THROMBOPHLEBITIS & THROMBOSIS

Definition

o an inflammatory process that causes a blood clot to form and block one or

more veins, usually in your legs. The affected vein might be near the

surface of your skin (superficial thrombophlebitis) or deep within a muscle

(deep vein thrombosis, or DVT).

Etiology/Cause

o Trauma

o Surgery

o Prolonged inactivity

Pathophysiology & Pre-disposing Factor

Assessment Findings or Clinical Manifestations

o Red, swollen, and irritated skin around the affected area

o Pain or tenderness that gets worse when you put pressure on the affected

area

o A swollen vein that feels like a tough "cord" under your skin

o Pain when flexing your ankle (keep in mind that thrombophlebitis can happen

in other parts of the body, but it usually happens in the legs)

o A swollen foot or ankle

Complications
 o Pulmonary embolism. If the clot breaks loose, it could move to your lungs

and block an artery. This condition can be life-threatening.

o Postphlebotic syndrome. It can show up months or years after DVT. It often

causes pain, swelling, and a feeling of heaviness in the affected leg or arm.

You might hear it called post-thrombotic syndrome, venous stasis syndrome,

or chronic venous insufficiency.

Laboratory & Diagnostic Studies/Therapeutic Intervention

o Ultrasound. A wandlike device (transducer) moved over the affected area

of your leg sends sound waves into your leg. As the sound waves travel

through your leg tissue and reflect back, a computer transforms the waves

into a moving image on a video screen.

 This test can confirm the diagnosis and distinguish between

superficial and deep vein thrombosis.

o Blood test. Almost everyone with a blood clot has an elevated blood level

of a naturally occurring, clot-dissolving substance called D dimer. But D

dimer levels can be elevated in other conditions. So a test for D dimer isn't

conclusive, but can indicate the need for further testing.

 It's also useful for ruling out DVT and for identifying people at

risk of developing thrombophlebitis repeatedly

Medical Management

o For superficial thrombophlebitis, doctors might recommend applying heat

to the painful area, elevating the affected leg, using an over-the-counter

 nonsteroidal anti-inflammatory drug (NSAID) and possibly wearing

compression stockings. The condition usually improves on its own.

Nursing Diagnosis

o Altered Peripheral Tissue Perfusion

 Ineffective tissue perfusion related to venous blood flow interruption

possibly evidenced by:

 Pallor and cyanosis (DVT)

 Prolonged capillary refill time

 Weak peripheral pulses

 Swelling of affected extremity

 Redness/erythema (superficial thrombophlebitis)

 Pain

o Acute Pain

 May be related to

 Presence of inflammatory process

 Vascular spasms

 Accumulation of lactic acid

 Possibly evidenced by

 Verbalizations of pain, tenderness, or burning

 Restlessness

 Guarding behavior

 Self-focus

 Autonomic responses
 o Deficient Knowledge related to lack of exposure/recall, misinterpretation

 Possibly evidenced by

 Verbalizations

 Inaccurate follow-through of instructions

 Development of preventable complications

o Anxiety

 May be related to

 Change in health status

 Interpersonal transmission of anxiety from family members

 Perceived or actual threat to self

 Situational crisis

Pharmacologic Therapy/Treatment

o Antibiotics . You might get them if poor circulation leads to an infection.

o Blood thinners . These medications are usually reserved for more severe

cases. You can give yourself heparin (Porcine) and enoxaparin (Lovenox)  to

yourself at home through shots under your skin. They help keep the clot from

getting bigger. You may also have to take an oral drug like warfarin

(Coumadin) for several months or longer to keep clots from coming back.

Your doctor will give you regular blood tests to make sure the meds are

working.

o Newer blood thinners, like direct thrombin inhibitors and factor Xa inhibitors,

are also available. But doctors don’t normally recommend them as the main

treatment for thrombophlebitis. That’s because they cost more and may cause
 uncontrollable bleeding. They include apixaban (Eliquis), dabigatran

(Pradaxa), edoxaban (Savaysa), and rivaroxaban (Xarelto).

o Compression stockings. The doctor may tell you that you need to

wear these thick stockings that go from toes to knee. They improve blood flow

to your legs and ease swelling. You might hear them called support hose.

o Filter. You might need it if there’s a high risk of tissue damage or if your clot

comes back. If you have a clot in a deep vein in your leg and cannot tolerate

blood thinners, your doctor might recommend an inferior vena cava (IVC)

filter. The vena cava is the main vein in your abdomen. The IVC filter prevents

clots in your legs from breaking loose and traveling to your lungs. You’ll need

surgery for this treatment.

o Varicose vein stripping. This can help with veins that cause pain or

recurring thrombophlebitis. The doctor makes small cuts to remove a long

vein. It doesn’t affect circulation -- veins deeper down can handle more blood.

Nursing Care/Implication/Management

o Evaluate circulatory and neurological studies of involved extremity—both

sensory and motor. Inspect for skin color and temperature changes, as

well as edema (from groin to foot). Note symmetry of calves; measure and

record calf circumference. Report proximal progression of inflammatory

process, traveling pain.

o Examine extremity for obviously prominent veins. Palpate gently for local

tissue tension, stretched skin, knots/bumps along course of vein.

o Assess capillary refill and check for Homans’ sign.

o Promote bedrest initially, with legs elevated above heart level during acute

phase

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

o Initiate active or passive exercises while in bed (e.g., flex/extend/rotate

foot periodically). Assist with gradual resumption of ambulation (e.g.,

walking 10 min/hr) as soon as patient is permitted out of bed.

o Caution patient to avoid crossing legs or hyperflexion at knee (seated

position with legs dangling, or lying in jackknife position)

o Instruct patient to avoid rubbing/ massaging the affected extremity

o Encourage deep-breathing exercises

o Increase fluid intake to at least 2000 mL/day, within cardiac tolerance

o Apply warm, moist compresses or heat cradle to affected extremity if

indicated.

o Administer anticoagulants, e.g.:Heparin, e.g., Panheparin or low molecular

weightheparin (LMWH), such as enorxaparin (Lovenox),dalteparin

(Fragmin), ardeparin (Normiflo) viacontinuous or intermittent IV,

intermittentsubcutaneous (SC) injections, and/or PO coumarinderivatives,

e.g., warfarin (Coumadin) or dicumarol(Sintrom) as ordered.

o Administer Thrombolytic agents, e.g., streptokinase, urokinase as ordered.

o Monitor laboratory studies as indicated: PT, PTT, aPTT, CBC, as well as

Platelet count, platelet/aggregation test, anti-heparin antibody assay

o Apply/regulate graduated compression stockings, intermittent pneumatic

compression, if indicated.
o Apply elastic support hose following acute phase. Take care to avoid

tourniquet effect.

o Prepare for surgical intervention when indicated

o If the patient is being discharged on subcutaneous heparin, the patient or

family needs to demonstrate the injection technique.

o The patient also needs to know to avoid over-the-counter medications,

particularly those that contain aspirin.

o Explain the need to avoid activities that could cause bumping or injury and

predispose the patient to excessive bleeding.

o Instruct the patient to notify the physician if abdominal or flank pain, heavy

bleeding during menstruation, and bloody urine or stool occurs.

o Recommend using a soft toothbrush and an electric razor to limit injury.

o Remind the patient to notify the physician or dentist of anticoagulant use

before any invasive procedure.

o Instruct the patient to report leg pain or swelling, skin discoloration, or

decreases in peripheral skin temperature to the physician.

o In addition, if the patient experiences signs of possible pulmonary

embolism (anxiety, shortness of breath, pleuritic pain, hemoptysis), he or

she should go to the emergency department immediately.