04.08 Thrombophlebitis (clot)

Overview

Thrombus (clot) formation with associated inflammation in extremity.

Nursing Points

General

  1. Thrombus v. Embolus
  2. Risk Factors
    1. Virchow’s Triad
      1. Venous stasis
      2. Damage to inner lining of vessel
      3. Hypercoagulability of blood
    2. Medical History
      1. History of thrombophlebitis
      2. Pelvic surgery
      3. Obesity
      4. HF, MI
      5. A-fib
      6. Immobility
      7. Pregnancy
      8. IV therapy

Assessment

  1. Unilateral findings on affected side
    1. Pain
    2. Warm skin
    3. Redness
    4. Tenderness
    5. Febrile state
    6. Homan’s sign – pain on dorsiflexion of foot**

**Not reliable or specific. Only 33% of patients with DVT are positive. No longer recommended for standard practice. This maneuver can also dislodge the clot**

  1. Confirm clinical picture with diagnostics:
    1. Ultrasound
    2. D-Dimer (positive)

Therapeutic Management

If patient has confirmed DVT:

  1. NO SCD/TED, NO massage, Bedrest.
    1. Could dislodge clot
  2. Initiate anticoagulant therapy
    1. Heparin
      1. Monitor PTT q6h
    2. Coumadin (warfarin)
      1. Monitor PT/INR
  3. IVC filter
    1. Sits in Inferior Vena Cava
    2. Collects clots before they reach the heart/lungs

Nursing Concepts

  1. Perfusion
    1. Monitor for s/s Emboli
      1. Heart – MI
        1. Chest Pain (CP)
      2. Lungs – Pulmonary Embolism
        1. Anxiety
        2. SOB
        3. ↑ HR
        4. ↑ RR
        5. CP
      3. Brain – Stroke
        1. Facial droop
        2. Arm Weakness
        3. Speech Difficulty
    2. Monitor distal pulses
    3. Elevate legs 10-20 minutes q2h
  2. Clotting
    1. Monitor circumference of limb BID
    2. SCD/TED + Lovenox
    3. Passive ROM
    4. Early ambulation
  3. Comfort
    1. Administer analgesics

Patient Education

  1. Smoking Cessation (↑ risk of clots, vasoconstriction)
  2. Avoid long periods of sitting
  3. S/S to report to HCP or RN
  4. Importance of early ambulation

Reference Links

Instantly Unlock over 1000+ Nursing Lessons

Create Your Free Account

Get Started

Video Transcript

Okay, let’s talk about Thrombophlebitis. But first, let’s break down this word – we know that ‘itis’ means inflammation, right? What about “phleb”? Think about ‘phlebotomy’ – it’s referring to the veins! Then “thrombo” refers to a “thrombus” or a blood clot. So this is inflammation of the veins because of a clot – make sense?

Now, we know in the blood we’ve got things in there like platelets and fibrin and clotting factors to help us clot when we need to, right? Sometimes, for reasons we’ll discuss in just a minute, a clot can form within the vessel that really shouldn’t be there. So in thrombophlebitis, a clot forms in the vein and causes inflammation. This causes more clotting and it just perpetuates itself. Now, what can happen is that this clot that has formed and gotten bigger here can actually break off from the vessel wall – even just pieces of it can break off. When that happens and the thrombus begins to travel through the circulatory system, it’s called an Embolus. The problem here is that it is heading for the heart – it can get lodged in the coronary arteries and cause an MI, it could go to the lungs and cause a Pulmonary Embolism or PE, or it could go to the brain and cause an ischemic stroke. So none of that is good, it’s important that we manage this issue.

So what causes thrombophlebitis? Well there’s something called Virchow’s Triad. Virchow’s triad tells us the three main things that create ideal conditions for clot formation. The first one is venous stasis – that happens when the blood is pooling and isn’t returning to the heart like it should. This happens a lot with our patients who are bedbound and not ambulatory. The second is any damage to the inner lining or the intima of the blood vessel. Any time there’s damage here, a clot can form around it. And finally hypercoagulability which is caused by various conditions that make the patient much more prone to clotting. So things you might see in the patient’s medical history to tell you they’re at risk would be a previous DVT – obviously it has happened before so it can happen again. Obesity is a risk factor. Any cardiovascular disorders like Heart Failure or MI can cause damage to the vessels. Then A-Fib puts them at risk because when the atria are just quivering, that causes blood to pool in the atria. That stasis of blood can cause clots to form which can be ejected out of the heart and get lodged in an extremity – and we call that a DVT. Now, it can also go to the lungs or brain and cause a PE or Stroke as well. Immobility again causes venous stasis. Pregnancy because of some venous pooling but also they’re hypercoagulable. And then any patient receiving IV therapy because we have damaged the vessel by placing that IV. Okay – that’s, like, every patient in the hospital, right?? So that’s why when patients are admitted to the hospital, we put everyone on what we call DVT Prophylaxis. That’s SCDs or TED hose/compression stockings, and usually either SubQ heparin or SubQ lovenox (enoxaparin). We’re trying to prevent this from happening in the first place.

Now, if it does happen, what will we see in the patient? Symptoms will be unilateral meaning they’ll only be on the affected side. You can see here the patient’s right leg is affected. We see swelling, or edema, pain, the skin will be warm to the touch and probably red as well. Now…for years they’ve been teaching Homans Sign, which is pain with dorsiflexion of the foot, as an indicator of DVT. But the truth is that only 33% of people who have a DVT will have a positive Homans sign. Not only that but 20% of people without a DVT will have a positive Homan’s sign. So Evidence-Based Practice shows that it is actually unreliable and nonspecific and really shouldn’t be used as standard practice. Not to mention it can actually dislodge the clot if we aren’t careful. So, instead, we will confirm our other clinical findings with an ultrasound and/or a D-dimer assay – that’s a lab test that indicates clotting is present in the body.

Now, I did my research on this because the question I always get is “yeah, but will it be on the NCLEX?”. I checked on the NCSBN’s website and found this quote. Essentially they’re saying it’s not reliable and we need to be sure to use the whole clinical picture. So I want you guys to know about it and know that it exists, but understand that it cannot be your only sign, okay?

So – we’ve assessed the patient and now they have a confirmed DVT – what do we do? Well the first thing you need to do as the nurse is take off the SCDs or TED hose. Think about it – if this is their leg and they have a clot in here – and we squeeze it every 30 seconds – what could happen? It could break off, right? For the same reason we do not allow leg massages and we put the patients on bedrest until we can address the clot. The provider will likely order anticoagulants unless there’s a reason they can’t have them. For example, in the Neuro ICU we’ve seen patients develop DVTs who are recovering from a hemorrhagic stroke – we can’t give them an anticoagulant – they just had a brain bleed! Now, if we DO anticoagulate, it will usually start with a weight-based heparin drip and transition to PO warfarin. Remember with heparin we monitor PTT and with Warfarin we monitor PT/INR.

If we can’t anticoagulate, and even sometimes if we can we’ll do both, we’ll insert an IVC filter. IVC stands for inferior Vena Cava. An IVC filter looks like this, like a little claw with a filter. We’ll go in through the femoral vein and it will sit right up here in the inferior vena cava so it can catch any clots that may migrate towards the heart. Typically they’ll be removed after a few weeks, once the patient has adequate anticoagulation on board.

So when it comes to nursing care for these patients, the top priorities are going to be perfusion, clotting, and comfort. In terms of perfusion we want to assess distal pulses and monitor for any signs of embolus to the heart, lungs, or brain. To address clotting we’ll administer anticoagulants, monitor the circumference of their leg, and encourage mobilization. Then, of course, we’ll address their pain with analgesics. You can see more nursing interventions in the outline and the care plan attached to this lesson, but those are the big ones.

So remember that Virchow’s Triad tells us what puts patients at high risk for thrombophlebitis – it’s venous stasis, vascular damage, and hypercoagulability. If a patient does develop a DVT, you’ll see swelling, pain, warmth, redness, and tenderness on the affected side. You might also have a positive Homan’s sign, but remember that it’s not reliable. Our biggest goal is to prevent embolism, so if they do have a clot, we’ll put them on bedrest while we get them anticoagulated and place an IVC filter. Our nursing priorities are under the concepts of perfusion, clotting, and comfort. And finally, remember that prevention is key – identify patients who may be at risk and implement DVT prophylaxis – that’s SCD’s, TED hose, and usually SubQ Heparin or Lovenox.

This is a really common thing that affects nearly every patient in the hospital, so we want you to be confident knowing how to deal with it. Go out and be your best selves today! As always, happy nursing!

Read more

  • Question 1 of 10

You have a patient who has a DVT. Their ABCs are intact, what is the priority intervention for this patient?

  • Question 2 of 10

The nurse is caring for a client who is taking warfarin. Which of the following client conditions would warrant a prescription for this medication? Select all that apply.

  • Question 3 of 10

A client is being discharged home from the hospital after being treated for a deep vein thrombosis (DVT). The client will need education on the anti-thrombotic that the client will be taking at home. Which of the following medications is an anti-thrombotic?

  • Question 4 of 10

A nurse is teaching a 67-year-old patient with a blood clot who has developed edema in the lower legs and feet. Which intervention should the nurse direct the client to perform to control fluid and promote tissue perfusion?

  • Question 5 of 10

The nurse is caring for a client with newly diagnosed atrial fibrillation. Which medication class does the nurse anticipate the client will need to take to prevent the formation of blood clots?

  • Question 6 of 10

A cardiac client is at high risk of developing a DVT during the post-op period following heart surgery. The factors that increase a client’s risk of developing a DVT, known as Virchow’s triad, include venous stasis, hypercoagulability, and which of the following?

  • Question 7 of 10

A nurse is teaching a client who has trouble with mobility about how best to decrease the risk of a blood clot. Which of the following statements made by the nurse is correct?

  • Question 8 of 10

The nurse elicits a positive Homan’s sign. The nurse knows this is a sign of which of the following?

  • Question 9 of 10

A nurse is caring for a 35-year-old client who suffered a pulmonary embolism an hour after she delivered a baby. The nurse knows that a pulmonary embolism is the result of a clot that lodges in the pulmonary artery after breaking off from a thrombus in another location. Which of the following are the most common sites of formation of the initial thrombus?

  • Question 10 of 10

A client is recovering from a heart transplant surgery and is at risk of blood clots because of immobility status. Which of the following interventions is a priority for the nurse in this scenario?