includes pain, tenderness, swelling, warmth, redness on the affected area.
|Evaluate for precipitating and risk factors contributing to thrombophlebitis.
|Risk factors for thrombophlebitis include the following:
Use of central venous catheters
History of varicosities
Immobility History of leg trauma and surgery Venous stasis
Use of oral contraceptives
It is worth noting that most patients with thrombophlebitis are asymptomatic, therefore identification of risk factors is pivotal in early detection and management of the disease.
|Secure a measurement of the affected leg, specifically its circumference, using a tape measure.
|Assessment of unilateral leg and thigh entails the measurement of the circumference of the affected leg 10-15 cm superior to the upper edge of the patella and 10 cm inferior to the tibial tuberosity. If the difference between the extremities is greater than 3 cm, Thrombophlebitis is suspected.
|Assess and monitor results of diagnostic tests such as follows:
|Monitoring these diagnostic tests will aid in identifying the location of the clot and examining the status of veins in the affected leg.
|D-dimer is a biomarker for fibrinolysis (clot lysis). This assay can also be used to monitor the effectiveness of the administered treatment.
|This provides an overview of blood flowing through the arteries and veins in the affected leg by producing images through the use of sound waves.
|This test is used to localize the thrombi in the deep venous system. A radiopaque contrast media is injected through a foot vein for better visualization.
|This test monitors the increase in blood volume in the affected limb and blocks the venous flow using an inflated cuff.
|Monitor the patient’s coagulation profile by measuring the internal normalized ratio (INR), prothrombin time (PT), and partial thromboplastin time (PTT).
|These tests are used to monitor the effectiveness of anticoagulant treatment. The PT/INR is used to monitor the patient’s response to warfarin. Baseline values must be measured before the first dose of the anticoagulant is administered. In adjusting drug doses, repeated tests must be done at constant intervals. Monitoring the patient’s coagulation profile will aid in achieving treatment goals for coagulation.
|Ensure that the patient has and is able to maintain adequate hydration status.
|Dehydration can contribute to increased viscosity which in turn can lead to venous stasis and coagulation. We do not want this for the patient as this can worsen the symptoms.
|Apply warm and moist heat on the affected leg.
|Application of heat reduces inflammation and provides comfort to the affected area.
|Use below-knee compression stocking, as indicated.
|Compression stockings improve the body’s circulation through the provision of graduated pressure on the affected leg. This will aid in improving venous return to the heart. Make sure that the stockings are of the correct size and are applied correctly. Improperly applied stockings can enhance clot formation.
|Administer analgesics and anticoagulants (e.g., heparin and warfarin), as prescribed.
|Analgesics help in pain relief and contribute to patient comfort. Anticoagulants can help prevent thrombogenesis by altering the normal clotting mechanism. Intravenous heparin or subcutaneous low-molecular weight heparin can be started initially. Since the onset of action of warfarin is 72 hours, it is important to note that warfarin shall be initiated while the patient is still receiving heparin. Once warfarin reaches its therapeutic levels, heparin can be discontinued.
|Administer thrombolytic therapy in patients with massive thrombophlebitis.
|Massive thrombophlebitis can severely compromise tissue perfusion (blood flow to tissues). It is important to note that thrombolytic therapy must only be used in severe embolism as these medications can cause sudden bleeding. Therapy must be initiated within 5 days, soon after symptom onset, to achieve maximum effectiveness.
|Surgical interventions shall be anticipated for patients who are unresponsive to anticoagulants. These methods include:
(1) placement of a vena cava filter
|The vena cava filter is responsible for capturing blood clots before they mobilize to the lungs, thereby preventing pulmonary embolism. This is indicated for patients that are nonresponsive to anticoagulant therapy or those with recurrent thrombophlebitis. Thrombectomy involves the removal of blood clot from a vein and is indicated for most severe cases of thrombophlebitis.
Thrombophlebitis Nursing Care Plan 5
Nursing Diagnosis: Acute Pain related to decreased arterial circulation and tissue perfusion with lactic acid accumulation and inflammatory process in affected vein secondary to thrombophlebitis as possibly evidenced by guarding of the affected limb, distraction behaviors, restlessness, and verbalization of pain, tenderness, aching, and burning.
- The patient will be able to verbalize that the pain is relieved or controlled.
- The patient will be able to employ methods to alleviate the pain.
- The patient will demonstrate a relaxed disposition and ability to sleep, rest, and engage in the desired activity.
|Thrombophlebitis Nursing Interventions
|Assess the degree of pain and characterize according to onset, duration, frequency, quality, radiation, palliative, and provocative factors, timing.
|The severity or degree of pain is dependent on several factors such as the degree of tissue ischemia, the extent of circulatory deficit, inflammatory process, and degree of edema associated with the development of thrombus. Alteration in pain characteristics may be indicative of the development of complications.
|Identify and investigate associated symptoms such as apprehension, sudden or sharp chest pain, shortness of breath, increased heart rate. Investigate also the radiation of pain, specifically to other sites with vascular involvement.
|These signs and symptoms are suggestive of pulmonary embolism as a complication of thrombophlebitis or peripheral arterial occlusion secondary to heparin-induced thrombocytopenia with thrombosis syndrome (HITT). Immediate medical treatment is paramount for both of these conditions
|Monitor the patient’s vital signs. Note for the presence of tachycardia and fever.
|Increased heart rate (tachycardia) is indicative of elevated patient discomfort or may occur in response to fever. Fever is a sign that an inflammatory process is ongoing and can also increase the patient’s discomfort.
|During the acute phase of thrombophlebitis, maintain the patient at bed rest.
|Bed rest decreases patient discomfort that is associated with muscle contraction and mobility.
|Urge the patient to frequently change their position.
|Positional changes can decrease muscle fatigue and reduce muscle spasms, leading to maximized tissue perfusion.
|Raise the affected extremity.
|Elevation of the affected extremity promotes venous return to ensure adequate circulation. This can therefore reduce venous stasis and edema development.
|Appy foot cradle on the bed.
|Foot cradles reduced patient discomfort by preventing the application of pressure of bed covers on the affected leg.
|Administer medications such as opioid and non-opioid analgesics as prescribed.
|Analgesics contributes to pain relief and decreases muscle tension. Local anesthetics work by inhibition of nociceptive impulse transmission along the primary afferents. On the other hand, opioids work by altering the perception of pain.
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Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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