Thrombophlebitis occurs when a clot forms in a vein secondary to inflammation or when the vein is partially occluded from some disease process. As a general rule, two out of the following three fac- tors occur prior to the formation of a thrombus-blood stasis, injury to the vessel, and altered blood coagulation.
Deep vein thrombosis, or DVT, pertains to clots that are formed in the deep veins and may result in complications such as pulmonary embolus and post phlebotic syndrome, or chronic venous insufficiency. This can be a residual effect of thrombophlebitis in which the veins are partially occluded or valves in the vessels have been dam- aged. This chronic insufficiency may cause increased venous pressure and fluid accumulation in the interstitial tissues, which results in chronic edema, tissue fibrosis, and induration.
DVT may be asymptomatic, but usually produces side effects such as fever, pain, edema, cyanosis or pallor to the involved extremity, and malaise. Superficial vein thrombophlebitis causes may include trauma, infection, chemical irritations, frequent IVs, and recreational drug abuse.
The goals in treatment of thrombophlebitis are to control thrombotic development, relieve pain, improve blood flow, and prevent complications.

used to visualize the vascular system and locate any impairment in blood flow
a non-invasive measurement of changes in calf volume that corresponds to changing blood volume as a result of impairment in blood flow
1251 Fibrinogen uptake test:
a radioactive scan performed after radioactive fibrinogen is injected, which concentrates in the area of clot formation; not sensitive to thrombi high on the iliofemoral region or with inactive thrombi
heparin, coumadin, warfarin to prolong clotting time to prevent further clot formation

Alteration in tissue perfussion: peripheral
Related to: impaired blood flow, venous stasis, venous obstruction
Defining characteristics: pain, tissue edema, decreased peripheral pulses, prolonged capillary refill time, pallor, cyanosis, erythema, paresthesia
Outcome Criteria
Patient will have improved peripheral perfusion, with palpable and equal pulses, normal skin color, temperature, and sensation, and have no evidence of edema.

Observe lower extremities for edema, color, and temperature. Measure calf circumference every shift. Monitor for capillary refill time.
Findings may help to differentiate between superficial thrombophlebitis and deep vein thrombosis. Measurements can facilitate early recognition of edema and changes. Edema, redness, and warmth are indicative of superficial phlebitis whereas DVT usually is exhibited by cool pale skin. DVT may prolong capillary refill time.
Observe extremity for prominence of veins, knots, bumps, or stretched skin.
Superficial veins may become distended because of backflow through veins. Evidence of thrombophlebitis to superficial veins may be visible or easily palpable.
Maintain bedrest.
Activity limitation may minimize the potential for dislodgment of the dot.
Elevate legs while in bed or sitting in chair.
Reduces swelling and increases venous return. Some experts believe that elevation may actually enhance the release of thrombi.
Observe for positive Homansign (pain in calf upon dorsi-flexion of foot).
Homan’s sign may or may not be present consistently and should not be used as a sole indicator of thrombophlebitis.
Perform active or passive ROM exercises while at bedrest.
Promote increased venous blood return and decrease venous stasis.
Apply TED hose after acute phase is over. Remove for at least 1 hour every shift.
Assists to minimize postphlebotic syndrome and increases blood flow to deep veins. Removal allows time for compression of veins to be relaxed.
Apply warm moist soaks as ordered.
Promotes vasodilation and may improve venous return and decrease in edema.
Administer anticoagulants as ordered.
Heparin is used initially because of its action on thrombin formation and the removal of the intrinsic pathway to prevent further clot formation.
Coumadin is usually used for long-term therapy.
Monitor laboratory studies for PT, PTT, AMT, and CBC.
Monitors efficacy of anticoagulant therapy and potential for dot formation due to hemoconcentration/dehydration.

Information, Instruction, Demonstration
Instruct on avoidance of rubbing
or massaging extremity involved.
May promote risk of dislodging clot and causing embolization.
Avoid crossing legs, prolonged positions with legs dangling, or knees bent.
Positions tend to restrict circulation and increases venous stasis, and increases edema.
Instruct in deep breathing exercises.
Promotes emptying of large veins by increasing negative pressure in the thorax.
Instruct on maintaining fluid intake of at least 2 L/day.
Dehydration promotes increased viscosity of blood, and increases venous stasis.
Prepare patient for surgery if warranted.
Surgical intervention may be required if circulation is severely compromised. Recurrent episodes of thrombi may require a vena cava umbrella to filter out thrombi going to lung.
Instruct on lying in a slightly reversed Trendelenburg position.
Promotes blood flow to dependent extremities; preferable to have extremities full of blood as opposed to empty.

Discharge or Maintenance Evaluation
·        Patient will have palpable pulses of equal strength to all extremities.
·        Skin will be within normal limits of coloration, temperature, and sensation.
·        Patient will be able to recall all instructions accurately.
·        Patient will have no complications from anticoagulation therapy.

Risk for impaired skin integrity
Related to: edema, venous stasis, bedrest, surgery, pressure, altered circulation and blood flow, altered metabolic states
Defining characteristics: skin surface disruptions, incisions, ulcerations, wounds that do not heal
Outcome Criteria
·        Patient will have no evidence of impairment to skin tissues.
·        Patient will have surgical wound approximated and well-healed with no evidence of infection.

Monitor extremities for presence of ulcers, wounds, symptoms of decreased circulation
Provides prompt assessment and treatment for impaired tissues.
If surgery is required, change dressing using aseptic or sterile technique as warranted. Leave wound open to air as soon as is feasible, or apply light dressing.
Prevents drainage accumulations from excoriating skin, provides assessment to monitor for changes in wound appearance and deterioration improvement, and prevents wound from contamination. Allowing air to reach wound facilitates drying and promotes the healing process. Sutures may be abrasive to skin or get caught on garments and irritation may be reduced with a light gauze dressing.
Cleanse wound as ordered with each dressing change.
Various agents can be used to remove exudate or necrotic material from wound to promote healing. Any packing of the wound should be done using sterile technique to reduce the risk of contamination.
Monitor wound for skin integrity to incision and surrounding tissues, noting increases and changes in characteristics of drainage.
Prompt recognition of problems with healing may prevent exacerbation of wound. Increased drainage or malodorous drainage may indicate infection and delayed wound healing.
Monitor any drainage tubes for amounts and character of drainage. Use ostomy bags over tubes when drainage is massive.
Provides indication of decreasing or increasing wound drainage and assessment of healing process. Collection of drainage in bags facilitates more accurate measurement of fluid loss and prevents excoriation of skin from copious drainage.
Use skin prep, moisture barrier, or benzoin to skin prior to tape application. Use hypoallergenic tape or Montgomery straps to se- cure dressings.
Provides protection to skin and reduces potential for skin trauma. Reduces potential for skin wound disruption when frequent dressing changes are required

Information, Instruction, Demonstration
Instruct to avoid scratching, hitting or bumping legs, or other injurious activities.
Injuries may damage tissues that may deteriorate into ulcer formation.
Instruct on signs/symptoms of infection to wound/skin and to report to nurse/MD.
Provides prompt notification to enhance prompt treatment.
Instruct on cleansing incision area post discharge.
Reduces skin surface contaminants and prevents infection.

Discharge or Maintenance Evaluation
Patient will have approximated, healed surgical wound with no drainage, erythema, or edema to site. Patient will be able to recall instructions accurately. Patient will be compliant with avoiding injurious activities, and will seek medical help when injury occurs.

Alteration in comfort
[See MI]
Related to: inflammation, impaired blood flow, intermittent claudication, venous stasis, lactic acid in tissues, surgical procedures, fever
Defining characteristics: complaints of pain, tenderness to touch, aching, burning, restlessness, facial grimacing, guarding of extremity

Knowledge deficit
Related to: lack of understanding, lack of under- standing of medical condition, lack of recall
Defining characteristics: questions regarding problems, inadequate follow-up on instructions given, misconceptions, lack of improvement of previous regimen, development of preventable complications
Outcome Criteria
Patient will be able to verbalize and demonstrate understanding of information given regarding condition, medications, and treatment regimen.

Information, Instruction, Demonstration

Determine patient’s baseline of knowledge regarding disease process, normal physiology, and function
Provides information regarding patient‘s understanding of condition as well as a baseline from which to base teaching.
Monitor patient’s readiness to learn and determine best methods to use for learning. Attempt to incorporate family/significant other in learning process. Reinstruct/reinforce information as needed.
Promotes optimal learning environment when patient shows willingness to learn. Family members may assist with helping the patient to make informed choices regarding his treatment. Anxiety or large volumes of instruction may impede comprehension and limit learning.

Provide time for individual interaction with patient.
Promotes relationship between patient and nurse, and establishes trust.
Instruct patient on procedures that may be performed.
Provides knowledge and promotes the ability to make informed choices.
Instruct on signs/symptoms of possible complications, such as pulmonary emboli, venous insufficiency, and venous stasis ulcers.
Provides knowledge and assists patient to understand health care needs.
Instruct on care to lower extremities and to notice MD for development of any lesion.
Chronic venous stasis may occur and promotes risk of infection and/or ulcer formation.
Instruct patient in medications, dose, effects, side effects, contraindications, and signs/ symptoms to report to MD.
Promotes understanding that side effects are common and may subside over time, and facilitates compliance.
Instruct on leg exercises and position changes. Assist with setting up activity program post-discharge.
Decreases venous pooling that can be potentiated by vasodilators and prolonged time in one position. Exercise may assist in developing collateral circulation and enhances venous return.
Instruct to rise slowly, allowing time between position changes.
Assist body to equilibrate and adjust in order to decrease the risk of syncope.
Instruct to balance rest with activity.
Rest decreases oxygen demands of compromised tissue and decreases potential for embolization of thrombus. Balancing rest with graduated activity prevents exhaustion and impairment of tissue perfusion.
Instruct on proper application of TED stockings.
Improper application may cause a tourniquet-like effect and impede circulation.
Avoid Valsalva-type maneuvers. Provide increased fiber to diet and administer stool softeners as warranted.
Increases venous pressure in the leg which increases potential for thrombophlebitis.
Instruct on anticoagulation therapy-dosage, effects, side effects, when to administer, other medications to avoid
Promotes compliance with medical regimen and decreases potential for improper dosage and adverse drug interactions. Aspirin and salicylates decrease prothrombin activity, vitamin K increases prothrombin activity, antibiotics may interfere with vitamin K synthesis, and barbiturates can potentiate anticoagulant effect.
Instruct on importance of keeping MD appointments for follow up laboratory studies.
Promotes compliance with treatment and decreases potential for non-therapeutic levels of anti- coagulation therapy.
Provide printed materials when possible for patient/family to review
Provides references for patient and family to refer to once discharged, and can enhance the understanding of verbally given instructions.
Have patient demonstrate all skills that will be necessary for post-discharge
Provides information that patient has gained a full understanding of instruction and is able to demonstrate correct information.

Discharge or Maintenance Evaluation

Patient will be able to verbalize understanding of condition, treatment regimen, and signs/symptoms to report. Patient will be able to correctly perform all tasks prior to discharge. Patient will be able to verbalize understanding of safety precautions, correct dosage and administration of all medications, and activity limitations.