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Disorders of Venous Circulation

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1 Disorders of Venous Circulation
Venous Thrombosis, Chronic Venous Insufficiency, Varicose Veins L & B pp 1010 / (Olds)

2 (Venous Thrombosis (Thrombophlebitis)
Condition in which a blood clot (thrombus) forms on wall of vein and partially or completely blocks flow of blood back to the heart—more common Usually due to slow movement of blood Thrombi can form in either arteries or veins; platelet aggregation is more likely due to the slower movement of blood

3 Factors Associated (See Box 33-5)
Bed rest IV catheters Immobilization Obesity MI CHF CA of breast, pancreas, prostate, ovary MS Oral contraceptives Pregnancy Childbirth Surgery >age 40 Altered coagulability states

4 Pathophysiology: Virchow’s Triangle
Statis of blood Increased blood coagulability Injury to vessel wall 2 of 3 factors must be present for thrombi to form The pathologic factors associated with thrombophlebitis are: increased blood coagulability, stasis of the blood, and: Occlusion of the vessel wall Injury to the vessel wall Vasodilation of the vessel wall Vasoconstriction of the vessel wall

5 A thrombus forms….. Trauma to the lining of the vein brings tissues in contact w/platelets that aggregate Deposit of fibrin, leukocytes & erythrocytes into the platelet clump causes a thrombus At first, the thrombus floats in the vein; within 7-10 days it sticks to the vein wall, but a portion may still float in the vessel Pieces may break loose & become traveling emboli Fibroblasts invade thrombus, scar the vein, & destroy venous valves--permanent

6 Deep Vein Thrombosis (DVT)
Most likely to occur in deep veins of the calf (80%) 25% of thrombi that occur in calf will extend to the popliteal & femoral veins PE may be the first sign of DVT Question: the most common site for the formation of thrombi seen in deep vein thrombosis are the deep veins of the: Groin area Thigh Abdominal cavity Calf

7 DVT Manifestations When clot is in formative stage, may notice no symptoms Usually profound tenderness; affected extremity may be larger (unilateral edema) Dull aching esp when walking: Most common Severe pain, esp when walking Cyanosis of extremity Slightly elevated temp General malaise (Study Guide) A client is told that she has a venous thrombus and must be on bedrest. She tells the nurse that she is much too busy and can’t stay on bedrest. The best response by the nurse is: “Activity and exercise may cause life-threatening complications”

8 Homan’s Sign Was long considered classic manifestation—this is no longer true Sign is not specific to DVT & can be elicited by any condition of the calf As calf muscles contract, there is risk of detaching thrombus from the wall

9 Major Complications of Thrombophlebitis
Chronic venous insufficiency Pulmonary embolism

10 Superficial Vein Thrombosis (SVT)
Thrombi form primarily in upper extremities Primary cause: trauma to venous wall assoc w/venous catheters, repeated venous punctures, use of strong IV solutions the produce inflammatory response

11 SVT Manifestations Dull, aching pain over affected area: KEY
Marked redness along vein Increased warmth over area of inflammation Palpable cordlike structure More immediate attention is required if edema, chills, high fever; suggests complications of inflammation Question: a client with superficial vein thrombophlebitis is experiencing chills and a high fever. What infective agent is most often associated with the bacteremia that causes superficial vein thrombophlebitis? Clostridium Streptococcus Staphylococcus Candida

12 Collaborative Care: Thrombophlebitis
Tx focus: inflammatory process, prevention of further clotting, extension & restoration of blood flow Must be differentiated from cellulitis, calf strain, contusion, lymphatic obstruction 3. Med tx: use of meds, treat inflammation/infection, dissolve clots

13 Lab & Diagnostics Duplex venous ultrasonography
Plethysmography : lg & superficial veins Magnetic Resonance Imaging Ascending contrast venography (most accurate) Doppler ultrasound Question: Which examination is the most valuable in the detection of large and superficial veins: c. plethysmography

14 Conservative Therapy: SVT
Prophylaxis: LMW Heparin Prevention is Key!: post op clients –leg exercises, TED’s, ambulate asap, no leg crossing, loose fitting clothes, exercise Focus: relief of symptoms and reversal of inflammatory process Apply warm, moist compresses over affected area & administer anti-inflammatory agents as prescribed Some clients may require antibiotics (therapeutic or prophylactic) Question: a 63 yr old male is being treated for a superficial thrombophlebitis of his left arm believed to be caused by repeated IV catheters. As a part of his pain control, the nurse provides him with naproxen and A sling A rubber ball to do hand exercises A warm compress An ice bag

15 Conservative Therapy: DVT
Anticoagulants may be prescribed for severe cases Strict bedrest until symptoms of tenderness & edema resolve Legs elevated, knees slightly flexed, above heart level to promote venous return & discourage venous pooling TED’s or pneumatic compression devices Question: a 38 yr old female is being discharged from the hospital after being successfully treated for a DVT of her left leg. The nurse preparing her discharge instructions should advise her to: Cross her legs only at the ankles to avoid further thrombus formation Sit at a 60 degree angle to prevent further thrombus formation Wear support hose to help prevent further thrombus formation Break up long periods of sitting with short walks to prevent further thrombus formation. So exercise is your best preventative measure!

16 Anti-inflammatories Anticoagulants*** Thrombolytics Antibiotics
Medications Anti-inflammatories Anticoagulants*** Thrombolytics Antibiotics

17 Anti-inflammatories NSAIDs Indomethacin (Indocin) Naproxen (Naprosyn)
When used w/warm, moist compresses, NSAIDs bring symptomatic relief to most clients w/SVT

18 Anticoagulants For DVT, most common tx to prevent propagation of thrombus & subsequent PE Initial bolus of 7500 to 10,000 u of heparin, then continuous heparin infusion started (via pump) Daily dosage is calculated based on results of APTT (activated partial thromboplastin time) Desired: APTT is 1.5 to 2 times normal APTT value Oral anticoagulation w/warfarin is started first week: important to overlap 4-5 days—full effect of warfarin is delayed Warfarin: PT should exceed normal value by times/INR 2-3 Oral anticoagulant tx may last from 2-6 months, depending on extent of disease (single occurrence vs PE)

19 Thrombolytics Dissolve blood clots by imitating natural enzymatic processes Have been shown to destroy venous thrombi that are < 72 hrs old More rapid & efficient than heparin while also preventing additional damage to venous valves Side effect of hemorrhage is more common than w/conventional heparinization

20 Antibiotics Limited to specific tx of identified infections
SVT; develop bacteremia, Staphlococcus If blood cultures are positive, antibiotics are started to prevent systemic sepsis

21 Surgery Most clients are tx w/meds and conservative tx
Venous thrombectomy; done when thrombi are lodged in femoral vein & excision of clots is required to prevent PE or to prevent gangrene Also can insert filtering devices into inferior vena cava via femoral or jugular vein; used forpts who can’t take anticoagulants & are at risk for PE or have recurrent problems Most common filter used: Greenfield filter, assoc w/97% success rate in preventing the recurrence of PE

22 Nursing Process Addresses clients responses to illness, primarily in areas of pain mgt, education re: disease process/med tx, & interventions to reduce inflammation & prevent complications. Prevention is very important! Provide info re: causes to venous thrombosis to all high risk clients

23 Nursing Diagnoses Pain Ineffective Protection
Impaired Physical Mobility Risk for Ineffetive Tissue Perfusion: Peripheral

24 Pain: r/t inflammation of vein caused by thrombotic process
Assess client level of pain on regular basis using 0-10 scale Measure diameter of calf & thigh of affected extremity on admission & QD Apply warm, moist heat to extremity 4 x QD (compresses or Aqua-K pad) Maintain BR and teach client rationale (Study Guide) With a venous occlusion of the calf, the most appropriate nursing intervention is to maintain bedrest and provide ROM exercises.

25 Ineffective Tissue Perfusion: r/t obstruction of blood flow & triggering of inflammatory response & subsequent swelling/pain Assess peripheral pulses, skin integrity, capillary refill times, & color of extremities at least once q shift Elevate extremities; keep knees slightly flexed and legs above heart level Maintain use of TEDs as ordered, remove only for short periods (30-60 min) during daily hygiene Use of mild soaps, lotions to clean leg/foot Assess skin q shift Positioning aids: eggcrate /sheepskin

26 Ineffective Perfusion: Result of obstruction of blood flow & triggering of inflammatory response & subsequent swelling/pain Administer & monitor effectiveness of analgesics, anticoagulants, thrombolytics, antibiotics Before administering anticoagulants, check lab values (APTT/PTT) Position changes q 2 hrs while awake (Study Guide) Which APTT level indicates effective anticoagulation therapy for DVT: Control 20, client 48 Control 22, client 28 Control 24, client 60 Control 18, client 36

27 Impaired Physical Mobility r/t prolonged bedrest (constipation, joint stiffening, muscle atrophy, boredom) Encourage active or perform passive ROM exercises at least 1 x qshift T, C, DB at least 4xshift while awake Increase fluid intake & dietary fiber Provide progressive ambulation within ordered guidelines Diversional activities

28 Other Nursing Dx Ineffective Protection r/t anticoagulant tx;
Monitor lab results: INR (PT) aPTT, H & H Assess regularly of evidence of bleeding Risk for Ineffective Tissue Perfusion: Cardiopulmonary Frequent assessment of respiratory status: RRD, & O2 Sat

29 Chronic Venous Insufficiency
Disorder involving stasis of blood in lower extremities as result of obstruction & reflux of venous valves 2. Assoc w/changes in venous circulation resulting from thrombophlebitis & valvular incompetence, varicose veins

30 Clinical Manifestions
Lower leg edema Itching Brown pigmentation/Cyanosis of skin of lower leg/foot Fibrosis/hardness of subcutaneous tissues Stasis ulcers over ankle, most often medial (Study Guide) The presence of stasis ulcers in the client with chronic venous insufficiency can best be explained by: Lack of exercise in the affected extremity Congestion of blood in the affected extremity Pressure applied to the affected extremity Increased temperature of the affected extremity

31 Complication: Ulcer development
Blood pools in lower limb and peripheral circulation slows; insufficient oxygen & nutrients to cells Cells die causing formation of venous stasis ulcers In attempt to heal stasis ulcer, body increases supply of oxygen, nutrients, and energy to area; but it does not reach the diseased tissues due to impaired circulation = enlarged ulcers

32 Complication: Ulcer development
Congested venous circulation prevents biochemicals from immune system to diseased tissues, interfering w/normal inflammatory response. Increases risk for wound infection Area around stasis ulcers appear shiny, atrophic, & cyanotic, w/brownish pigmentation. May have eczema or stasis dermatitis, scar tissue Slight trauma will result in serious tissue breakdown

33 Assessment: Lab & Diagnostics
No specific labs or diagnostic tests Diagnosis is usually based on clinical findings Interview data Family Hx Past medical Hx Physical exam

34 Possible Nursing Diagnoses
Ineffective health maintenance r/t lack of knowledge Ineffective tissue perfusion: peripheral r/t incompetent venous valves Anxiety r/t inability to control chronic disease Disturbed Body image r/t edema & statis ulcers Risk for infection r/t ulcerations Impaired physical mobility r/t pain & lower leg edema Impaired skin integrity r/t stasis ulcers

35 Nursing Interventions/Teaching
BR, w/feet elevated above heart level Avoid long periods of standing –walk as much as possible Avoid anything that pinches skin (knee-highs) While sitting, do not cross legs & avoid pressure behind knees Elastic support hose/TEDs Follow guidelines for care of legs & feet (p. 1219) (Study Guide) Which statement by the client with chronic venous insufficiency indicates the need for further teaching? “I should elevate my legs while resting or sleeping.” OK “I should walk as little as possible.” Not OK “I should not wear anything that pinches my legs. OK “I should keep the skin on my legs clean, soft, and dry.” OK

36 Other Interventions Ulcer may be treated w/semirigid boot applied to affected area; device may be made of Unna’s paste or Gauzetex bandage. Changed q 1-2 wks Surgery for large, chronic ulcers; Incompetent veins ligated, ulcer excised, skin grafted

37 Medications: Topical Agents &/or Antibiotics
Acute weeping dermatitis: wet compresses w/boric acid, Burow’s soln, isotonic saline 4 x qd for 1 hr intervals, followed w/topical ointments (0.5% hydrocortisone cream) Subsiding/Chronic: continue use of hydrocortisone cream. Other: zinc oxide ointment, broad-spectrum antifungal creams (clotrimizole/Lotrimin, miconazole/Monistat) Ulcerations: saline compresses to promote wound healing or prepare for skin graft

38 Evaluation…the client
Verbalizes s/s infection; remains free of infection Verbalizes understanding of disease process, tx, regimen, limitations & is compliant Demonstrates improved perfusion AEB skin color & reduction/absence of edema Displays increasing tolerance to activity Pain/discomfort relieved

39 Irregular, tortuous veins with incompetent valves
Varicose Veins Irregular, tortuous veins with incompetent valves

40 Varicose Veins May develop anywhere in body, but most develop in lower extremities Vein in legs most often affected: Long Saphenous Occur in 1 out of 5 people; more common females > 35; Whites > Blacks; familial tendency Causes Severe damage or trauma to saphenous vein Effects of gravity produced by long periods of standing Types Primary: no deep veins involved Secondary: caused by obstruction of deep veins (Most Common)

41 Pathophysiology Major cause: sustained stretching of vascular wall die to long-standing increased intravenous pressure Valves become incompetent because they cannot close properly due to stretching Prolonged standing, the force of gravity, lack of lower limb exercise, & incompetent venous valves all weaken muscle-pumping mechanism, & return of venous blood to heart decreases As client stands for long time, blood pools and vessel wall continues to stretch, and valves become increasingly incompetent

42 Normal vs Abnormal

43 Clinical Manifestations
Severe, aching pain in leg Leg fatigue &/or heaviness Itching over affected leg (stasis dermatitis) Feelings of heat in the leg Visibly dilated veins Thin, discolored skin above ankles Complications: insufficiency, stasis ulcers, chronic stasis dermatitis, thrombophlebitis

44 Assessment: Labs & Diagnostics
No specfic labs Diagnostics Doppler ultrasound flow tests & angiographic studies or Duplex Doppler ultrasound Trendelenburg tests assists w/diagnosis

45 Collaborative Interventions
Conservative measures include antiembolism stockings and regular walking & leg elevation Mild analgesics may relieve pain Compression sclerotherapy & vein stripping are surgical techniques that may alleviate the major symptoms of varicose veins, however there is no cure

46 Nursing Process Focus: Restore venous circulation Relieve symptoms
Prevent complications Promote behaviors that minimize symptoms

47 Nursing Dx: chronic pain r/t prolonged interruption in return of venous blood to heart & subsequent pooling of blood in extremity Assess pain Teach & reinforce methods for relieving pain that do not involve use of analgesics Encourage discussion of possible relationships between pain and life stressors Collaborate w/client to determine pain control plan Regularly evaluate effectiveness of interventions used to minimize pain

48 Nursing Dx: Ineffective tissue perfusion r/t insufficient supply of nutrients/oxygen & incompetent valves Assess peripheral pulses, capillary refill time, skin temp, and degree of edema Teach client use of antiembolic stockings—remove daily for minutes Teach to exercise extremities at regular intervals Teach client to elevate affected extremities to reduce tissue congestion and promote return of venous blood to heart (Study Guide) A nurse is teaching a health education class. A participant asks how she can prevent varicose veins. The nurse should tell her that the best prevention is to: a. Walk regularly and daily

49 Nursing Dx: Ineffective tissue perfusion r/t insufficient supply of nutrients/oxygen & incompetent valves Assess skin on lower extremities for warmth, erythema, moisture, signs of breakdown Teach about daily skin hygiene Teach client to protect extremities from external forces that may cause skin breakdown Encourage adequate nutrition and fluid intake

50 Nursing Dx: Risk for peripheral neurovascular dysfunction
Assess circulation, sensation, & motion in lower extremities Teach to avoid flexing the extremity & to maintain positions that promote effective neurovascular function Teach client/family to report and signs of impaired neurovascular function, such as numbness, coldness, pain, or tingling of extremity Teach about importance of maintaining safety and adhering to plan of care

51 Other Nursing Dx Risk for infection r/t disruption incontinuity of skin Impaired home health maintenance r/t prescribed postural limitations Anxiety r/t possible need for surgery

52 Evaluation Skin is of normal color,temp, nontender, nonswollen, intact
Client actively moves extremity; verbalizes reduced pain

53 Other info… Home Care Older Adult
Teach clients how to adapt to accommodate prescribed health regimen (eg: daily walks, TEDs, elevate legs) Older Adult Foster acceptance of interventions Safety when walking Strategies for minimizing standing & incorporating activity into the job May require home-based care


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