Which is the nurses initial action immediately after assisting with a precipitous birth in the triage area of the emergency department?

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Thrombophlebitis is inflammation with the formation of blood clots. It occurs in 1 in 1500 pregnancies. The three most common thromboembolic conditions during the postpartum period are superficial venous thrombosis (SVT), deep vein thrombosis (DVT), and pulmonary embolism (PE). The size of the clot can increase as circulating blood passes over it and deposits more platelets, fibrin, and cells. The levels of fibrinogen and other clotting factors normally increase during pregnancy, whereas levels of clot-dissolving factors are normally decreased, resulting in a state of hypercoagulability.

Superficial thrombophlebitis is more prevalent postpartum than during pregnancy and is seen more in women experiencing varices. It involves the saphenous vein of the lower leg and is characterized by a painful, hard, reddened, warm vein that is easily seen.

While approximately 50% of clients with DVT are asymptomatic, DVT is more serious in potential complications, such as pulmonary embolism, post-thrombotic syndrome, chronic venous insufficiency, and vein valve destruction. DVT can involve veins from the feet to the femoral area and is characterized by pain, calf tenderness, leg edema, color changes, pain when walking, and sometimes a positive Homan’s sign. However, the Homan’s sign is not always reliable during the postpartum period because it is not specific to blood clots postpartum.

Pulmonary embolism occurs when the pulmonary artery is obstructed by a blood clot that breaks off and lodges in the lungs. It may have dramatic signs and symptoms, such as sudden chest pain, cough, dyspnea, a decreased level of consciousness, and signs of heart failure.

Although thromboembolic disorders occur in less than 1% of all postpartum women, pulmonary embolism can be fatal if a clot obstructs the lung circulation; thus, early identification and treatment are paramount. Nursing management focuses on preventing thrombotic conditions, promoting adequate circulation if thrombosis occurs, and educating the client about preventive measures, anticoagulant therapy, and danger signs.

Nursing care plan goals for a client diagnosed with postpartum thrombophlebitis include enhancing tissue perfusion, facilitating the resolution of thrombus, promoting optimal comfort, preventing complications, and providing information and emotional support.

Here are five nursing care plans (NCP) and nursing diagnoses for postpartum thrombophlebitis:

1. Ineffective Peripheral Tissue Perfusion
2. Acute Pain
3. Impaired Gas Exchange
4. Anxiety
5. Deficient Knowledge

1. Ineffective Peripheral Tissue Perfusion

Ineffective Peripheral Tissue Perfusion

The pregnant woman is at increased risk for venous thrombosis because of the venous stasis from compression of the blood vessels by the heavy uterus or by pressure behind the knees when the legs are placed in stirrup leg supports episiotomy repair. If the client has varicose veins or remains on bed rest, her hypercoagulability state increases her risk of thrombus formation.

Nursing Diagnosis

• Ineffective Peripheral Tissue Perfusion

• Decreased blood flow
• Venous stasis

Possibly evidenced by

• Pallor and cyanosis (DVT)
• Prolonged capillary refill time
• Weak peripheral pulses
• Swelling of the affected extremity
• Redness/erythema (superficial thrombophlebitis)
• Pain

Desired Outcomes

• The client will demonstrate improved perfusion as evidenced by palpable and equal peripheral pulses, good capillary refill, reduced edema, and erythema.
• The client will engage in behaviors or actions to enhance peripheral tissue perfusion.
• The client will display increased tolerance to activity.

Nursing Assessment and Rationales

1. Assess the client’s vital signs closely.
It is important to closely monitor the client’s vital signs for slight elevations in temperature, possibly to 101℉ (38.3℃), and report this finding. Because the client diagnosed with DVT is at risk of developing a pulmonary embolism, be alert and immediately report any sudden onset of breathing difficulties.

2. Monitor capillary refill time.
Diminished capillary refill usually presents in DVT. A positive Homan’s sign is not a definitive diagnostic sign anymore. Several studies have been conducted to ascertain the predictive value of Homan’s sign for DVT. One study showed that all clinical signs were inconsistent, and Homan’s sign was seen in only 1/3rd of controlled subjects with actual thrombosis (Ambesh et al., 2017). It is no longer recommended to indicate deep vein thrombosis because a strained muscle or contusion can also cause calf pain. Homan’s sign is of more value if used in addition to more accurate diagnostic procedures (e.g., ultrasonography and venography).

3. Assess the client closely for risk factors and signs and symptoms of thrombophlebitis.
Look for risk factors in the client’s history such as the use of oral contraceptives before pregnancy, smoking, employment that necessitates prolonged standing, history of thrombosis, thrombophlebitis, or endometritis, or evidence of current varicosities. Also, look for other factors that can increase a client’s risk, such as prolonged bed rest, diabetes, obesity, cesarean birth, progesterone-induced distensibility of the veins of the lower legs during pregnancy, severe anemia, varicose veins, advanced maternal age (older than 35), and multiparity.

4. Identify symptoms that differentiate SVT from DVT.
Symptoms help differentiate between superficial thrombophlebitis and DVT. Localized edema, redness, warmth, and tenderness indicate superficial involvement. Pallor and coolness of extremity are more characteristic of DVT. Calf vein involvement of DVT is usually associated with the absence of edema; mild to moderate edema suggests femoral vein involvement, and severe edema is characteristic of iliofemoral vein thrombosis.

5. Assess respiration and auscultate for lung sounds, noting crackles or friction rub. Investigate reports of chest pain or feelings of anxiety.
Be alert for signs and symptoms of pulmonary embolism, including unexplained sudden onset of shortness of breath and severe chest pain. The client may be apprehensive and diaphoretic. Additional manifestations may include tachypnea, decreased oxygen saturation by pulse oximetry, and a sudden change in mental status due to hypoxemia.

6. Assess for pain or tenderness in the lower extremities.
Suspect superficial thrombosis in a client diagnosed with varicose veins who reported tenderness and discomfort over the site of the thrombosis, most commonly in the calf area. The area appears reddened along the vein and is warm to the touch. The client will report increased pain in the affected leg when she ambulates and bears weight.

7. Examine extremities for obviously prominent veins. Palpate gently for local tissue tension, stretched skin, and knots or bumps along the course of the vein.
Distention of superficial veins can occur in DVT because of backflow through communicating veins. Thrombophlebitis in superficial veins may be visible or palpable.

Nursing Interventions and Rationales

1. Instruct the client to avoid massaging or rubbing the affected extremity.
Never massage the skin over the clotted area because this could loosen the clot, causing a pulmonary or cerebral embolism.

2. Elevate the client’s feet and lower legs above heart level when sitting or lying down.
Implement bed rest and elevation of the affected extremity for the client diagnosed with DVT. These actions help to reduce interstitial swelling and promote venous return from that leg.

3. Instruct the client to avoid wearing constrictive clothing and crossing her legs.
While the client is on bed rest, she should be encouraged to change positions frequently but avoid placing her knees in a sharply flexed position that could cause blood pooling in the lower extremities.

4. Encourage increased fluid intake of 2500 ml/day unless contraindicated
Dehydration increases blood viscosity and venous stasis, predisposing to thrombus formation.

5. Emphasize the importance of deep breathing exercises.
There have been few reports on the relationship between breathing exercises and venous thromboembolism. Clients admitted for acute exacerbations of chronic obstructive pulmonary disease appear to be at an increased risk of developing thrombosis. These findings suggested the potential effectiveness of regular deep breathing in postoperative clients to prevent venous thrombosis (Guo et al., 2019).

6. Facilitate and assist with active or passive ROM while on bedrest; Assist with the gradual resumption of ambulation as advised.
Short, frequent walks are better for extremities and prevent pulmonary complications than one long walk. If the client is confined to bed, ensure range-of-motion exercises. Initiate active or passive exercises while in bed, such as periodically flexing, extending, and rotating the feet.

7. Apply warm, moist compresses or heating pads to the affected extremity as ordered.
Apply warm compresses as ordered. When applying the compresses, ensure that they are at the appropriate temperature. Altered blood flow may diminish the client’s ability to sense temperature extremes, placing her at risk for a burn injury. Make sure that the weight of the compresses does not rest on the leg, compromising the blood flow. Check the client’s bed linens and change them as necessary because the linens may become damp from the moist heat applications. If possible, use a waterproof pad to protect the linens.

8. Apply support stockings as prescribed. Caution is advised to prevent a tourniquet effect.
If the client is diagnosed with varicose veins before or during pregnancy, wearing support stockings for the first two weeks after birth can help increase venous circulation and prevent stasis. If these are prescribed, be certain the client knows to buy medical support stockings, not pantyhose advertised as offering support and put them on before she rises in the morning. If she waits until she is up and walking, venous congestion will have already occurred, and the stockings will be less effective. Encourage her to remove the support stockings twice daily and assess her skin underneath for mottling or inflammation that would suggest inflammation of her veins.

9. Apply mechanical devices such as sequential compression stockings and thromboembolic (TED) stockings as indicated.
Apply anti-embolism stockings to both extremities as ordered. Fit the stockings correctly to avoid excess pressure and constriction and urge the client to wear them. Sequential compression devices can also be used for clients with varicose veins, a history of thrombophlebitis, or surgical birth.

10. Monitor laboratory studies such as aspartate aminotransferase (AST), lactate dehydrogenase (LDH), prothrombin time (PT), activated partial thromboplastin time  (aPTT); hemoglobin (Hb), and hematocrit (Hct)
Monitor the client’s coagulation studies closely. A therapeutic aPTT value typically ranges from 35 to 45 seconds, depending on which standard values are used. Hemoconcentration potentiates the risk of thrombus formation. The coagulation profile identifies clotting problems that may increase one’s risk of DVT.

11. Administer medication for postpartum thrombophlebitis as indicated: 

• 11.1. Antimicrobial agents
  If an infection were the condition’s underlying cause, an antibiotic to treat the initial infection would be prescribed. Reproductive tract infection may result in septic pelvic thrombophlebitis. The length of antibiotic therapy is still a matter of debate; according to some authors, a short course is advocated, and antibiotics should be discontinued after clinical improvement (afebrile state for at least 48-72 hours) and normalization of laboratory values. In contrast, others recommend continuing therapy until discharge from the hospital (Kozar & Savc, 2021).
• 11.2. Thrombolytic agents (streptokinase, urokinase)
  Thrombolytic agents may be used to treat acute or massive DVT to prevent valvular damage and the development of chronic venous insufficiency. Heparin is usually begun several hours after the completion of thrombolytic therapy.
• 11.3. Heparin (via continuous IV drip, intermittent administration using heparin lock, or subcutaneous administration) or coumarin derivatives
  A heparin regimen should be restarted 12 hours after a cesarean delivery or six hours after vaginal birth, assuming significant bleeding has not occurred (Malhotra & Weinberger, 2021).Heparin is usually preferred initially, owing to its prompt and predictable antagonistic action toward thrombin formation and prevention of further clot formation. Because of its large molecular size, heparin does not pass through to breast milk as coumarin derivatives do; however, coumadin, which blocks the formation of prothrombin from vitamin K, may be used for long-term therapy following discharge.

12. Prepare client for surgical intervention as indicated.
Thrombectomy (thrombus excision) is usually done if inflammation extends proximally or circulation is severely compromised. Recurrent thrombotic episodes that are unresponsive/ contraindicated to anticoagulant therapy may require the insertion of an inferior vena cava (IVC) filter.

1. Ineffective Peripheral Tissue Perfusion

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.

• Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
  An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
• Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
  A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
• NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
  The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
• Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
  Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
  Useful for creating nursing care plans related to mental health and psychiatric nursing.
• Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
  Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
• Maternal Newborn Nursing Care Plans (3rd Edition)
  If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
• Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
  An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
• All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
  Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.

See also

Other recommended site resources for this nursing care plan:

• Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
  Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
• Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
  Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.

Other care plans related to the care of the pregnant mother and her baby:

• Abruptio Placenta | 3 Care Plan
• Abortion (Termination of Pregnancy) | 8 Care Plans UPDATED!
• Cesarean Birth | 11 Care Plans UPDATED!
• Cleft Palate and Cleft Lip | 7 Care Plans UPDATED!
• Gestational Diabetes Mellitus | 8 Care Plans UPDATED!
• Hyperbilirubinemia (Jaundice) | 4 Care Plans UPDATED!
• Labor Stages, Induced, Augmented, and Dysfunctional Labor | 41 Care Plans UPDATED!
• Neonatal Sepsis | 5 Care Plans
• Perinatal Loss (Miscarriage, Stillbirth) | 6 Care Plans UPDATED!
• Placenta Previa | 3 Care Plans
• Postpartum Hemorrhage | 8 Care Plans UPDATED!
• Postpartum Thrombophlebitis | 5 Care Plans UPDATED!
• Prenatal Hemorrhage | 9 Care Plans UPDATED!
• Precipitous Labor | 3 Care Plans
• Preeclampsia and Gestational Hypertension | 6 Care Plans UPDATED!
• Premature Dilation of the Cervix | 3 Care Plans
• Prenatal Infection | 3 Care Plans
• Preterm Labor | 7 Care Plans UPDATED!
• Puerperal & Postpartum Infections | 5 Care Plans UPDATED!
• Substance Abuse in Pregnancy | 9 Care Plans UPDATED!

References and Sources

Recommended journals, books, and other interesting materials to help you learn more about postpartum thrombophlebitis nursing care plans and nursing diagnosis:

• Ambesh, P., Obiagwu, C., & Shetty, V. (2017). Homan’s sign for deep vein thrombosis: A grain of salt?. Indian heart journal, 69(3), 418.
• Cashion, K., Perry, S. E., Alden, K. R., Olshansky, E. F., & Lowdermilk, D. L. (Eds.). (2015). Maternity and Women’s Health Care. Elsevier.
• Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span. F.A. Davis Company.
• Guo, M., Lu, L., Sun, Y., Li, L., Wu, M., & Lang, J. (2019, June). Comprehensive functional exercises with patient education for the prevention of venous thrombosis after major gynecologic surgery: A randomized controlled study. Thrombosis Research, 178, 69-74.
• Hatfield, N., & Kincheloe, C. (2021). Introductory Maternity & Pediatric Nursing. Wolters Kluwer Health.
• Hoirisch-Clapauch, S. (2018, October). Anxiety-Related Bleeding and Thrombosis. Seminars in Thrombosis and Hemostasis, 44(7), 656-661.
• Kozar, S., & Savc, H. (2021). Deep septic pelvic thrombophlebitis: A life-threatening condition in postpartum period. Acta Clinica Croatia, 60(4), 773-776.
• Leifer, G. (2018). Introduction to Maternity and Pediatric Nursing. Elsevier.
• Malhotra, A., & Weinberger, S. E. (2021, March 18). Deep vein thrombosis and pulmonary embolism in pregnancy: Treatment. UpToDate.
• Nagarsheth, K. H., & Lopez, V. (2021, February 25). Superficial Thrombophlebitis Medication: Nonsteroidal Anti-inflammatory Drugs, Anticoagulants, Hematologic, Antibiotics. Medscape Reference. Retrieved May 6, 2022, from
• Pillitteri, A., & Silbert-Flagg, J. (2018). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. Wolters Kluwer.
• Ricci, S. S. (2008). Essentials of Maternity, Newborn, and Women’s Health Nursing. Lippincott Williams & Wilkins.
• Ricci, S. S., Kyle, T., & Carman, S. (2013). Maternity and Pediatric Nursing. Wolters Kluwer Health/Lippincott Williams & Wilkins.
• Varghese, A. T. (2018, June 18). Effectiveness of magnesium sulfate with glycerine versus cold compress on patients with peripheral intravenous cannula-induced phlebitis. Asian Journal of Pharmaceutical and Clinical Research, 11(10).

Reviewed and updated by M. Belleza, R.N.

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