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What is Thromboembolic Disease—Maternal:Nursing Case Study

Sunday, 16 March 2014

Thromboembolic disease is a complication of the postpartum period that includes thrombophlebitis and phlebothrombosis, forms of deep vein thrombosis (DVT). Thrombophlebitis is the formation of a thrombus or clot after vein inflammation. The inflammatory process can cause the thrombus to attach more firmly to the vein, minimizing the opportunity for dislodgment and embolism. Phlebothrombosis is the formation of a clot in the absence of inflammation, possibly resulting in a greater risk of dislodgment and, subsequently, pulmonary embolism. All thrombi have the potential to dislodge and result in embolism.

Postpartum women are at risk for thromboembolic disease due to clotting factors that increase during pregnancy and remain elevated; the fetal head exerting pressure on the veins of the lower extremities, causing them to dilate; and inactivity during labor and delivery.

Predominant sites of thrombus formation include the legs, thighs, and pelvis. Management aims to prevent or recognize early symptoms of the disease, prevent further complications, and provide pain relief.

Pathophysiology
A thrombus occurs when an alteration in the epithelial lining causes platelet aggregation and consequent fibrin entrapment of red and white blood cells and additional platelets. Thrombus formation is more rapid in areas where blood flow is slower, resulting from greater contact between platelet and thrombin accumulation. The rapidly expanding thrombus initiates a chemical inflammatory process in the vessel epithelium, which leads to fibrosis. The enlarging clot can partially or totally occlude the vessel lumen, or it can detach and embolize to lodge elsewhere in the systemic circulation.


Complications

■ Pulmonary embolism

Assessment
Health perception and management

■ Known risk factors for thrombophlebitis

Activity and exercise
■ Recent prolonged immobility

Cognition and perception
■ Acute onset of local pain (relieved by elevation of extremity), tenderness, edema, erythema, warmth, induration, or febrile reaction

Physical examination
Integumentary
■ Local erythema
■ Warmth
■ Local induration
■ Ulceration

Cardiovascular
■ Local edema
■ Engorged vessel
■ Positive Homans' sign

Diagnostic studies
■ d-dimer level is elevated.
■ Doppler ultrasound blood flow detector test shows evidence of narrowing or closure.
■ Venography may indicate loss of significant venous return.

Circulatory care: Venous insufficiency; Circulatory precautions; Embolus care: Peripheral; Embolus care: Pulmonary; Emergency care; Oxygen therapy

Teaching checklist
■ Signs and symptoms of recurring thrombophlebitis
■ Antiembolism stockings
■ Purpose, dosage, administration schedule, food and drug interactions, and adverse effects requiring medical attention for all discharge medications
■ Activity level permitted
■ Risk factor modification
■ Procedure for obtaining follow‑up laboratory tests such as prothrombin time
■ Date, time, and location of follow‑up appointments
■ Reportable signs and symptoms such as those of pulmonary embolism
■ Reasons for contacting the practitioner
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