- is swelling (inflammation) of a vein caused by a blood clot
- refers to thrombus formation on the wall of a vein with resulting inflammation
Signs and Symptoms:
• Vary depending on thrombus size, location, and adequacy of collateral circulation. May be asymptomatic
• SVT—Tenderness, redness, palpable cord-like vein, increased warmth over involved vein
• DVT—Unilateral edema, tenderness over involved vein, warm skin, elevated temperature, cyanosis of affected extremity, general malaise
Diagnosis: Ascending phlebography (injection of contrast medium into a vein), Doppler ultrasound, plethysmography (measures changes in fluid volume passing through a vessel), blood cultures, WBC, ESR, venous pressure measurement (high in affected limb until collateral circulation is developed)
Laboratory:
If the cause cannot be easily identified, one or more of the following tests may be done:
- Blood coagulation studies
- Doppler ultrasound
- Venography
• SVT—relief of symptoms and reversal of inflammation process
—Warm moist heat application
—Anti-inflammatory medications
—Antibiotic therapy
—Anticoagulants if condition is progressing
• DVT
—Anticoagulant therapy with heparin (APTT at 1.5–2 times the control) or with low molecular weight heparin (LMWH) such as enoxaparin (Lovenox) which is prescribed according to weight 1 mg/kg subcutaneously every 12 hours
—Bed rest with leg elevated
—Oral anticoagulation with warfarin (Coumadin) is initiated along with heparin and LMWH. Therapeutic international normalized ratio (INR) is 2.0–3.0
—Thrombolytic therapy with streptokinase, urokinase, or tissue plasminogen activator
—Surgical intervention: venous thrombectomy, transvenous filtration devise placed in the inferior vena cava
Nursing Process Elements
• Assess for risk factors
• Asses pain level
• Provide bed rest with elevation of affected extremity
• Apply continuous warm moist compresses if ordered
• Administer medications
—Heparin
■ Use infusion pump to administer IV heparin
■ Inject heparin into fatty layer of abdomen above iliac crest and 2 inches away from umbilicus
■ Insert needle at 90 degree angle
■ Do not aspirate
■ Apply pressure after injection but do not massage
■ Assess for S&S of bleeding: petechiae, epistaxis, bleeding gums
■ Have antidote protamine sulfate available
—Warfarin
■ Instruct client to use soft tooth brush and to maintain bleeding precautions
■ Have antidote vitamin K available
■ Instruct client on factors that may affect anticoagulant response
• Monitor laboratory values
• Apply antiembolic stockings if ordered
• Monitor for possible complications like pulmonary emboli
• Measure involved extremity daily
• Provide client teaching
