Thromboplebitis

Thrombophlebitis

Deep or superficial veins may be affected by thrombophlebitis, which is an inflammation of the vascular wall accompanied by the development of a clot (thrombus). It may cause ischemia, necrosis, and injury to the surrounding tissues. The saphenous, femoral, and palatial veins are the ones most frequently affected.

Obesity, CHF, long-term use of birth control, trauma, sepsis, smoking, dehydration, venous cannulation, complications from surgery, etc. are risk factors.

Signs and Symptoms

• Pain in the affected extremity.
• Superficial vein:
  • Tenderness & redness.
  • Induration along course of the vein.
• Deep vein:
  • Swelling,
  • Venous distension of the limb,
  • Tenderness over involved vein,
  • Positive Homan's sign,
  • Cyanosis.
• Elevated WBC, and ESR

Diagnosis

• Venography (phlebography): increased uptake of radioactive material,
• Doppler ultrasonography: impairment of blood flow ahead of thrombus,
• Venous pressure measurements: high in affected limb until collateral circulation is developed.

Management

•  Anticoagulant therapy
  • Heparin: Blocks conversion of prothrombin thrombin and reduces formation or extension of thrombus.
  • Warfarin: Blocks prothrombin synthesis by interfering with vitamin K synthesis.
• Surgery:
  • Vein ligation and stripping,
  • Venous thrombectomy: removal of a clot in the iliofemoral region,
  • Plication of the inferior vena cava: insertion of an umbrella-like prosthesis into the lumen of the vena cava to filter incoming blood.

Nursing Management

• Provide bed rest, elevating involved extremity to increase venous return and decrease edema,
• Apply continuous warm, moist soaks to decrease lymphatic congestion,
• Administer anticoagulants as prescribed.

Heparin

• Monitor PTT; doses should be adjusted to keep PTT between 1.5 to 2.5 times normal control level,
• Use infusion pump to administer IV heparin,
• Ensure proper injection technique,
• Assess for increased bleeding tendencies,
• Have antidote (protamine) available,
• Instruct the patient to avoid aspirin antihistamines and obtain the physician's permission before using other OTC drugs.

Warfarin (Coumadin)

• Assess PT daily; dosage should be adjusted to maintain Pt at 1.5 to 2.5 times normal contre level; INR of 2.
• Obtain careful medication history (dru interaction).
• Advise the patient to withhold dose and notify the physician immediately if the bleeding occurs.
• Instruct the patient to use a soft tooth brust and to floss gently.
• Have antidote available (vit K)
• Alert the patient about the factors that may affect the anticoagulant response (high-fat diet, vit K rich food).
• Instruct the patient to wear medical alert bracelet
  • Assess vital signs every 4 hours Monitor for chest pain or SOB.
  • Measure thighs, calves, ankles every morning.
  • Provide teaching.
• Need to avoid standing, sitting for longer periods; constrictive clothing: crossing legs at the knees; smoking and oral contraceptives.
• Importance of adequate hydration to prevent hypercoagulability.
• Use of elastic stocking when ambulating.
• Importance of planned rest periods with elevation of the feet.
• Drug regimen.
• Plan for exercise/activity
  • Pegin with dorsiflexion of the feet while sitting or lying down.
  • Swing several times weekly.
  • Gradually increase walking distance.
• Importance of weight reduction if obese.