1. General information
    1. Inflammation of the vessel wall with formation of a clot (thrombus); may affect superficial or deep veins.
    2. Most frequent veins affected are the saphenous, femoral, and popliteal.
    3. Can result in damage to the surrounding tissues, ischemia, and necrosis.
    4. Risk factors: obesity, CHF, prolonged immobility, MI, pregnancy, oral contraceptives, trauma, sepsis, cigarette smoking, dehydration, severe anemias, venous cannulation, complication of surgery
  2. Medical management
    1. Anticoagulant therapy
      1. Heparin
        1. blocks conversion of prothrombin to thrombin and reduces formation or extension of thrombus
        2. side effects: spontaneous bleeding, injection site reactions, ecchymoses, tissue irritation and sloughing, reversible transient alopecia, cyanosis, pain in arms or legs, thrombocytopenia
      2. Warfarin (coumadin)
        1. blocks prothrombin synthesis by interfering with vitamin K synthesis
        2. side effects
          1. GI: anorexia, nausea and vomiting, diarrhea, stomatitis
          2. hypersensitivity: dermatitis, urticaria, pruritus, fever
          3. other: transient hair loss, burning sensation of feet, bleeding complications
    2. Surgery
      1. Vein ligation and stripping (see Thrombophlebitis)
      2. Venous thrombectomy: removal of a clot in the iliofemoral region
      3. Plication of the inferior vena cava: insertion of an umbrella-like prosthesis into the lumen of the vena cava to filter incoming clots
  3. Assessment findings
    1. Pain in the affected extremity
    2. Superficial vein: tenderness, redness, induration along course of the vein
    3. Deep vein: swelling, venous distension of limb, tenderness over involved vein, positive Homan's sign, cyanosis
    4. Elevated WBC and ESR
    5. Diagnostic tests
      1. Venography (phlebography): increased uptake of radioactive material
      2. Doppler ultrasonography: impairment of blood flow ahead of thrombus
      3. Venous pressure measurements: high in affected limb until collateral circulation is developed
  4. Nursing interventions
    1. Provide bed rest, elevating involved extremity to increase venous return and decrease edema.
    2. Apply continuous warm, moist soaks to decrease lymphatic congestion.
    3. Administer anticoagulants as ordered
      1. Heparin
        1. monitor PTT; dosage should be adjusted to keep PTT between 1.5-2.5 times normal control level.
        2. use infusion pump to administer IV heparin.
        3. ensure proper injection technique.
          1. use 26- or 27-gauge syringe with 1/2-5/8-in needle, inject into fatty layer of abdomen above iliac crest.
          2. avoid injecting within 2 inches of umbilicus.
          3. insert needle at 90° to skin.
          4. do not withdraw plunger to assess blood return.
          5. apply gentle pressure after removal of needle, avoid massage.
        4. assess for increased bleeding tendencies (hematuria; hematemesis; bleeding gums; petechiae of soft palate, conjunctiva, retina; ecchymoses, epistaxis, bloody sputum, melena) and instruct patient to observe for and report these.
        5. have antidote (protamine sulfate) available.
        6. instruct client to avoid aspirin, antihistamines, and cough preparations containing glyceryl guaiacolate, and to obtain physician's permission before using other OTC drugs.
      2. Warfarin (Coumadin)
        1. assess PT daily; dosage should be adjusted to maintain PT at 1.5-2.5 times normal control level; INR of 2.
        2. obtain careful medication history (there are many drug-drug interactions).
        3. advise client to withhold dose and notify physician immediately if bleeding or signs of bleeding occur (see Heparin, above).
        4. instruct client to use a soft toothbrush and to floss gently.
        5. have antidote (vitamin K) available.
        6. alert client to factors that may affect the anticoagulant response (high-fat diet or sudden increases in vitamin K-rich foods).
        7. instruct client to wear Medic-Alert bracelet.
    4. Assess vital signs every 4 hours.
    5. Monitor for chest pain or shortness of breath (possible pulmonary embolism).
    6. Measure thighs, calves, ankles, and instep every morning.
    7. Provide client teaching and discharge planning concerning
      1. Need to avoid standing, sitting for long periods; constrictive clothing; crossing legs at the knees; smoking; oral contraceptives
      2. Importance of adequate hydration to prevent hypercoagulability
      3. Use of elastic stockings when ambulatory
      4. Importance of planned rest periods with elevation of the feet
      5. Drug regimen
      6. Plan for exercise/activity
        1. begin with dorsiflexion of the feet while sitting or lying down
        2. swim several times weekly
        3. gradually increase walking distance
      7. Importance of weight reduction if obese