THROMBOPHLEBITIS

THROMBOPHLEBITIS

inflammation of a vein accompanied by the formation of a clot

THROMBOPHLEBITIS

more common in women than in men and among hospitalized clientsalso in one third of clients older than 40 years who have had a major surgery, orthopedic surgery, or an AMIhigh risk if client is with cancer or family history of clotting disorders

PREVALENCE

Prevalence

THROMBOPHLEBITIS PATHOPHYSIOLOGY

Virchow’s Triad

PathophysiologyEndothelial

Damage

Venous Stasis

Hypercoagulability


Venous Stasis


Hypercoagulability


Endothelial Damage


Review of Clot Formation

THROMBOPHLEBITIS CLINICAL MANIFESTATIONS

Clinical Manifestations

Superficial Thrombophlebitisredness (rubor), induration, warmth (calor), and tenderness along a veinrisk of becoming emboli is very low



Deep Vein Thrombosisabout half of clients are asymptomaticunilateral leg swelling (larger circumference)pain, redness or warmth of the legdilated veinslow-grade feverfirst clinical manifestation may be Pulmonary EmboliHoman’s Sign – discomfort in the upper calf during forced dorsiflexion of the foot

present in less than one third of clients with DVTmore than half of clients with (+) Homan’s sign do not have venous thrombosis


Site of Thrombus Formation According to Physical FindingsVenous 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 thrombosisPain and tenderness in the distal thigh and popliteal area

Ileofemoral thrombusSwelling, pain and tenderness over the entire extremity


THROMBOPHLEBITISLaboratory & Diagnostic

ProceduresComplete Blood Count

elevated WBC countelevated sedimentation rate

Venous Duplex/ Color Duplex UTZnoninvasive test for visualization of the thrombus including any free-floating or unstable thrombi that may cause embolimost effective in detecting thrombus in lower extremities

LABORATORY & DIAGNOSTIC PROCEDURES

Impedance Pletysmographynoninvasive measurement of changes in calf volume corresponding to changes in blood volume brought about by temporary venous occlusion with a high-pneumatic cuffelectrodes measure electrical impedance as cuff is inflatedSlow decrease in impedance indicates diminished blood flow associated with thrombus

THROMBOPHLEBITIS LABORATORY & DIAGNOSTIC PROCEDURES


RF (radioactive fibrinogen) TestingRF administered IV images are taken through nuclear scanning at 12-24 hoursRF will be concentrated at the area of clot formation

VenographyIV injection of a radiocontrast agentvascular tree is visualized and obstruction is identified


D-dimer Blood TestD-dimer is a product of fibrin degradationindicative of fibrinolysis, which occurs with thrombosis


Goalsdetect the thrombus earlyprevent extension or embolization (PE) of the thrombusprevent further/recurrent thrombus formationlimit venous valvular damage

THROMBOPHLEBITIS MEDICAL MANAGEMENT

Medical Management

Preventive Measuresleg 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 ambulatorygood alternative to clients who cannot tolerate anticoagulationshould not be used in clients with known DVT


elevating the foot of the bedapplying compression stockingspassive ROM exerciseencouraging postoperative deep breathing exercise promotes thoracic pullWarfarin, ASA, unfractioned Heparin, LMW heparin

unfractioned Heparin administered subQcommon site is the fatty area anterior to either iliac crestavoid injection site within 2 inches of umbilicus to prevent entry to a large blood vessel


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 needleDO 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

Dalteparin (Fragmin) 2500 IU SC ODEnoxaparin (Clexane) 20 mg/0.2 ml SC ODNadroparin (Fraxiparine) 0.3-0.4 ml SC OD


avoid using pillows under the clients knees postoperativelyteach client to avoid sitting or standing in one position for prolonged periodsavoidance of infiltration during intravenous therapy


Anticoagulationto prevent initiation or extension of thrombiinhibit the synthesis of clotting factors/ accelerate their inactivationdo not break up or dissolve clots, rather, prevent clots from formingintermittent/ continuous IV infusion of Heparin for 5 to 7 days

prevent extension of a thrombus and development of a new thrombi


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 therapyrange of 700 to 1400 units/hrpreferred delivery by electronic infusion device to prevent infusion of large volumes


if PTT elevated, assessment of bleeding or bruising and institution of bleeding precautions

avoidance of injectionsbrushing teeth with a soft sponge devicesupervision with ambulation to prevent fallsincrease intake of fiber and fluids to prevent straining and constipation

be ready with antidote: Protamine SO4slow IV injection administration to minimize bradycardia and hypotensioncan be used with LMWH but more effective on Heparin


Injected LMWHlonger 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 monitoringdoses are adjusted according to weight

Dalteparin (Fragmin) 100 IU/kg SC BIDEnoxaparin (Clexane) 1 mg/kg SC BIDNadroparin (Fraxiparine) 0.9 mg/kg

extremely high bioavailability and more predictable pharmacokinetics


fewer bleeding complicationsmay be used safely in pregnant womenpatient is more mobile and have an improved quality of life


Coumadin (Warfarin/Coumarin)oral anticoagulantlong-term anticoagulant after acute DVT has been treated with injectable Heparin3-5 days half-life (3-5 days to effect)

stopped 3 days before any invasive procedureusually administered concurrently with heparin until desired anticoagulation has been achieved

prescribed based on INR levels with therapeutic range of 2.0-2.5in the hospital, Warfarin is administered in the afternoon or early evening


for dose adjustments based on daily INR/PT results

warfarin antidote: Vit. K (phytonadione) PO/ low-dose IV


Nursing Considerations: Anticoagulationblood is sampled every 4-8 hrs. for PTT/INR for dose adjustmentif in Warfarin therapy, PT or INR should be drawn on a regular basisno testing for LMWHmonitoring/ managing bleeding

for invasive studies, apply pressure for 30 minutes to the puncture site; apply ice if patient is prone to bleeding


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 Heparinhigh risk for patients receiving Heparin for a prolonged period of time


autoimmune mechanism that causes destruction of plateletsregular monitoring of platelet counts

decreasing platelet countneed for increase dose of heparin to maintain therapeutic levelthromboembolic 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, alternate anticoagulant therapy rapidly initiated


Lepirudin (Refludan)½ life of 1.3H, excreted by the kidneys, monitored using aPTTinitial IV bolus infusion followed by subsequent infusions with subsequent adjustmentsmaintain aPTT between 1.5 – 2.5 times baselinestrict dosage adjustment in renal failure (clearance is proportional to patient’s creatinine clearance

Argatroban½ life of 30-45 minutes, metabolized by liver, unaffected by renal functioneffect is dose dependent and requires monitoring either aPTT/ACT


contraindications to therapy


lack of px cooperation severe hepatic or renal disease

bleeding from the ff. systems: GI, GU, Respiratory, Reproductive

recent cerebrovascular hemorrhage

hemorrhagic blood dyscrasias

infections

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

Thrombolytic Therapyadministration of thrombolytic agents to dissolve any formed thrombusfor parenteral use onlycommonly used include streptokinase (Streptase) and tissue plasminogen activator (t-PA)other drugs include reteplase (r-PA, Retavase), tenecteplace (TNKase), staphylokinase, urokinase, streptokinase


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 insufficiencythree-fold greater incidence of bleeding than heparin; d/c if bleeding occurs and cannot be stopped


Nursing Considerations: Thrombolyticsmonitor 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 holdaminocaproic acid (Amicar) on hand to treat bleeding

WOF allergic reactionnew rash, fever, chills


any suspected allergic reaction and report immediatelycorticosteroids to treat reaction

move patient as little as possibleminimize phlebotomy


Nonpharmacologic Therapybed rest with unfractioned heparin; if LMWH, patient is encouraged to walkelevation of extremity at least 10 to 20 degrees above the level of the heart (enhance venous return and decrease swelling)

pillows to support popliteal spaceif upper extremity, sling or stockinette attached to an IV pole may be used


compression (promotes venous return and reduces swelling)

electrically/ pneumatically controlled stockings, boots, or sleeveselastic stockings/ garments (30 to 40 mmHg)


when anticoagulant or thrombolytic therapy is contraindicateddanger of pulmonary embolism is extremevenous drainage is so severely compromised that permanent damage to the extremity is high

THROMBOPHLEBITIS SURGICAL MANAGEMENTSurgical

Management

Thrombectomyremoval of the thrombosisprocedure of choice

THROMBOPHLEBITIS SURGICAL MANAGEMENT


Inferior Vena Cava Filtertraps large emboli and prevents pulmonary embolipatient who has recurrent emboli in the presence of anticoagulation


Nursing Diagnosis: Acute Pain related to decreased venous blood flow

Nursing Interventions:elevate legs to promote venous drainage and reduce swellingapply warm compress or heating pad as directed to promote circulation and reduce pain

THROMBOPHLEBITIS NURSING MANAGEMENT

Nursing Management

check that water temperature is not too hotcover 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 bleedingavoid massaging/ rubbing calf because of danger of breaking up the clot, which can travel as embolus


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 elevatedprevent pressure ulcers that may occur over bony prominences (sacrum, hips, knees and heels)in side lying position, place a soft pillow between legs


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)

encourage adequate fluid intake, frequent changes in position, pulmonary toilet


• 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 popliteal vessel)


– if patient permitted OOB, encourage walking 10 min. every hour

– discourage crossing of legs and long periods of sitting to avoid compression of vessels


Date post:	15-Nov-2014
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THROMBOPHLEBITIS

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