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
considerations: 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.

NURSING DIAGNOSIS: Tissue Perfusion, ineffective

May be related to
Decreased blood flow/venous stasis (partial or complete venous obstruction)
Possibly evidenced by
Tissue edema, pain
Diminished peripheral pulses, slow/diminished capillary refill
Skin color changes (pallor, erythema)
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Tissue Perfusion: Peripheral (NOC)
Demonstrate improved perfusion as evidenced by peripheral pulses present/equal, skin color and temperature
normal, absence of edema.
Engage in behaviors/actions to enhance tissue perfusion.
Display increasing tolerance to activity.
ACTIONS/INTERVENTIONS RATIONALE
Embolus Care: Peripheral (NIC)

Independent
Evaluate circulatory and neurological studies of involved Symptoms help distinguish between thrombophlebitis
extremity—both sensory and motor. Inspect for skin color and DVT. Redness, heat, tenderness, and localized edema
and temperature changes, as well as edema (from groin to are characteristic of superficial involvement. Pallor and
foot). Note symmetry of calves; measure and record calf coolness of extremity are characteristic of DVT. Calf
circumference. Report proximal progression of vein involvement is associated with absence of edema;
inflammatory process, traveling pain. femoral vein involvement is associated with mild to
moderate edema; iliofemoral vein thrombosis is
characterized by severe edema.

Examine extremity for obviously prominent veins. Distension of superficial veins can occur in DVT because
Palpate gently for local tissue tension, stretched skin, of backflow through communicating veins.
knots/bumps along course of vein. Thrombophlebitis in superficial veins may be visible or
palpable.

Assess capillary refill and check for Homans’ sign. Diminished capillary refill usually present in DVT.
Positive Homans’ sign (deep calf pain in affected leg
upon dorsiflexion of foot) is a classic but unreliable sign
because it is not specific for DVT.

Promote bedrest initially, with legs elevated above heart Until treatment is instituted, limitation of activity
level during acute phase. minimizes the possibility of dislodging thrombus/creating
emboli.

Elevate legs when in bed or chair, as indicated. Reduces tissue swelling and rapidly empties superficial
and tibial veins, preventing overdistension and thereby
increasing venous return. Note: Some physicians believe
that elevation may potentiate release of thrombus, thus
increasing risk of embolization and decreasing circulation
to the most distal portion of the extremity.

Initiate active or passive exercises while in bed (e.g., These measures are designed to increase venous return from
flex/extend/rotate foot periodically). Assist with gradual lower extremities and reduce venous stasis, as well as
resumption of ambulation (e.g., walking 10 min/hr) as improve general muscle tone/strength. They also promote
soon as patient is permitted out of bed. normal organ function and enhance general well-being.

Caution patient to avoid crossing legs or hyperflexion at Physical restriction of circulation impairs blood flow and
knee (seated position with legs dangling, or lying in increases venous stasis in pelvic, popliteal, and leg
jackknife position). vessels, thus increasing swelling and discomfort.

Instruct patient to avoid rubbing/ massaging the affected This activity potentiates risk of fragmenting/dislodging
extremity. thrombus, causing embolization, and increasing risk of
complications.

Encourage deep-breathing exercises. Increases negative pressure in thorax, which assists in

emptying large veins.

Increase fluid intake to at least 2000 mL/day, within Dehydration increases blood viscosity and venous stasis,
cardiac tolerance. predisposing to thrombus formation.
ACTIONS/INTERVENTIONS RATIONALE
Embolus Care: Peripheral (NIC)

Collaborative
Apply warm, moist compresses or heat cradle to affected May be prescribed to promote vasodilation and venous
extremity if indicated. return and resolution of local edema. Note: May be
contraindicated in presence of arterial insufficiency, in
which heat can increase cellular oxygen
consumption/nutritional needs, furthering imbalance
between supply and demand.

Administer anticoagulants, e.g.: Heparin is preferred initially because of its prompt,

Heparin, e.g., Panheparin or low molecular weight predictable, antagonistic action on thrombin as it is
heparin (LMWH), such as enorxaparin (Lovenox), formed and also because it removes activated coagulation
dalteparin (Fragmin), ardeparin (Normiflo) via factors XII, XI, IX, and X (intrinsic pathway), preventing
continuous or intermittent IV, intermittent further clot formation. LMWH is administered
subcutaneous (SC) injections, and/or PO coumarin subcutaneously in small doses, has a more predictable
derivatives, e.g., warfarin (Coumadin) or dose response and longer half-life than heparin.
dicumarol(Sintrom); Coumadin has a potent depressant effect on liver
formation of prothrombin from vitamin K and impairs
formation of factors VII, IX, and X (extrinsic pathway).
Coumadin is generally used for long-term/ postdischarge
therapy to keep international normalized ratio (INR) at 2–
3.

Thrombolytic agents, e.g., streptokinase, urokinase. May be used for treatment of acute (less than 5 days old)
or massive DVT to prevent valvular damage and
development of chronic venous insufficiency. Heparin is
usually begun several hours after the completion of
thrombolytic therapy.

Monitor laboratory studies as indicated: PT, PTT, aPTT, Monitors anticoagulant therapy and presence of risk
CBC factors, e.g., hemoconcentration and dehydration, which
potentiate clot formation. Note: Lovenox does not require
serial monitoring because PT and aPTT are not affected.

Platelet count, platelet/aggregation test, antiheparin On occasion, platelet count may decrease as a result of an
antibody assay immune reaction leading to platelet aggregation or the
formation of “white clots.” If bacteremia/DIC
(disseminated intravascular coagulation) have been ruled
out, condition may be the result of heparin-induced
thrombocytopenia and thrombosis (HITT), requiring a
change to Coumadin or other agents, e.g., dipyridamole
(Persantine) and ASA.

Apply/regulate graduated compression stockings, Sequential compression devices may be used to improve
intermittent pneumatic compression, if indicated. blood flow velocity and empty vessels by providing
artificial muscle-pumping action.

Apply elastic support hose following acute phase. Take Properly fitted support hose are useful (once ambulation
care to avoid tourniquet effect. has begun) to minimize or delay development of
postphlebotic syndrome. They must exert a sustained,
evenly distributed pressure over entire surface of calves
and thighs to reduce the caliber of superficial veins and
increase blood flow to deep veins.
ACTIONS/INTERVENTIONS RATIONALE
Embolus Care: Peripheral (NIC)

Collaborative
Prepare for surgical intervention when indicated. Thrombectomy (excision of thrombus) is occasionally
necessary if inflammation extends proximally or
circulation is severely restricted. Multiple/recurrent
thrombotic episodes unresponsive to medical treatment
(or when anticoagulant therapy is contraindicated) may
require insertion of a vena caval screen/umbrella.

NURSING DIAGNOSIS: Pain, acute/[Discomfort]

May be related to
Diminished arterial circulation and oxygenation of tissues with production/accumulation of lactic acid in tissues
Inflammatory process
Possibly evidenced by
Reports of pain, tenderness, aching/burning
Guarding of affected limb
Restlessness, distraction behaviors
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Pain Control (NOC)
Report pain/discomfort is alleviated or controlled.
Verbalize methods that provide relief.
Display relaxed manner; be able to sleep/rest and engage in desired activity.

ACTIONS/INTERVENTIONS RATIONALE
Pain Management (NIC)

Independent
Assess degree and characteristics of discomfort/pain. Degree of pain is directly related to extent of circulatory
Note guarding of extremity. Palpate leg with caution. deficit, inflammatory process, degree of tissue ischemia,
and extent of edema associated with thrombus
development. Changes in characteristics of pain may
indicate progression of problem/development of
complications.

Maintain bedrest during acute phase. Reduces discomfort associated with muscle contraction
and movement.

Elevate affected extremity. Encourages venous return to facilitate circulation,

reducing stasis/edema formation.

Provide foot cradle. Cradle keeps pressure of bedclothes off the affected leg,
thereby reducing pressure discomfort.
ACTIONS/INTERVENTIONS RATIONALE
Pain Management (NIC)

Independent
Encourage patient to change position frequently. Decreases/prevents muscle fatigue, helps minimize
muscle spasm, maximizes circulation to tissues.

Monitor vital signs, noting elevated temperature. Elevations in heart rate may indicate increased
pain/discomfort or occur in response to fever and
inflammatory process. Fever can also increase patient’s
discomfort.

Investigate reports of sudden and/or sharp chest pain, These signs/symptoms suggest presence of pulmonary
accompanied by dyspnea, tachycardia, and apprehension, emboli as a complication of DVT, or peripheral arterial
or development of a new pain with signs of another site of occlusion associated with heparin-induced
vascular involvement. thrombocytopenia and thrombosis (HITT). Both
conditions require prompt medical evaluation and
treatment.

Collaborative
Administer medications, as indicated:
Analgesics (narcotic/nonnarcotic); Relieves pain and decreases muscle tension.

Antipyretics, e.g., acetaminophen (Tylenol); Reduces fever and inflammation. Note: Risk of bleeding
may be increased by concurrent use of drugs that affect
platelet function, e.g., ASA and nonsteroidal anti-
inflammatory drugs (NSAIDs).

Apply moist heat to extremity, if indicated. Causes vasodilation, which increases circulation, relaxes
muscles, and may stimulate release of natural endorphins.

NURSING DIAGNOSIS: Gas Exchange, impaired (in presence of pulmonary embolus)

May be related to
Altered blood flow to alveoli or to major portions of the lung
Alveolar-capillary membrane changes (atelectasis, airway/alveolar collapse, pulmonary edema/effusion,
excessive secretions/active bleeding)
Possibly evidenced by
Profound dyspnea, restlessness, apprehension, somnolence, cyanosis
Changes in ABGs/pulse oximetry, e.g., hypoxemia and hypercapnia
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Respiratory Status: Gas Exchange (NOC)
Demonstrate adequate ventilation/oxygenation by ABGs within patient’s normal range.
Report/display resolution or absence of symptoms of respiratory distress.
ACTIONS/INTERVENTIONS RATIONALE
Embolus Care: Pulmonary (NIC)

Independent
Note respiratory rate and depth, work of breathing (use of Tachypnea and dyspnea accompany pulmonary obstruction.
accessory muscles/nasal flaring, pursed-lip breathing). Dyspnea (“air hunger”) and increased work of breathing
may be first or only sign of subacute pulmonary embolus
(PE). Severe respiratory distress/failure accompanies
moderate to severe loss of functional lung units.

Auscultate lungs for areas of decreased/absent breath Nonventilated areas may be identified by absence of
sounds and the presence of adventitious sounds, e.g., breath sounds. Crackles occur in fluid-filled
crackles. tissues/airways or may reflect cardiac decompensation.

Observe for generalized duskiness and cyanosis in “warm Indicative of systemic hypoxemia.
tissues” such as earlobes, lips, tongue, and buccal membranes.

Monitor vital signs. Note changes in cardiac rhythm. Tachycardia, tachypnea, and changes in BP are associated
with advancing hypoxemia and acidosis. Rhythm alterations
and extra heart sounds may reflect increased cardiac
workload related to worsening ventilation imbalance.

Assess level of consciousness/mentation changes. Systemic hypoxemia may be demonstrated initially by

restlessness and irritability, then by progressively
decreased mentation.

Assess activity tolerance, e.g., reports of These parameters assist in determining patient response to
weakness/fatigue, vital sign changes, increased dyspnea resumed activities and ability to participate in self-care.
during exertion. Encourage rest periods, and limit
activities to patient tolerance.

Airway Management (NIC)

Institute measures to restore/maintain patent airways, e.g., Plugged/collapsed airways reduce number of functional
coughing, suctioning. alveoli, negatively affecting gas exchange.

Elevate head of bed as patient requires/tolerates. Promotes maximal chest expansion, making it easier to
breathe and enhancing physiological/psychological
comfort.

Assist with frequent changes of position, and get patient Turning and ambulation enhance aeration of different
out of bed/ambulate as tolerated. lung segments, thereby improving oxygen diffusion.

Assist patient to deal with fear/anxiety that may be Feelings of fear and severe anxiety are associated with in
present: ability to breathe and may actually increase oxygen
consumption/demand.

Encourage expression of feelings, inform patient/SOs of Understanding basis of feelings may help patient regain
normalcy of anxious feelings, sense of impending doom. some sense of control over emotions.

Provide brief explanations of what is happening and Allays anxiety related to unknown and may help reduce
expected effects of interventions. fears concerning personal safety.

Monitor frequently, arrange for individual (volunteer, Provides assurance that changes in condition will be
family, others) to stay with patient as indicated. noted and that assistance is readily available.
ACTIONS/INTERVENTIONS RATIONALE
Embolus Care: Pulmonary (NIC)

Collaborative
Prepare for lung scan. May reveal pattern of abnormal perfusion in areas of
ventilation (ventilation/perfusion mismatch), confirming
diagnosis of pulmonary embolus (PE) and degree of
obstruction. Absence of both ventilation and perfusion
reflects alveolar congestion/airway obstruction.

Monitor serial ABGs/pulse oximetry. Hypoxemia is present in varying degrees, depending on

the amount of airway obstruction, usual cardiopulmonary
function, and presence/degree of shock. Respiratory
alkalosis and metabolic acidosis may also be present.

ACTIONS/INTERVENTIONS RATIONALE
Airway Management (NIC)
Administer supplemental oxygen by appropriate method. Maximizes available oxygen for gas exchange, reducing
work of breathing. Note: If obstruction is large or
hypoxemia does not respond to supplemental
oxygenation, it may be necessary to move patient to
critical care area for intubation and mechanical
ventilation.
Administer fluids (IV/PO) as indicated.
Increased fluids may be given to reduce hyperviscosity of
blood (potentiates thrombus formation) or to support
circulating volume/tissue perfusion.

Administer medications as indicated:

Thrombolytic agents, e.g., streptokinase Indicated in massive pulmonary obstruction when patient
(Kabikinase, Streptase), urokinase (Abbokinase), is seriously hemodynamically threatened. Note: These
alteplase (t-PA, Activase); patients will probably be initially cared for in/transferred
to the critical care setting.

Morphine sulfate, antianxiety agents. May be necessary initially to control pain/anxiety and
improve work of breathing, maximizing gas exchange.

Provide supplemental humidification, e.g., ultrasonic Delivers moisture to mucous membranes and helps
nebulizers. liquefy secretions to facilitate airway clearance.

Assist with chest physiotherapy (e.g., postural drainage Facilitates deeper respiratory effort and promotes
and percussion of nonaffected area, blow bottles/incentive drainage of secretions from lung segments into bronchi,
spirometer). where they may more readily be removed by
coughing/suctioning.

Prepare for/assist with bronchoscopy. May be done to remove blood clots and clear airways.

Prepare for surgical intervention if indicated. Vena caval ligation or insertion of an intracaval umbrella
may be useful for patients who experience recurrent
emboli despite adequate anticoagulation, when
anticoagulation is contraindicated, or when septic emboli
 arising from below the renal veins do not respond to
treatment. Additionally, pulmonary embolectomy may be
considered in life-threatening situations.

NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding condition, treatment

program, self-care, and discharge needs
May be related to
Lack of exposure or recall
Misinterpretation of information
Unfamiliarity with information resources
Possibly evidenced by
Request for information, statement of misconception
Inaccurate follow-through of instructions
Development of preventable complications
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Knowledge: Disease Process (NOC)
Verbalize understanding of disease process, treatment regimen, and limitations.
Participate in learning process.
Identify signs/symptoms requiring medical evaluation.
Knowledge: Treatment Regimen (NOC)
Correctly perform therapeutic actions and explain reasons for actions.

ACTIONS/INTERVENTIONS RATIONALE
Teaching: Disease Process (NIC)

Independent
Review pathophysiology of condition and Provides a knowledge base from which patient can make
signs/symptoms of possible complications, e.g., informed choices and understand/identify healthcare
pulmonary emboli, chronic venous insufficiency, venous needs. Up to 33% experience a recurrence of DVT.
stasis ulcers (postphlebotic syndrome).

Explain purpose of activity restrictions and need for Rest reduces oxygen and nutrient needs of compromised
balance between activity/rest. tissues and decreases risk of fragmentation of thrombosis.
Balancing rest with activity prevents exhaustion and
further impairment of cellular perfusion.

Establish appropriate exercise/activity program. Aids in developing collateral circulation, enhances

venous return, and prevents recurrence.

Problem-solve solutions to predisposing factors that may Actively involves patient in identifying and initiating
be present, e.g., employment that requires prolonged lifestyle/behavior changes to promote health and prevent
standing/sitting, wearing restrictive recurrence of condition/development of complications.
clothing(girdles/garters), use of oral contraceptives,
obesity, prolonged bedrest/immobility, dehydration.

Recommend sitting with feet touching the floor, avoiding Prevents excess pressure on the popliteal space.
crossing of legs.

ACTIONS/INTERVENTIONS RATIONALE
Embolus Care: Pulmonary (NIC)

Independent
Discuss purpose, dosage of anticoagulant. Emphasize Promotes patient safety by reducing risk of inadequate
importance of taking drug as prescribed. therapeutic response/ deleterious side effects.

Identify safety precautions, e.g., use of soft toothbrush, Reduces the risk of traumatic injury, which potentiates
electric razor for shaving, gloves for gardening, avoiding bleeding/clot formation.
sharp objects (including toothpicks), walking barefoot,
engaging in rough sports/activities, or forceful blowing of
nose.

Review possible drug interactions, and stress need to read Salicylates and excess alcohol decrease prothrombin
ingredient labels of OTC drugs. activity, whereas vitamin K (multivitamins, bananas,
leafy green vegetables) increases prothrombin activity.
Barbiturates increase metabolism of coumarin drugs;
antibiotics alter intestinal flora and may interfere with
vitamin K synthesis.

Identify untoward anticoagulant effects requiring medical Early detection of deleterious effects of therapy
attention, e.g., bleeding from mucous membranes (nose, (prolongation of clotting time) allows for timely
gums), continued oozing from cuts/punctures, severe intervention and may prevent serious complications.
bruising after minimal trauma, development of petechiae. Note: Even regular use of acetaminophen may prolong
clotting times. In addition, use of herbal products, such as
ginkgo biloba, garlic, vitamin E, also impairs clotting and
should be avoided during anticoagulant therapy.

Stress importance of medical follow-up/laboratory Understanding that close supervision of anticoagulant

testing. therapy is necessary (therapeutic dosage range is narrow
and complications may be deadly) promotes patient
participation.

Alerts emergency healthcare providers to use of

Encourage wearing of medical alert identification anticoagulants.
bracelet/ tag, as indicated.
Understanding may enhance cooperation with prescribed
Review purpose and demonstrate correct application/ therapy and prevent improper/ineffective use.
removal of antiembolic hose.
Chronic venous congestion/postphlebotic syndrome may
Instruct in meticulous skin care of lower extremities, e.g., develop (especially in presence of severe vascular
prevent/promptly treat breaks in skin and report involvement and/or recurrent episodes), potentiating risk
development of lesions/ulcers or changes in skin color. of stasis ulcers/infection.

POTENTIAL CONSIDERATIONS following discharge from care setting (dependent on patient’s age,
physical condition/presence of complications, personal resources, and life responsibilities)
Therapeutic Regimen: ineffective management—perceived seriousness of condition, susceptibility to recurrence,
benefit of therapy.