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TL Thrombophlebitis
Nursing of the adult with thrombophlebitis
| Question | Answer |
|---|---|
| Define Thrombophlebitis. | Inflammation of the venous wall with the formation of a clot |
| What are some other names for thrombophlebitis? | DVT, Phlebothrombosis, venous thrombosis |
| What might the nurse find on assessment of a patient with Thrombophlebitis? | positive Homan sign, calf pain, functional impairment of the affected extremity, edema and warmth of the extremity, asymmetry, pain with gentle touch |
| How reliable is Homan sign? | Only about 10% of patients with phlebitis manifest Homan sign and there are many false positives |
| What does a positive Homan sign indicate? What else could illicit a positive Homan sign? | early thrombophlebitis; muscle inflammation |
| Why is it important not to perform the Homan sign if thrombosis has been confirmed? | Can precipitate embolism |
| What assessments does the nurse make to check for asymmetry related to thrombophlebitis? | Inspect legs from groin to feet; measure diameter of calves |
| What diagnostic tests could confirm an occlusion of a vein? | Venogram, Dopplar ultrasound, Fibrinogen scanning |
| Give 8 risk factors for thrombophlebitis. | Prolonged strict bed rest, general surgery, leg trauma, previous venous insufficiency, obesity, oral contraceptives, pregnancy, malignancy |
| Give a couple applicable nursing diagnoses for a patient with thrombophlebitis. | Ineffective tissue perfusion; pain |
| Why is it so important not to cause tissue damage when giving heparin subQ? | because the clotting mechanism is prolonged tissue damage could lead to bleeding |
| How should SubQ heparin be administered? | No massaging or aspiration – give in the abdomen between the pelvic bones and 2 inches below umbilicus, rotate injection sites |
| What type of prescription would you anticipate for the patient with thrombophlebitis? | Anticoagulant |
| What is the main side effect that the nurse should watch for when the patient is taking an anticoagulant? | bleeding |
| Name 2 lab values that are important to determine the efficacy of heparin. | PTT and APTT |
| What is the goal PTT value for a patient on heparin? | 1.5 to 2.5 the normal control value |
| What is the antidote for heparin? | Protamine sulfate |
| What are the lab values that tells us if Coumadine is effective? | PT and INR |
| What are the goal numbers for Coumadine effectiveness? | PT - 1.5 -2.5 times normal control, INR – 2-3 seconds |
| What drug’s effectiveness is measured by PTT? | Heparin |
| What drug’s effectiveness is measured by PT? | Coumadine |
| When performing venipuncture on a patient with thrombophlebitis how do we minimize the possibility of hematoma formation? | apply pressure to the venipuncture site |
| When the patient is receiving anticoagulant the nurse should report any signs of unusual bleeding. Name 6 possible sources of unusual bleeding. | Vaginal bleeding, nosebleed, melena, hematuria, gums, hemoptysis |
| What advice and teaching should the patient on anticoagulants for thrombophlebitis receive? | soft toothbrush/waxed floss; safety razor, no alcoholic beverages or aspirin, wear antiembolic stocking/medical alert symbol, elevate extremities, strict bed rest if prescribed – no potty privileges, avoid straining, increased risk for future DVT |
| What are some things we watch for when our patient is being treated for thrombophlebitis? | bleeding, decreasing symptomology (pain, edema), development of pulmonary embolism (chest pain, shortness of breath) |
Created by:
Perseverandovercome
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