THROMBOPHLEBITIS

inflammation of a vein
accompanied by the
formation of a clot
THROMBOPHLEBITIS PREVALENCE

Prevalence
more common in women than in
men and among hospitalized
clients
also in one third of clients older
than 40 years who have had a
major surgery, orthopedic
surgery, or an AMI
high risk if client is with cancer
or family history of clotting
THROMBOPHLEBITIS PATHOPHYSIOLOGY
Pathophysiolog
y
Endothelial
Damage

Venous Hypercoagulab
Stasis ility

Virchow
THROMBOPHLEBITIS PATHOPHYSIOLOGY

Venous
Stasis
THROMBOPHLEBITIS PATHOPHYSIOLOGY

Hypercoagulab
ility
THROMBOPHLEBITIS PATHOPHYSIOLOGY

Endothelial
Damage
THROMBOPHLEBITIS PATHOPHYSIOLOGY

Review of Clot
Formation
THROMBOPHLEBITIS CLINICAL MANIFESTATIONS
Clinical
Manifestations
Superficial Thrombophlebitis
redness (rubor), induration, warmth (calor), and tenderness
along a vein
risk of becoming emboli is very low
THROMBOPHLEBITIS CLINICAL MANIFESTATIONS
THROMBOPHLEBITIS CLINICAL MANIFESTATIONS

Deep Vein Thrombosis

about half of clients are asymptomatic
unilateral leg swelling (larger
circumference)
pain, redness or warmth of the leg
dilated veins
low-grade fever
first clinical manifestation may be
Pulmonary Emboli
Homan’s Sign – discomfort in the upper
calf during forced dorsiflexion of the foot
present in less than one third of clients
 THROMBOPHLEBITIS CLINICAL MANIFESTATIONS

Site of Thrombus Formation According to

Physical Findings
Venous sinuses in the soleus muscle and
posterior tibial peroneal veins
swelling in the foot and ankle (may be
slight/absent)
calf pain and tenderness are common
Femoral vein thrombosis with calf
thrombosis
Pain and tenderness in the distal thigh
and popliteal area
Ileofemoral thrombus
Swelling, pain and tenderness over the
THROMBOPHLEBITIS CLINICAL MANIFESTATIONS
 THROMBOPHLEBITIS LABORATORY & DIAGNOSTIC
Laboratory & Diagnostic PROCEDURES

Procedures
Complete Blood Count
– elevated WBC count
– elevated sedimentation rate
Venous Duplex/ Color Duplex UTZ
– noninvasive test for visualization of the
thrombus including any free-floating or
unstable thrombi that may cause emboli
– most effective in detecting thrombus in lower
extremities
 THROMBOPHLEBITIS LABORATORY & DIAGNOSTIC
PROCEDURES
Impedance Pletysmography
– noninvasive measurement of changes in calf volume
corresponding to changes in blood volume brought
about by temporary venous occlusion with a high-
pneumatic cuff
– electrodes measure electrical impedance as cuff is
inflated
– Slow decrease in impedance indicates diminished
blood flow associated with thrombus
THROMBOPHLEBITIS LABORATORY & DIAGNOSTIC
PROCEDURES
 THROMBOPHLEBITIS LABORATORY & DIAGNOSTIC
PROCEDURES
RF (radioactive fibrinogen) Testing
– RF administered IV
– images are taken through nuclear scanning at 12-24
hours
– RF will be concentrated at the area of clot
formation
Venography
– IV injection of a radiocontrast agent
– vascular tree is visualized and obstruction is
identified
THROMBOPHLEBITIS LABORATORY & DIAGNOSTIC
PROCEDURES

D-dimer Blood Test

– D-dimer is a product of fibrin
degradation
– indicative of fibrinolysis, which occurs
with thrombosis
THROMBOPHLEBITIS MEDICAL MANAGEMENT

Medical Management

Goals
detect the thrombus early
prevent extension or embolization
(PE) of the thrombus
prevent further/recurrent thrombus
formation
limit venous valvular damage
THROMBOPHLEBITIS MEDICAL MANAGEMENT

Preventive Measures
• leg exercise and ambulation promote
venous return
• early ambulation after childbirth (6H after
delivery)and surgery
• passive leg muscle contraction
through sequential compression
device
• applied after surgery and care used until
client is ambulatory
• good alternative to clients who cannot
tolerate anticoagulation
• should not be used in clients with known
THROMBOPHLEBITIS MEDICAL MANAGEMENT

elevating the foot of the bed

applying compression stockings
passive ROM exercise
encouraging postoperative deep
breathing exercise promotes thoracic
pull
Warfarin, ASA, unfractioned Heparin,
LMW heparin
– unfractioned Heparin administered subQ
• common site is the fatty area anterior to
either iliac crest
THROMBOPHLEBITIS MEDICAL MANAGEMENT
• sponge the area with alcohol gently, DO
NOT RUB! (might initiate damage to the
tissue)
• attempt to stretch skin out (to empty blood
vessels)
• do not move needle tip when inserted, DO
NOT ASPIRATE! (can damage small blood
vessel wall)
• release skin roll on withdrawal of the needle
• DO NOT RUB/ INSTRUCT PATIENT NOT TO
RUB the area after administration (to
minimize likelihood of bleeding)
– LMWH for prevention of DVT for General/
Orthopedic Surgery
THROMBOPHLEBITIS MEDICAL MANAGEMENT

avoid using pillows under the clients

knees postoperatively
teach client to avoid sitting or
standing in one position for
prolonged periods
avoidance of infiltration during
intravenous therapy
THROMBOPHLEBITIS MEDICAL MANAGEMENT

Anticoagulation
• to prevent initiation or extension of
thrombi
• inhibit the synthesis of clotting
factors/ accelerate their inactivation
• do not break up or dissolve clots,
rather, prevent clots from forming
• intermittent/ continuous IV infusion
of Heparin for 5 to 7 days
– prevent extension of a thrombus and
development of a new thrombi
THROMBOPHLEBITIS MEDICAL MANAGEMENT

– administered at aPTT or PTT maintained

at either more than 60 seconds or at a
level 1.5 to 2.5 times baseline
established before therapy
– range of 700 to 1400 units/hr
– preferred delivery by electronic infusion
device to prevent infusion of large
volumes
THROMBOPHLEBITIS MEDICAL MANAGEMENT

– if PTT elevated, assessment of bleeding

or bruising and institution of bleeding
precautions
• avoidance of injections
• brushing teeth with a soft sponge device
• supervision with ambulation to prevent falls
• increase intake of fiber and fluids to prevent
straining and constipation
– be ready with antidote: Protamine SO4
• slow IV injection administration to minimize
bradycardia and hypotension
• can be used with LMWH but more effective
on Heparin
THROMBOPHLEBITIS MEDICAL MANAGEMENT

• Injected LMWH
– longer acting but much more expensive
than heparin
• can be given in 1 or 2 subQ per day
– no anticoagulant function test like
Heparin’s PTT but needs less monitoring
– doses are adjusted according to weight
• Dalteparin (Fragmin) 100 IU/kg SC BID
• Enoxaparin (Clexane) 1 mg/kg SC BID
• Nadroparin (Fraxiparine) 0.9 mg/kg
extremely high bioavailability and
more predictable pharmacokinetics
THROMBOPHLEBITIS MEDICAL MANAGEMENT

– fewer bleeding complications

– may be used safely in pregnant women
– patient is more mobile and have an
improved quality of life
THROMBOPHLEBITIS MEDICAL MANAGEMENT

• Coumadin (Warfarin/Coumarin)
– oral anticoagulant
– long-term anticoagulant after acute DVT
has been treated with injectable Heparin
– 3-5 days half-life (3-5 days to effect)
• stopped 3 days before any invasive
procedure
• usually administered concurrently with
heparin until desired anticoagulation has
been achieved
– prescribed based on INR levels with
therapeutic range of 2.0-2.5
– in the hospital, Warfarin is administered
THROMBOPHLEBITIS MEDICAL MANAGEMENT

• for dose adjustments based on daily INR/PT

results
– warfarin antidote: Vit. K (phytonadione)
PO/ low-dose IV
THROMBOPHLEBITIS MEDICAL MANAGEMENT

Nursing Considerations:
Anticoagulation
• blood is sampled every 4-8 hrs. for
PTT/INR for dose adjustment
• if in Warfarin therapy, PT or INR
should be drawn on a regular basis
• no testing for LMWH
• monitoring/ managing bleeding
– for invasive studies, apply pressure for
30 minutes to the puncture site; apply
ice if patient is prone to bleeding
THROMBOPHLEBITIS MEDICAL MANAGEMENT

– WOF frank bleeding in the urine (often

the first sign of excessive dosage),
nosebleeds, tarry or frank blood in the
stool, bleeding with brushing teeth, easy
subQ bruising, flank pain
• monitoring/ managing Heparin-
Induced Thrombocytopenia (HIT)
– a sudden decrease in platelet count by
at least 30% of baseline levels in
patients receiving Heparin
– high risk for patients receiving Heparin
for a prolonged period of time
THROMBOPHLEBITIS MEDICAL MANAGEMENT

– autoimmune mechanism that causes

destruction of platelets
– regular monitoring of platelet counts
• decreasing platelet count
• need for increase dose of heparin to
maintain therapeutic level
• thromboembolic or hemorrhagic
complications
– skin necrosis at site of injection or at distal sites
where thromboses occur, skin discoloration
consisting of large hemorrhagic areas,
hematomas, purpura, blistering
– if HIT occurs, platelet aggregation
studies are conducted, Heparin d/c,
THROMBOPHLEBITIS MEDICAL MANAGEMENT

• Lepirudin (Refludan)
– ½ life of 1.3H, excreted by the kidneys, monitored
using aPTT
– initial IV bolus infusion followed by subsequent
infusions with subsequent adjustments
– maintain aPTT between 1.5 – 2.5 times baseline
– strict dosage adjustment in renal failure
(clearance is proportional to patient’s creatinine
clearance
• Argatroban
½ life of 30-45 minutes, metabolized by liver,
unaffected by renal function
effect is dose dependent and requires monitoring
either aPTT/ACT
THROMBOPHLEBITIS MEDICAL MANAGEMENT

contraindications to therapy
lack of px cooperation severe hepatic or renal
disease
bleeding from the ff. recent cerebrovascular
systems: GI, GU, hemorrhage
Respiratory, Reproductive
hemorrhagic blood infections
dyscrasias
aneurysms open ulcerative wounds
severe trauma occupations that involve a
significant hazard for injury
alcoholism recent delivery of a baby
recent/ impending surgery
of eye, spinal cord, brain
THROMBOPHLEBITIS MEDICAL MANAGEMENT

Thrombolytic Therapy
administration of thrombolytic
agents to dissolve any formed
thrombus
for parenteral use only
commonly used include
streptokinase (Streptase) and tissue
plasminogen activator (t-PA)
other drugs include reteplase (r-PA,
Retavase), tenecteplace (TNKase),
staphylokinase, urokinase,
THROMBOPHLEBITIS MEDICAL MANAGEMENT

given within the first 3 days after

acute thrombosis (if beyond five
days, less effective)
less long-term damage to the venous
valves’
reduced incidence of postthrombotic
syndrome and chronic venous
insufficiency
three-fold greater incidence of
bleeding than heparin; d/c if bleeding
THROMBOPHLEBITIS MEDICAL MANAGEMENT

Nursing Considerations: Thrombolytics

• monitor clotting profiles every 2-4H
(to rule-out bleeding tendencies,
establish baseline for assessment of
drug efficacy)
• WOF signs of bleeding and report
immediately
– have typed and cross-matched blood on
hold
– aminocaproic acid (Amicar) on hand to
treat bleeding
THROMBOPHLEBITIS MEDICAL MANAGEMENT

– any suspected allergic reaction and

report immediately
– corticosteroids to treat reaction
• move patient as little as possible
• minimize phlebotomy
THROMBOPHLEBITIS MEDICAL MANAGEMENT

Nonpharmacologic Therapy
• bed rest with unfractioned heparin; if
LMWH, patient is encouraged to walk
• elevation of extremity at least 10 to
20 degrees above the level of the
heart (enhance venous return and
decrease swelling)
– pillows to support popliteal space
– if upper extremity, sling or stockinette
attached to an IV pole may be used
THROMBOPHLEBITIS MEDICAL MANAGEMENT

• compression (promotes venous

return and reduces swelling)
– electrically/ pneumatically controlled
stockings, boots, or sleeves
– elastic stockings/ garments (30 to 40
mmHg)
THROMBOPHLEBITIS SURGICAL MANAGEMENT
Surgical
Management

when anticoagulant or thrombolytic

therapy is contraindicated
danger of pulmonary embolism is
extreme
venous drainage is so severely
compromised that permanent
damage to the extremity is high
THROMBOPHLEBITIS SURGICAL MANAGEMENT

Thrombectomy
removal of the thrombosis
procedure of choice
THROMBOPHLEBITIS SURGICAL MANAGEMENT
THROMBOPHLEBITIS SURGICAL MANAGEMENT

Inferior Vena Cava Filter

traps large emboli and prevents
pulmonary emboli
patient who has recurrent emboli in
the presence of anticoagulation
THROMBOPHLEBITIS NURSING MANAGEMENT

Nursing Management

Nursing Diagnosis: Acute Pain related

to decreased venous blood flow
Nursing Interventions:
• elevate legs to promote venous
drainage and reduce swelling
• apply warm compress or heating pad
as directed to promote circulation
and reduce pain
THROMBOPHLEBITIS NURSING MANAGEMENT

– check that water temperature is not too

hot
– cover plastic water bottle or heating pad
with towel before applying
• administer acetaminophen, codeine
or other analgesics as prescribed and
as needed; avoid the use of ASA and
NSAIDs during anticoagulation
therapy to prevent further risk of
bleeding
• avoid massaging/ rubbing calf
because of danger of breaking up the
THROMBOPHLEBITIS NURSING MANAGEMENT

Nursing Diagnosis: Impaired Physical

Mobility related to pain and imposed
treatment
Nursing Interventions:
• prevent venous stasis by proper
positioning in bed
– support full length of leg when they are
to be elevated
– prevent pressure ulcers that may occur
over bony prominences (sacrum, hips,
knees and heels)
– in side lying position, place a soft pillow
THROMBOPHLEBITIS NURSING MANAGEMENT

– avoid hyperflexion at knee (Jackknife

position) because this promotes stasis in
pelvis and extremities
• initiate active exercise unless
contraindicated, then use passive
exercise
– stimulate walking if lying on back (5 min
q 2H)
– stimulate bicycle pedaling if lying on
side (5 min q 2H)
– if contraindicated, resort to passive
exercises (5 min q2H)
THROMBOPHLEBITIS NURSING MANAGEMENT

• WOF pulmonary embolism: chest

pain, dyspnea, anxiety,
apprehension; report immediately
• after 5-7 days, apply elastic
stockings as directed; remove twice
daily and WOF skin changes,
pressure points, and calf tenderness
• encourage ambulation when allowed
– if permissible, have the patient sit up
and move to side of bed in sitting
position; provide foot support (dangling
not allowed to prevent pressure against
THROMBOPHLEBITIS NURSING MANAGEMENT

– if patient permitted OOB, encourage

walking 10 min. every hour
– discourage crossing of legs and long
periods of sitting to avoid compression
of vessels