Primary Nursing Diagnosis

Altered peripheral tissue perfusion related to obstructed venous blood flow

OUTCOMES. Tissue integrity: Peripheral; Tissue integrity: Skin and mucous membranes; Circulation status

INTERVENTIONS. Circulatory care; Laboratory monitoring; Peripheral sensation management; Positioning; Skin surveillance; Embolus precautions; Embolus care: Peripheral

H PLANNING AND IMPLEMENTATION Collaborative

To prevent thrombus formation, most physicians prescribe compression of the legs by graduated compression stockings to reduce venous stasis in low-risk general surgical patients. In higher-risk patients, intermittent pneumatic compression boots prevent venous stasis and increase the normal breakdown of fibrin in the body with increased fibrinolytic activity.

Most patients who develop thrombophlebitis are placed on bedrest with extremity elevation to avoid dislodging the thrombus. Local heat with warm soaks may also be used to reduce venospasm and decrease inflammation. Generally, the patient is given analgesics for pain control and anticoagulant therapy, initially with heparin, to prevent further clot formation. From 1 to 3 days later, warfarin (Coumadin) therapy is started. Heparin is usually discontinued 48 hours after the patient's prothrombin time (PT) reaches a therapeutic value (Box 1).

Some patients may continue heparin subcutaneously for several weeks before changing to warfarin. Because prothrombin assays are performed in various ways, PT results are now also reported as an International Normalized Ratio (INR). The target INR for oral anticoagulation is at least 2.0; current recommendations are to stop heparin therapy after 5 to 7 days ofjoint therapy when the INR is 2.0 to 3.0 with the patient off heparin. For patients with massive DVT in proximal veins, thrombolytic therapy may be considered. Before initiating therapy, the risk that the clot presents to the patient is compared with the risk of bleeding from thrombolytic agents.

SURGICAL. Other treatments that may be used for severe, obstructive DVT are thrombectomy (surgical clot removal) and surgical prophylaxis against pulmonary embolism (implantation of a Greenfield filter or an umbrella filter in the inferior vena cava). If a filter device cannot be placed, the inferior vena cava may be tied off (ligated) or stitched (plicated) to limit movement of emboli.

894 Thrombophlebitis

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