Thrombophlebitis, or the formation of a clot within the vein, commonly occurs within the deep veins in the legs, and may also occur in the arms. Initially platelets and white cells clump together, sticking to the inside of the vessel wall. As blood flows over the area, other cells may deposit onto the area, making the thrombus larger. Compression of blood flow, which will increase the venous pressure or sluggishness of the blood flow, can increase the risk of clot formation. Immobility,obesity, or hormonal changes such as pregnancy can all contribute to increased risk.
Nursing Diagnosis Deep Vein Thrombosis
• Risk for acute pain
• Impaired physical mobility
Nursing Intervention for Deep Vein Thrombosis
• Monitor vital signs .
• Monitor for signs of pulmonary embolism, shortness of breath, chest pain,
tachycardia (rapid heart rate), tachypnea (rapid respirations), and diaphoresis
• Monitor for signs of bleeding or bruising.
• Avoid massaging the area to lessen the possibility of dislodging the clot.
• Intermittent warm, moist soaks. Assess skin between changes.
• Follow weight-dosed heparin protocol.
• Monitor lab results: PT, PTT, INR, and CBC with platelets.
• Low molecular weight heparin (enoxaparin, dalteparin).
• Warfarin orally.
• Instruct patient to:
• Report signs of bleeding or bruising to physician, nurse practitioner, or
• Avoid injury.
• Use of electric razor and soft toothbrush; avoid flossing between teeth.
• Diet restrictions, and to check with health care provider or pharmacist
about interactions of any medications, if on warfarin as outpatient.
Medical-Surgical Nursing Demystified