Pathophysiology
Blood clots formed from any source, lodging in the patient leg or arm, impeding blood flow and causing inflammation. This backup of blood pools in the extremity causing swelling, redness, warmth, and pain. These clots can dislodge and become embolic, lodging in the heart, lungs, or brain.
Etiology
Narrowing or occlusion of the vessels in an extremity. If caused by plaque (cholesterol and other substances) this could be from poor diet, lack of exercise, or genetics. However, blood stasis can cause aggregation of platelets and other blood products forming a clot that travels to the extremity (or heart, lungs, or brain!). The most common cause of blood pooling (stasis) is Atrial Fibrillation (AFib). Other major causes are prolonged sitting, pregnancy, smoking, and birth control. Virchow’s triad explains the 3 major contributors to the development of thrombophlebitis: venous stasis, damage to the inner lining of the vessel, and hypercoagulability.
Desired Outcome
Stabilization of the blood clot or disintegration of the blood clot as well as prophylaxis treatment for future blood clots. Prevention of complications such as embolic strokes, myocardial infarction, or pulmonary embolism.
Thrombophlebitis / Deep Vein Thrombosis (DVT) Nursing Care Plan
Subjective Data:
- Unilateral findings on affected extremity:
- Painful
- Numbness
- Tingling
- Symptoms of Embolism
- Lungs → Pulmonary Embolism (PE)
- Anxiety
- Shortness of Breath (SOB)
- Chest Pain (CP)
- Heart → Myocardial Infarction (MI)
- Brain → Stroke
- Facial asymmetry
- Confusion
- One-sided deficit
Objective Data:
- Unilateral findings on affected extremity:
- Warmth
- Redness
- Swelling (firm)
- Decreased peripheral pulse
- Positive D-Dimer
- Evidence of Clot on Ultrasound
- Possible Positive Homan’s Sign (pain with dorsiflexion of the foot) *caution – this maneuver may dislodge the clot*
*Note – the evidence shows that Homan’s Sign is an unreliable and nonspecific finding. It is only present in 33% of those with a DVT and should not be used as standard practice in isolation.
Nursing Interventions and Rationales
- Assess for evidence of embolus
- Neuro Status
- Respiratory Status
- Chest Pain / ECG
A potential complication of thrombophlebitis and DVT is thrombi can break off and become emboli to other vital organs such as the lungs (PE), heart (MI), or brain (CVA). Monitor for signs of these occurrences.
- Administer Heparin-Transition into a SubQ or oral anticoagulant to prevent future clots.
This is an anticoagulant that prevents the worsening of clots or the development of new clots. It does not breakdown clots but allows the body’s natural fibrinolysis to occur without new clots forming. Monitor aPTT q6h to adjust and maintain therapeutic levels. Follow your facility protocols for the administration of bolus and dosing. Refer to the Pharmacology course for more details of this drug.
- Administer Enoxaparin (Lovenox) and/or Warfarin (Coumadin)
Both SubQ and oral anticoagulant therapy are used as prophylactic (prevention) therapy. Patients will need to have frequent blood draws to monitor their INR if taking Coumadin. The therapeutic range is between 2 and 3. Follow your facility protocols for administration and dosing. Refer to the Pharmacology course for more details of these drugs.
- Encourage ambulation / Compression socks / SCDs (Prevention)
The sooner you get a patient moving the less likely they are to form any more blood clots. Compression socks and SCDs encourage blood flow back to the heart and prevent blood stasis.*Caution – as soon as the patient has a confirmed DVT, all three of these should be held until an IVC filter can be placed
- Educate about avoiding vitamin K (both supplements as well as food)
Vitamin K works to help increase clotting, this is the opposite of what we are trying to do for this patient. The only time Vitamin K is used therapeutically is if the patient is bleeding out, in which case the treatment may be vitamin K with Fresh Frozen Plasma (FFP). Vitamin K is also the antidote for Coumadin (warfarin)
- Continuous monitoring:
- 3 or 5 lead cardiac monitoring
- Pulse oximetry monitoring
This monitors for changes in the heart and allows for quick intervention if the clot moves and is stuck in the heart. This monitors for changes in oxygenation if the clot moves to the lungs.
- Bleeding/fall precautions because of anticoagulant therapy
This isn’t just for in the hospital, it is also for when the patient goes home. The patient is a major risk for bleeding out, thus educating about s/sx of internal bleeding as well as educating about fall precautions is vital.
- GI bleeding: Dark, tarry stool (Upper GI bleed) OR bright red bloody stools (lower GI bleed)
- Epistaxis: Nosebleeds are obvious, however, inform the patient that if they bleed through nasal packing for longer than 15 minutes they should go to the ER. Also, they feel dizzy, faint, or are losing color in their face they should go to the ER.
- Cuts that don’t stop bleeding: if the cut has had pressure applied for longer than 15 minutes and the gauze is being soaked through the patient should go to the ER.
- Brain bleeds: Have patients and the people who are around them look for S/Sx such as confusion, facial droop, one-sided weakness.
References
Cornell Note-Taking System Instructions:
- Record: During the lecture, use the note-taking column to record the lecture using telegraphic sentences.
- Questions: As soon after class as possible, formulate questions based onthe notes in the right-hand column. Writing questions helps to clarifymeanings, reveal relationships, establish continuity, and strengthenmemory. Also, the writing of questions sets up a perfect stage for exam-studying later.
- Recite: Cover the note-taking column with a sheet of paper. Then, looking at the questions or cue-words in the question and cue column only, say aloud, in your own words, the answers to the questions, facts, or ideas indicated by the cue-words.
- Reflect: Reflect on the material by asking yourself questions, for example: “What’s the significance of these facts? What principle are they based on? How can I apply them? How do they fit in with what I already know? What’s beyond them?
- Review: Spend at least ten minutes every week reviewing all your previous notes. If you do, you’ll retain a great deal for current use, as well as, for the exam.
For more information, visit www.nursing.com/cornell
