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Course Task 4 - Thrombophlebitis (De Jesus, LG E.)

The document describes a nursing care plan for a patient, Mary, who developed thrombophlebitis after giving birth. The plan includes assessing Mary for pain on foot dorsiflexion and red streaks on her legs, diagnosing her with ineffective peripheral tissue perfusion and acute pain related to thrombophlebitis. Interventions include instructing Mary on avoiding massaging/rubbing her legs, wearing constrictive clothing, crossing her legs, encouraging fluid intake and deep breathing. The plan also includes elevating Mary's legs, applying moist heat and compression stockings, and administering medications as needed. The goal is for Mary to have improved perfusion and reduced pain.

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592 views

Course Task 4 - Thrombophlebitis (De Jesus, LG E.)

The document describes a nursing care plan for a patient, Mary, who developed thrombophlebitis after giving birth. The plan includes assessing Mary for pain on foot dorsiflexion and red streaks on her legs, diagnosing her with ineffective peripheral tissue perfusion and acute pain related to thrombophlebitis. Interventions include instructing Mary on avoiding massaging/rubbing her legs, wearing constrictive clothing, crossing her legs, encouraging fluid intake and deep breathing. The plan also includes elevating Mary's legs, applying moist heat and compression stockings, and administering medications as needed. The goal is for Mary to have improved perfusion and reduced pain.

Uploaded by

LOVELLE GRACE DE JESUS
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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De Jesus, Lovelle Grace E.

BSN 2-Y2-2

Course Task 4: Thrombophlebitis

Case Study:

When Mary returns for a postpartal checkup, you notice red streaks on both legs along the course of her veins, and she has pain
on dorsiflexion of her foot. You are concerned that she is developing thrombophlebitis.

Describe a plan of care that could have reduced this risk during labor and in the immediate postpartal period.

Nursing Care Plan

Assessment Nursing Diagnosis Planning Interventions Evaluation


Ineffective Peripheral After the nursing • Instruct the client to After performing all the nursing
Subjective Data: Tissue Perfusion as intervention the patient avoid massaging or intervention, the patient:
evidenced by will be able to: rubbing the affected • demonstrate improved
• Pain on redness/erythema • demonstrate extremity. perfusion as evidenced by
dorsiflexion of (superficial improved perfusion • Instruct the client to palpable and equal
her foot thrombophlebitis) as evidenced by avoid wearing peripheral pulses, good
• Red streaks palpable and equal constrictive clothing capillary refill, reduced
on both legs Acute Pain Related to peripheral pulses, and crossing her legs. edema, and erythema.
along the Thrombophlebitis as good capillary refill, • Encourage increased • report pain is
course of her evidenced by reduced edema, and fluid intake of 2500 relieved/controlled.
veins verbalization of pain erythema. mL/day unless
• engage in behaviors contraindicated.
or actions to • Emphasize the
enhance peripheral importance of deep
tissue perfusion. breathing exercise.
• display increased • Encourage change of
tolerance to activity. position, keeping
extremely elevated.
• report pain is • Elevate affected
relieved/controlled. extremity; provide foot
• participate in or bed cradle.
behaviors/techniques • Maintain bed rest
to promote comfort. during the acute
• demonstrate a phase.
relaxed manner and • Explain procedures,
engage in the treatments, and
desired activity. nursing interventions.
• Apply moist heat to the
extremity.
• Apply compression
stockings as
appropriate.
• Administer
antipyretics, anti-
inflammatory drugs,
and analgesics as
indicated.
• Administer magnesium
sulfate compresses, as
indicated.

Reference:

RN, I. D. T. (2018, January 30). 5 Postpartum Thrombophlebitis Nursing Care Plans. Nurseslabs.
https://nurseslabs.com/postpartum-thrombophlebitis-nursing-care-plans/2/

5 Postpartum Thrombophlebitis Nursing Care Plans. (2018, January 30). Nurseslabs. https://nurseslabs.com/postpartum-
thrombophlebitis-nursing-care-plans/

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