THROMBOPHL

EBITIS
SANTOS, MARIA ERICKA B.
BSN III - 1

WHAT IS THROMBOPHELIBITIS?
Inflammation of the wall of a vein with associated thrombosis,
occurs when a blood clot blocks one or more of your veins,
typically in your legs.
a. Superficial Thrombophlebitis
This is when the inflammation is just below the surface of the skin.
Thrombosis of superficial veins produces pain or tenderness, redness, and
warmth in the involved area. The clots will gradually break apart as they
flow along with the blood. They could also be a symptom of deep vein
thrombophlebitis.

b. Deep Vein Thrombophlebitis (DVT)

This is when the inflammation is in a deep vein, normally in your abdomen

 Upper extremity venous thrombosis is

more common in patients with IV
catheters or in patients with an
underlying disease that causes
hypercoaguability.
Internal trauma to the vessels may
result from pacemaker lead,
chemotherapy ports, dialysis catheters,
or parenteral nutrition lines.

PATHOPHYSIOLOGY OF
THROMBOPHLEBITIS

Although the exact cause of venous

thrombosis remains unclear, three factors,
known as Virchows triad, are believed to
play a significant role in its development:
a. Vessel wall Injury
b. Stasis of Blood
c. Altered Coagulation

 Veins transport blood with the help of muscle

contractions while you move or walk.
Veins have valves that keep blood from moving
backward.
Venous stasis occurs when blood flow is reduced, as
in heart failure or shock; when veins are dilated, as
with some medication therapies; and when skeletal
muscle contraction is reduced, as in immobility,
paralysis of the extremities, or anesthesia. Moreover,
bed rest reduces blood flow in the legs by at least 50%
(Porth, 2005).

 Vessel wall Injury

Trauma and surgery usually result in reduced
physical activity, injury to vessels, and release
of procoagulant substances from tissues.
Direct trauma to the vessels, as with fractures
or dislocation, diseases of the veins, and
chemical irritation of the vein from IV
medications or solutions, can damage veins.

 Altered Coagulation
Increased blood coagulability occurs most commonly in
patients for whom anticoagulant medications have been
abruptly withdrawn. Oral contraceptive use and several
blood dyscrasias (abnormalities) also can lead to
hypercoagulability. Formation of a thrombus frequently
accompanies thrombophlebitis, which is an inflammation of
the vein walls.
Increased blood coagubility can result from inherited or
acquired disorders.

CLINICAL MANIFESTATIONS
Superficial Veins
Thrombosis of superficial veins produces pain or
tenderness, redness, and warmth in the involved
area. The risk of the superficial venous thrombi
becoming dislodged or fragmenting into emboli is very
low because most of them dissolve spontaneously. This
condition can be treated at home with bed rest, elevation
of the leg, analgesics, and possibly anti inflammatory
medication.

 Deep Vein Thrombosis

With obstruction of the deep veins comes edema and
swelling of the extremity because the outflow of venous
blood is inhibited.
Tenderness, which usually occurs later, is produced by
inflammation of the vein wall and can be detected by gently
palpating the affected extremity.
Homans' sign (pain in the calf after the foot is sharply
dorsiflexed) is not specific for DVT because it can be elicited
in any painful condition of the calf. In some cases, signs and
symptoms of a pulmonary embolus are the first indication of
DVT.

ASSESSMENT AND DIAGNOSTIC

FINDINGS
Careful assessment is invaluable in detecting early
signs of venous disorders of the lower extremities.
Patients with a history of varicose veins,
bypercoagulation, neoplastic disease,
cardiovascular disease, or recent major surgery or
injury are at high risk.
Other patients at high risk include those who are
obese or elderly and women taking oral,
contraceptives.

When performing the nursing assessment, key

concerns include:
limb pain
feeling of heaviness
functional impairment
ankle engorgement, and
edema
differences in leg circumference bilaterally from
thigh to ankle
increase in the surface temperature of the leg,
particularly the calf or ankle and
areas of tenderness or superficial thrombosis (ie,
cord-like venous segment).

 UltrasoundAs the sound waves travel

through your leg tissue and reflect back, a
computer transforms the waves into a moving
image on a video screen. A clot may be visible
in the image.
Doppler ultrasonography findings are
diminished or absent compared with those for
opposite leg
Phlebography (venography) shows an
unfilled segment of the vein in an otherwise
completely filled vein with its connecting
collaterals, this test is generally most
indicative in diagnosing venous thrombosis

PREVENTION
Venous thrombosis, thrombophlebitis, and DVT
can be prevented esp. if patients who are
considered at high risk are identified and
preventive measures are instituted without delay.
Preventive measures include:
- Application of elastic compression stockings
- Intermittent pneumatic compression devices
- Special body positioning
- Exercise

MEDICAL MANAGEMENT
Objectives of treatment:
- Prevent thrombus from growing and
fragmenting and to prevent recurrent
thromboemboli.

PHARMACOLOGIC THERAPY

UNFRACTIONATED HEPARIN

- Administered subcutaneously to prevent development of DVT, or

by intermittent or continuous IV infusion of 5 7 day to prevent
extension of thrombus and development of new thrombi.
- Oral medications, such as warfarin, are administered with heparin
therapy.
LOW-MOLECULAR WEIGHT HEPARIN
- Sc LMWHs that may include medications such as dalteparin
(Fragmin) & enoxaparin (Lovenox) are effective treatments for
some cases of DVT.
- LMWHs prevent the extension of a thrombus and development of
new thrombi, and they are associated with fewer bleeding
complications and lower risks of heparin-induced
thrombocytopenia (HIT) than unfractionated heparin.

- These agents have longer half-lives than unfractionated heparin,

so doses can be given in one or two subcutaneous injections
each day. Doses are adjusted according to weight
- The cost of LMWH is higher than that of unfractionated heparin;
however, LMWH may be used safely in pregnant women, and
patients who take it may be more mobile and have an improved
quality of life.
THROMBOLYTICTHERAPY
-Unlike the heparins, thrombolytic (fibrinolytic) therapy lyses and
dissolves thrombi in 50% of patients.
- Thrombolytic therapy (eg, t-PA [Alteplase, ActivaseJ, reteplase [rPA, Retavase], tenecteplase [TNKase], staphylokinase, urokinase,
strepto- kinase) is given within the first 3 days after acute
thrombosis

- The advantages of thrombolytic therapy include less longterm damage to the venous valves and a reduced incidence
of post thrombotic syndrome and chronic venous
insufficiency.
FACTOR XA INHIBITOR
- Fondaparinux (Arixtra) selectively inhibits factor Xa.
- This agent is given daily subcutaneously at a fixed-dose,
has a half-life of 17 hours, and is excreted unchanged via
the kidneys (and therefore must be used with caution in
patients with renal insufficiency).
- Fondaparinux has no effect on routine tests of coagulation,
such as the aPTT or activated clotting time (ACT), so routine
coagulation monitoring is unnecessary (Weitz, 2004).

 ORAL ANTICOAGULANTS

Warfarin (Coumadin) is a vitamin K antagonist that is

frequently used for extended-therapy.
- Routine coagulation monitoring is essential to ensure that a
therapeutic response is obtained and maintained over time.
- Interactions with a range of other medications can reduce or
enhance the anti-coagulant effects of warfarin, as can
variable intake of foods containing vitamin K.
- Warfarin has a narrow therapeutic window, and there is a
slow onset of action.
- Treatment is initially supported with concomitant parenteral
anticoagulation with heparin until the warfarin demonstrates
anticoagulant effectiveness.

SURGICAL MANAGEMENT
Surgery is necessary for DVT when anticoagulant or
thrombolytic therapy is contraindicated, the danger of
pulmonary embolism is extreme, or the venous drainage is
so severely compromised that permanent damage to the
extremity is likely.
A thrombectomy (removal of the thrombosis) is the
procedure of choice. A vena cava filter may be placed at
the time of the thrombectomy; this filter traps large emboli
and prevents pulmonary emboli. Balloon angioplasty and
stent placement are being used in the iliac veins of
patients with acute and chronic venous disease.

NURSING MANAGEMENT
Assessing and Monitoring Anticoagulant
Therapy
- Continuous IV infusion by an electronic infusion device is the
preferred method of administering unfractionated heparin.
- To prevent inadvertent infusion of large volumes of unfractionated heparin, which could cause haemorrhage

- Dosage calculations are based on the patient's weight, and

any possible bleeding tendencies are detected by a
pretreatment clotting profile. If renal insufficiency exists, lower
doses of heparin are required. Periodic coagulation tests and
hematocrit levels are obtained. Heparin is in the effective, or
therapeutic, range when the aPTT is 1.5 times the control.

- Oral anticoagulants, such as warfarin (Coumadin), are

monitored by the PT or the INR. Because the full anticoagulant
effect of warfarin is delayed for 3 to 5 days, it is usually
administered concurrently with heparin until desired
anticoagulation has been achieved (ie, when the PT is 1.5 to 2
times normal or the INR is 2.0 to 3.0).

Monitoring and Managing Potential

Complications
BLEEDING
THROMBOCYTOPENIA
DRUG INTERACTIONS

 Providing comfort
- Bed rest, elevation ofthe affected extremity, elastic compression
stockings, and analgesics for pain relief are adjuncts to therapy.
- help improve circulation and increase comfort.

- Depending on the extent and location of a venous thrombosis, bed rest

may be required for 5 to 7 days after diagnosis.
- This is approximately the time necessary for the thrombus to adhere to
the vein wall, preventing embolization.

- Warm, moist packs applied to the affected extremity reduce the

discomfort associated with DVT, as do mild analgesics prescribed for
pain control.
- When the patient begins to ambulate, elastic compression stockings
are used. Walking is better than standing or sitting for long periods.
Bed exercises, such as repetitive dorsiflexion of the foot, are also
recommended.

 Compression Therapy
STOCKINGS
- Elastic compression stockings usually are prescribed for
patients with venous insufficiency.
- These stockings exert a sustained, evenly distributed,
pressure over the entire surface of the calves, reducing the
caliber of the superficial veins in the legs and resulting in
increased flow in the deeper veins.
- The stockings maybe knee-high, thigh-high, or panty hose.
Thigh-high stockings are difficult for the patient to wear
because they tend to roll down. The roll of the stocking
further restricts blood (low rather than providing evenly
distributed pressure over the thigh.

WRAPS
Short stretch elastic wraps may be applied from the toes
to the knee in a 50% spiral overlap. These wraps are
available in a two-layer system, which includes an inner
layer of soft padding. These wraps are rectangular and
become squares on stretching, indicating the appropriate
degree of stretch and reducing the possibility of
wrapping a leg too loosely or too tightly. Three- and fourlayer systems are also available (Profore, Dynacare), but
these maybe used only once compared to the two-wrap
system, which can be used multiple times.

Other types of compression are available:

Unna boot, which consists of a paste bandage impregnated
with zinc oxide, glycerin, gelatin, and sometimes calamine,
is applied without tension in a circular fashion from the
base of the toes to the tibial tuberosity with a 50% spiral
overlap. It is important to keep the foot dorsillexed at a 90degree angle to the leg, thus avoiding excess pressure or
trauma to the anterior ankle area. This type of compression
may remain in place for as long as 1 week.
The CirCaid, a nonelastic leg wrap with a series of
overlapping, interlocking Velcro straps, augments the effect
of the muscle pump while the patient is walking. The
CirCaid is usually worn during the day. Patients may find the
CirCaid easier to apply and wear than the Unna boot.

INTERMITTENTPNEUMATICCOMPRESSION DEVICES
- These devices can be used with elastic compression stockings
to prevent DVT. They consist of an electric controller that is
attached by air hoses to plastic knee-high or thigh- high
sleeves. The leg sleeves are divided into compartments, which
sequentially fill to apply pressure to the ankle, calf, and thigh
at 35 to 55 mmHg of pressure. These devices can increase
blood velocity beyond that produced by the stockings. Nursing
measures include ensuring that prescribed pressures are not
exceeded and assessing for patient comfort.

 Positioning the Body and Encouraging Exercise

- When the patient is on bed rest, the feet and lower legs should be
elevated periodically above the level of the heart.
- This position allows the superficial and tibial veins to empty rapidly
and to remain collapsed. Active and passive leg exercises, particularly
those involving calf muscles, should be performed to increase venous
flow.
- Early ambulation is most effective in preventing venous stasis.
- Deep-breathing exercises are beneficial because they produce
increased negative pressure in the thorax, which assists in emptying
the large veins. Once ambulatory, the patient is instructed to avoid
sitting for more than 2 hours at a time.
- The goal is to walk at least 10 minutes every 1 to 2 hours. The
patient is also instructed to perform active and passive leg exercises
as fre- quently as necessary when he or she cannot ambulate, such

 Promoting Home and Community-Based Care

In addition to teaching the patient how to apply elastic compression
stockings and explaining the importance of elevating the legs and
exercising adequately, the nurse teaches about the medication, its
purpose, and the need to take the correct amount at the specific times
prescribed.
The patient should also be aware that periodic blood tests are
necessary to determine if a change in medication or dosage is
required. If the patient fails to adhere to the therapeutic regimen,
continuation of the medication therapy should be questioned.
A person who refuses to discontinue the use of alcohol should not
receive anticoagulants
- Chronic alcohol use decreases their effectiveness. In patients with
liver disease, the potential for bleeding may be exacerbated by
anticoagulant therapy.