Nursing Care Plan for Postpartum Thrombophlebitis

Superficial thrombophlebitis is seen more often during the postpartal period than during pregnancy and is more common in women with preexisting varices. Postpartal deep vein thrombosis (DVT) and superficial thrombophlebitis have been attributed to trauma to pelvic veins from pressure of the presenting fetal part, sluggish circulation caused by mechanical edema, and alterations in coagulation related to the large amounts of estrogens produced during pregnancy. Thrombosis that involves only the superficial veins of the leg or thigh is unlikely to generate pulmonary emboli (PE). While approximately 50% of clients with DVT are asymptomatic, DVT is more serious in terms of potential complications, including PE, postphlebotic syndrome, chronic venous insufficiency, and vein valve destruction.

NURSING PRIORITIES
1. Maintain/enhance tissue perfusion, facilitate resolution of thrombus.
2. Promote optimal comfort.
3. Prevent complications.
4. Provide information and emotional support.

DISCHARGE GOALS
1. Tissue perfusion improved in affected limb/area
2. Pain/discomfort relieved
3. Complications prevented/resolved
4. Disease process/prognosis and therapeutic needs understood
5. Plan in place to meet needs after discharge

Nursing diagnosis for postpartum thrombophlebitis: altered peripheral tissue perfusion may be related to interruption of venous flow possibly evidenced by edema of affected extremity; erythema (superficial thrombophlebitis) or pallor and coolness (DVT), diminished peripheral pulses, pain.

Desired Outcomes:
1. Demonstrate improved circulation of involved extremity with palpable peripheral pulses of good quality, timely capillary refill, and decreased edema and erythema.
2. Engage in behaviors/activities to enhance tissue perfusion.
3. Display increasing tolerance to activity.

Nursing intervention with rationale:
1. Encourage bedrest with elevation of feet and lower legs 6 in above heart level during acute phase.
Rationale: Minimizes the possibility of dislodging thrombus and creating emboli. Rapidly empties superficial and tibial veins and keeps veins collapsed, thereby increasing venous return. Note: Caution is required in presence of leg ischemia.

2. Evaluate neurological function of extremity (both sensory and motor). Observe extremity for color; inspect from groin to foot for edema. Note asymmetry; measure and record calf/thigh circumference of both legs as appropriate. Report proximal progression of inflammation, traveling pain.
Rationale: Symptoms help distinguish between superficial thrombophlebitis and DVT. Redness, heat,tenderness, and localized edema are characteristic of superficial involvement. Pallor and coolness of extremity are more characteristic of DVT. Calf vein involvement of DVT is usually associated with absence of edema; mild to moderate edema suggests femoral vein involvement, and severe edema is characteristic of ileofemoral vein thrombosis.

3.Assess capillary refill, and check for Homans’ sign.
Rationale: Diminished capillary refill usually present in DVT. Positive Homans’ sign (deep calf pain in affected leg upon dorsiflexion of foot) is not as consistent a clinical manifestation as once thought and may or may not be present.

4. Instruct client to elevate legs when in bed or chair, as indicated. Periodically elevate feet and legs above heart level.
Rationale: Reduces tissue swelling and rapidly empties superficial and tibial veins, preventing overdistension and, thereby, increasing venous return. Note: Some physicians believe that elevation may potentiate release of thrombus, thus increasing risk of embolization and decreasing circulation to the most distal portion of the extremity.

5. Caution client not to cross legs or wear constrictive clothing.
Rationale: Physical restriction of circulation impairs blood flow, thus increasing venous stasis, pain, and trauma.

6. Instruct client to avoid rubbing and massaging the affected extremity.
Rationale: Prevents fragmentation/dislodging thrombus, which could lead to embolism.

7.Initiate active or passive exercises while in bed (e.g., flex/extend/rotate foot periodically). Assist with gradual resumption of ambulation (e.g., walking 10 min/h) as soon as client is permitted out of bed.
Rationale: These measures are designed to increase venous return from lower extremities and reduce venous stasis, as well as improve general muscletone/strength. They also promote normal organ function and enhance general well-being.

8. Encourage deep-breathing exercises.
Rationale: Produces increased negative pressure in thorax, which assists in emptying large veins.

9. Observe respiratory ease and auscultate lung sounds, noting crackles or friction rub. Investigate reports of chest pain or feelings of anxiety.
Rationale: Pulmonary congestion, sharp substernal chest pain, sudden apprehension, dyspnea, tachypnea, and hemoptysis are indicative of pulmonary emboli, especially in DVT. Note: Client may remain symptom-free and undiagnosed until emboli develop.

10. Recommend increased fluid intake to 2000+ ml/day.
Rationale: Dehydration increases blood viscosity and venous stasis, predisposing to thrombus formation.