1. Venous Disorder
First Semester
Nur 221

2. Venous Disorders
Venous thromboemolism (deep vein thrombosis (DVT) + pulmonary embolism), Thrombophelibitis and phlebothrombosis.
Do not reflect same disease process but these terms used interchangeably
Superficial veins such as greater saphenous, lesser saphenous, basilic, external jugular veins are thick walled muscular structures that lie under the skin
Deep vein are thin walled and have less muscle in the media. Run parallel to arteries and carry same names.
Deep and superficial vein have valves that keep blood in one-way flow from superficial to the deep system.

3. Pathophysiology
Exact cause is not known, yet 3 reasons are known called (Virchow’s triad): blood stasis (venous stasis), vessel wall injury, & altered blood coagulation.
Thrombophelibitis: formation of thrombus with inflammation to the veins wall
Phlebothrombosis: development of thrombus in the veins as a result of stasis or hypercoagulability but without inflammation.

4. Vein Thrombosis (VT) Occurs in any veins but mainly in lower extremities, but also can occur in upper extremities
Upper extremities VT occurs from IV catheter, disease cause hypercoagulability
Internal trauma occurrence, chemotherapy, dialysis catheter, parenteral nutrition line, repetitive motion injury ( tennis players, construction workers)

5. venous thrombi: aggregates of platelets attached to the vein wall, along with a tail-like appendage containing fibrin, WBC's, and RBC's
Complication of VT:( Chart 31-8 P 875)
Chronic venous occlusion
Pulmonary embolism
Valvar destruction ( Chronic Venous Insufficiency , ↑ venous pressure, varicosities, venous ulcer)
Venous obstruction (↑ distal pressure, fluid stasis, edema, venous gangrene)

8. Clinical Manifestation
Deep veins:
Edema and swelling of extremities
warm (affected extremity)
Superficial vein appears more prominent
Tenderness
+ve homan’s sign (not specific)
S&S of Pulmonary Embolism may be the 1st signs for DVT.
Superficial veins:
pain or tenderness, redness, and warmth.
Can be treated with bed rest, leg elevations, analgesics, and anti-inflammatory drug.

10. Diagnosis:
Venography: The radiologist injects contrast material into a vein on the top of the foot. The blood clot appears as a defect in contrast material on the X-ray picture of the veins.
2. Duplex ultrasound: noninvasive procedure reflects gray-scale imaging for vein or artery. Help in determination the level and extent of venous disease and locate the disease stenosis or occlusion

11. Color Flow Duplex Image

12. Assessment: Detecting early signs and symptoms: feeling of heaviness, limb pain, functional impairment, ankle engorgement, edema, circumference differences, temp (hotness at calf and ankle), tenderness
Prevention: achieved by applying elastic stockings, use of intermittent pneumatic compression devices, special body positioning and exercise, administration of heparin or low molecular weight heparin. wt loss, smoking cessation and regular exercise.

13. Medical Management Objectives:
Prevent thrombus from growing and fragmenting
Prevent recurrent thromboemboli
Achieved by pharmacologic therapy or surgical therapy.

14. Pharmacologic therapy
Indicating for pt with Thrombophelibitis, recurrent embolus formation, persistent leg edema from HF, elderly with hip fracture
Unfractionated heparin: 5-7 days to prevent formation of new thrombi.
Low-molecular-weight heparin: more effective than heparin, longer half life
Thrombolytic therapy: (Streptokinas&Urokinase)
cause the thrombus to dissolve in 50% of pts
Given in the 1st 3 day of acute thrombosis
** Advantage: less-long-term damage to the venous valves and reduced incidence of postthrombotic syndrome and chronic venous insufficiency
** Disadvantage: The incidence of bleeding is greater than heparin

15. Factor Xa inhibitor:
Fondaparinux (Arixtra): inhibit factor Xa
Given S\c in a daily fixed dose
Has no effect on PTT or PT
Used as prophylactic in major orthopedic surgery.
Oral anticoagulant: (warfarin)
Is a vit K antagonist
Surgical management:
Is necessary when anticoagulant and thrombolytic therapy is Contraindicated.
Thrombectomy is done to prevent the risk of pulmonary emboli.
Balloon angiography with stent used for iliac vein

16. Nursing Management
If patient is taking anticoagulant medication: the nurse should monitor PT and PTT, Hb and HCT values, platelets count, fibrinogen level. Control bleeding (bruises, nose bleeding, gum bleeding).
The nurse should monitor for potential complication as (bleeding, thrombocytopenia)
Providing comfort: bed rest (5-7days from diagnosis, elevation of the leg), elastic stocking (when pt start to ambulate), analgesic, bed exercise as repetitive Dorsiflexion of foot
Walking is better than standing or sitting for long period
Warm compress over affected area to promote comfort

17. Compression therapy:
Stocking:
Used for pt with venous insufficiency
Exert sustained evenly distributed pressure over the entire calves resulting in ↑ flow in the deeper veins
They may be knee high, thigh high, or panty hose
When stocking are off inspect skin for irritation and tenderness in calves
Contraindicated in pt with severe pitting edema.

18. Intermittent pneumatic compression devices:
used with elastic stocking to prevent DVT
Increased blood velocity
Nursing measure: to ensure that prescribed pressure are not exceeding mmHg & assess pt comfort.
Positioning the body and encouraging exercise:
Elevate feet and the lower leg above heart level when pt in bed rest
Deep breathing exercise
Instruct pt to avoid sitting for more than 1hr
Perform active and passive leg exercise when pt cannot ambulate
Walk for at least 10 min every 1-2 hr’s
Instruct pt to avoid sitting for more than 1hr’s

20. Patient’s education: anticoagulant medication
Take the medication at the same time each day
Wear identification band So that others would know, and notify healthcare providers.
Avoid alcohol and drug interact with anticoagulant medications: Aspirin, common cold medicine, antibiotics, mineral oil, vitamin, ibuprofen, and anti-inflammatory drug
If the following symptoms appear notify the doctor: faintness, dizziness, increased weakness, severe headache and Abd pain, reddish or brownish urine, any bleeding that does not stop, bruises that is enlarged, nose bleeding

21. Chronic Venous Insufficiency
Occurs due to venous obstruction of the venous valves in the legs or a reflux of blood back through valves. Superficial and deep veins can be affected
Resulted in increased venous pressure, walls distended and leaflets of valves are stretched and prevent from completely closing allowing backflow of blood in the veins. Pooling of blood in the legs.
Duplex Ultrasonography confirm the obstruction & identify the level of valvar incompetence

23. Blood flow and function of valves in veins
Blood flow and function of valves in veins. Note impaired blood return due to incompetent valve.

24. Clinical Manifestations
Pain, edema, pigmentations, stasis dermatitis. More pain in the evening, superficial veins are dilated. This condition is difficult to treat, and often disabling the patient.
Stasis ulcers appear due to rupture of small skin veins and subsequent ulceration, Usually occur in the lower part of the body in the area of medial malleous and the ankle
Skin becomes dry, cracked, itches, subcutaneous tissue atrophy and damage.
The risk of infection and injury increase.

25. Complications: venous ulcerations (is the most serious complication from venous insufficiency), cellulilitis and dermatitis
Management:
Is directed to reducing venous stasis and preventing ulcerations.
Elevating the legs and wearing elastic compression stockings
Walking should be encouraged, avoid leg crossing, sitting and standing for long hours, constricting garments such as tight socks or panty should be avoided
Pt should sleep with the foot of the bed elevated 15 degrees
Keep skin clean, dry and soft
Report signs of ulceration immediately
The affected extremities should be kept from trauma,
Encourage exercise

26. Leg ulcers
Excavation of the skin surface that occurs when inflamed necrotic tissue sloughs off. 75 % is due to venous insufficiency and 20 % arterial, 5 % burns, sickle cell anemia and other factors
Pathophysiology:
Arterial ulcer : Inadequate O2 and other nutrient exchange occur ( metabolic abnormality) →cell death (necrosis) →alteration in blood vessel →formation of ulcers
Venous ulcer C\M: due to rupture of superficial veins and fragile skin: aching or heaviness like pain. Foot and ankle are edematous, large, ulceration occur in medial or lateral malleous, superficial and highly exudative.

27. Venous & Arterial Ulcers
Arterial ulcer venous ulcer

28. Medical Management AB therapy (oral or topical) Compression therapy
Debridement: Flush with normal saline if not healed debridement is done.
- Purpose to keep wound clean of drainage and necrotic tissue.
Is the removable of nonviable tissue( necrotic) from wound
Performed by:
Surgical Debridement : fastest method
Non selective (applying of isotonic saline to fine mesh gauze to the ulcer, then dry and necrotic removed, painful, analgesics given)
Enzymatic: using enzymatic ointment to ulcer only not surrounding tissues then ulcer is covered with saline guaze.
Ca alginate dressing : containing fibers used only for exudative ulcers (for absorption), fibers then changed to gel that easily (painlessly) removed.

29. Topical therapy: used with debridement to promote healing and keep the wound moist and clean.
Wound dressing: done to promote a moist environment, use of wound contact material so does not disturb the capillary bed.

30. Nursing Process: The Care of the Patient with Leg Ulcers: Assessment
History of the condition
Assess for presence of infection.
Assess nutrition.
Treatment depends upon the type of ulcer

31. Diagnosis Impaired skin integrity R\t vascular insufficiency
Impaired physical mobility R\T activity restriction from pain
Imbalanced nutrition : less than body requirement R\T increased need for nutrient that promote wound healing.

32. Collaborative Problems/Potential Complications
Infection
Gangrene

33. Planning Major goals include: restoration of skin integrity
improved physical mobility
promoting adequate nutrition
absence of complications.

34. Restoring skin integrity:
Gentle cleaning with mild soap and lukewarm water
In venous insufficiency: elevate the extremity. In arterial insufficiency, the pt should be referred to be evaluated for vascular reconstruction.
Avoid trauma, Use protective boots
Avoid heating pads or cold exposure

35. Improved Physical Mobility:
When infection resolved and healing begins, resume gradual ambulation
Patient should be encouraged to move in bed to maintain muscle tone and strength
Give analgesic if pain increase
Promote adequate nutrition:
Instruct pt to take diet high in protein, Vit C &A,
Encourage zinc intake
Iron intake

36. Varicose Veins (Varicosities)
Are abnormally dilated, tortuous, superficial veins caused by incompetent venous valves
Occurs in lower extremities, in the saphenous system or the lower trunk
Correlated with ↑ age, most in women, and people with occupation required prolonged standing
Other factors that cause VV are: hereditary, pregnancy

37. Pathophysiology:
Primary: without involvement of deep veins)
Secondary: resulting from obstruction of deep veins
Reflux of venous blood result in venous stasis
Clinical Manifestations:
Dull aches muscle cramps
↑ muscle fatigue in lower legs
Feeling of heaviness of the legs
Ankle edema
If deep veins obstructed pt will have S&S of chronic venous insufficiency (edema, pain, pigmentation, ulceration)
Increased susceptibility to injury & infection.

38. Dx test is duplex ultrasound scan (document the anatomic site of reflux and provide a measure for the severity of valvular reflux

39. Prevention:
Avoid activity that cause venous stasis as ( wearing constrictive clothing, crossing the legs, sitting or standing for long periods)
Change position frequently
Elevating the legs
Walking 1-2 miles each day
Elastic stoking
Control wt.

40. Medical Management
Ligation and stripping: is done for primary VV, deep veins should be patent. Saphenous vein ligated in the groin where the saphenous vein meets the femoral vein, then 2-3cm incision is made below the knee, stripper( wire) is inserted to the point of ligation, the wire is then withdrawn and vein as it is removed.
Thermal ablation
sclerotherapy

42. Thermal Ablation
Us thermal energy. Ablation uses electrical contact inside the vein as the device withdrawn the vein sealed

43. Sclerotherapy
Injection of irritating chemical substance to produce localized fibrosis of the vein therefore obliterating the vein(non surgical)

44. Nursing Management After surgery: Ligation and stripping
Bed rest is discouraged and early ambulation is encouraged
Instruct pt to walk Q one hour for 5-10min while awake for the 1st 24hr, then ↑ activity as tolerated
Wear elastic stocking continuously for 1-2wk
Elevate foot of bed
Discourage standing and sitting

45. Promote comfort and understanding:
Analgesic,
Inspect dressing for bleeding,
Alert for reported sensations of “pins and needles.” Hypersensitivity to touch in the involved extremity may indicate a temporary or permanent nerve injury resulting from surgery
The pt is instructed to dry the incisions well with a clean towel using a patting technique, rather than rubbing
The patient is instructed to apply sunscreen or zinc oxide to the incisional area prior to sun exposure
If the patient underwent sclerotherapy, a burning sensation in the injected leg may be experienced for 1 or 2 days