On the thrombophlebitis by AHN ppt ashe.pptx

WOLLEGA UNIVERSITY
INSTITUTE OF HEALTH SCIENCE
SCHOOL OF NURSING AND
MIDWIFERY
POSTGRADUATE PROGRAM OF
ADULT HEALTH NURSING
Presentation of Thrombophlebitis
By : Ashenafi Tesfaye
Ashenafi Tesfaye (Thrombophlebitis) 1

Presentation Outline
Thrombophlebitis
Superficial venous thrombosis
 Deep venous thrombosis
Clinical manifestation
Diagnosis
Management
Reference

Objectives
• At the end of this session the learners will be able to:
Explain the assessment & diagnostic Thrombophlebitis
 Describe the nursing role and medical management of the
patient with Thrombophlebitis.
 Explain the prevention of thrombophlebitis.

THROMBOPHLEBITIS

Brian storming
What is Thrombophlebitis ???

Superficial vein

Anatomy and physiology…

DEFINITION
• Thrombo” means “Clot”.
• Phlebitis is an inflammation of a
vein.
• Thrombophlebitis occurs when a
blood clot causes inflammation in a
vein.
• Blood clots typically form in the
legs or pelvis.

Venous Thrombosis (phlebothrombosis)
- Venous thrombosis affects veins of the lower extremity in 90% of
cases(in the superficial or deep veins of the leg).
A) Superficial venous thrombosis
- Usually occur in Superficial saphenous Varicose Veins of Legs
particularly when there are varicosities
- Blood clots with inflammation in superficial veins (called
superficial thrombophlebitis or phlebitis) rarely cause serious
problems.

- Such thrombi can cause local congestion, local edema, pain, and
tenderness along the course of a superficial vein and secondary
ischemic skin changes including stasis dermatitis and ulcerations
after slight trauma.
- Poor wound healing and superimposed infections can become
chronic varicose venous ulcers.
- The medial lower leg and ankle is the most common site.

B. Deep venous thrombosis (DVT)
• DVT involving one of the large leg veins—at or above the knee
(e.g., the popliteal, femoral, and iliac veins)—is more serious
because such thrombi more often embolize to the lungs and give
rise to pulmonary infarction
• Although DVTs may cause local pain and edema due to venous
obstruction.
• DVTs are asymptomatic in approximately 50% of affected
individuals and are recognized only in retrospect after
embolization.

Deep Venous thrombosis

Formation of a venous clot depends on the presence of at least of one
of Virchow’s triad factors:
- venous stasis
- injury to the vessel wall
- hypercoagulable state

Risk Factors
General
• Age >60
• smoking
• Immobilization
• Pregnancy and the postpartum
period
• Major surgery
• Long plane or car trips
Medical
• Cancer
• Previous DVT
• Stroke
• Sepsis
• Nephrotic syndrome
• Ulcerative colitis
• Protein deficiency
• Obesity

ETIOLOGY
 Varicose disease
Lung cancer
 Blood clotting disorders( Thrombophilia)
 Strokes
Trauma

PATHOPHYSIOLOGY
o Vascular endothelial injury reliably results in thrombus
formation by triggering an inflammatory response that results
in immediate platelet adhesion.
oThrombi usually form at the venous cusps of deep veins where
altered or static blood flow causes clot formation
o The leg is white due to arterial spasm secondary to massive
iliofemoral thrombosis, often mistaken for arterial occlusion.

PATHOPHYSIOLOGY
oPost phlebitic syndrome (PPS) may develop after the resolution of a
DVT
o PPS is due to valvular incompetence, persistent outflow
obstruction, and abnormal microcirculation.
o PPS can be difficult to differentiate from recurrent DVT due to
pain, swelling, and ulceration of the skin.
o Up to one-third of the patients with DVT can develop PPS.

Major risk
 chronic diseases
Trauma and surgery
 Pregnancy and oral
contraceptives usage
Major sign and symptom
 Tenderness
 Limb swelling
 Pulmonary embolism was
the greatest complication

Areas to Avoid setting IV Cannulae
Areas of joint flexion
 Hardened / Sclerosed veins
 Veins near arteries
 Veins in lower extremities
 Areas of surgery
 small veins
 Previously cannulated veins

SCORE 0
IV site appears healthy

Score 2
Two of the following signs are evident:
- Pain at IV site (pain score 4-6)
- Redness near IV site or
- Swelling
 interferes with activities

SCORE 3
All of the following signs are evident:
- Pain along path of cannula – Moderate pain
(pain score 4-6 )
- Redness around site
- Swelling
- Warmth
 Interferes with concentration

SCORE 4
All of the following signs evident and extensive:
- Pain along path of cannula - severe pain (pain score 7-9)
- Redness around IV site
- Swelling
- Palpable venous cord
 Interferes with basic needs

SCORE 5
All of the following signs are evident & extensive:
- Pain along the path of cannula (worst pain possible) Pain score 10
- Redness around IV site
- Swelling palpable venous cord
- Pyrexia
 Bed rest required

NURSING RESPONSIBILITIES:-
1. Hand Hygiene:-
Hands are decontaminated immediately
before and after each episode of patient
contact using the correct hand hygiene
technique.

2. Observe aseptic technique :-
 Alcohol wipes are used to decontaminate port
and surrounding area, and allowed to dry prior to
the administration fluid or injections via the
cannula.
 Patency is maintained.

3. Monitoring :-
 Monitor intravenous therapy
Check the infusion and the IV cannulation
site at least every 4 hours or when necessary
 Flow of fluid
 IV site: erythema, wetness, and edema
 Phlebitis
 Infiltration
Assess for chills, fever, headache, nausea,
vomiting, anxiousness, and dyspnea.
 Cannula should be removed where it is no
longer indicated. Ashenafi Tesfaye (Thrombophlebitis) 32

4. Dressings:-
 A sterile, semi-permeable, transparent dressing is used allowing
observation of the insertion site made accessible.
 Ensure that the IV line is anchored & secured properly.

5. Cannula replacement:-
 Resite cannula after 72 hours or as clinically
indicated eg. blood transfusion eg. Size 18G
 Document each time after the change of IV site.

6. Documentation:-
Document in Thrombophlebitis observation chart and in
the Patient’s case notes the date and time of removal of
cannula and signature of the nurse undertaking the task.

CLINICAL SYMPTOMS AND SIGNS
• Pain in the part of the body affected
• Warmth
• Tenderness
• Fever
• Skin redness or inflammation
• Swelling (edema) of the extremities (thigh, leg, ankle and
foot).

Clinical features
Clinical signs and symptoms of PE
In patients with angiographically proven PE, DVT is found
• Unilateral edema
• Bluish discoloration
• Absent or decreased pulse

Diagnosis
History
Physical examination(work up)
Blood test
D-dimer
Imaging study
 MRI , U/S, venography

Physical Examination
• Homans' test : Dorsiflexion of foot elicits pain in posterior calf.
Warning: it must be noted that it is of little diagnostic value and
is theoretically dangerous because of the possibility of
dislodgement of loose clot.
• Pratt's sign: Squeezing of posterior calf elicits pain.

Blood test
 Complete blood count
 Primary coagulation studies
 Renal function test and electrolytes
 Liver function test

D-dimer testing :
• D-dimer antibodies account for their high sensitivity for venous
thromboembolism.
• D-dimer level may be elevated in any medical condition where clots form.
• D-dimer level is elevated in trauma, recent surgery, hemorrhage, cancer, and
sepsis.
• The D-dimer assays have low specificity for DVT; therefore, they should only
be used to rule out DVT, not to confirm the diagnosis of DVT.

D-dimer results should be used as follows:
 A negative D-dimer assay result rules out DVT in
patients with low-to-moderate risk and a Wells DVT
score less than 2.
 All patients with a positive D-dimer assay result and all
patients with a moderate-to-high risk of DVT (Wells
DVT score >2) require a diagnostic study (duplex
ultrasonography).

Duplex ultrasonography ultrasonography
• Technological advances in ultrasonography have permitted the
combination of real-time ultrasonographic imaging with Doppler
flow studies (duplex ultrasonography).
• The absence of the normal phasic Doppler signals arising from the
changes to venous flow provides indirect evidence of venous
occlusion

Duplex x ultrasonography
73%
Sensitivity in calf vein
97%
Sensitivity in proximal vein
95%
Specificity

Advantage
 helpful to differentiate venous
thrombosis from hematoma,
abscess, and other causes of
leg pain and edema.
Disadvantage
 Venous thrombi proximal to
the inguinal ligament are
also difficult to visualize
 not be able to differentiate
between old and new clots

CT venography(gold stander)
• The gold standard is intravenous venography, which involves
injecting a peripheral vein of the affected limb with a contrast agent
and taking CT, to reveal whether the venous supply has been
obstructed.
• A number of small studies have compared CT venography alone to
duplex ultrasonography alone for the diagnosis of lower extremity
DVT.
• Similar high sensitivities for ultrasonography and CT have been
reported

Complications of deep vein thrombosis
There are two main complications of deep vein thrombosis (DVT):
1.pulmonary embolism
2. post-thrombotic syndrome
- occurs in 15% of patients with deep vein thrombosis (DVT).
- It presents with leg oedema, pain, nocturnal cramping, venous
claudication, skin pigmentation, dermatitis and ulceration (usually
on the medial aspect of the lower leg).

Management
• Non-pharmcological
we can reduce risk of DVT by making changes to patient lifestyle,
such as:
Avoid smoking
 Eating a healthy balanced diet
 Getting regular exercise and
 Maintaining a healthy weight or losing weight if patient obese
• Rise leg , This reduces the pressure in the calf veins

Cont.…
Drink enough amount of water
Perform simple leg exercises, such as regularly flexing
ankles
 Take occasional short walks when possible
 Wear elastic compression stockings
 Elevate the affected area to reduce swelling.
 Keep pressure off the area to reduce pain and decrease
the risk of further damage.

Compression stockings
• Elastic compression stockings should be routinely applied
"beginning within 1 month of diagnosis of proximal DVT
and continuing for a minimum of 1 year after diagnosis
• use knee-high stockings to reduced incidence of post-
phlebitic syndrome.

Medications:
Analgesics(pain medications)
 Anticoagulants e.g. warfarin or heparin to prevent new clot
formation
 Thrombolytics to dissolve an existing clot such as
intravenous streptokinase.
 Nonsteroidal anti-inflammatory medications (NSAIDS) such
as ibuprofen to reduce pain and inflammation.

Surgery for DVT
Indication
 Anticoagulant therapy is ineffective
Unsafe
Contraindication
 The major surgical procedures for DVT are clot removal and partial
interruption of the inferior vena cava to prevent PE

Prevention
• Routine changing of intravenous (IV) lines helps to prevent
phlebitis related to IV lines.
• See the specific disorders associated with thrombophlebitis
for other preventive measures.

Reference
Medical-surgical nursing, 14th ed - brunner & suddarth
American family physicians
Canadian family physicians

Thank you

On the thrombophlebitis by AHN ppt ashe.pptx

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