Venous Disorder First Semester Nur 221

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.

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.

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)

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)

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.

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

Color Flow Duplex Image

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.

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

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

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

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

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.

Intermittent pneumatic compression devices: used with elastic stocking to prevent DVT Increased blood velocity Nursing measure: to ensure that prescribed pressure are not exceeding 35- 55 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

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

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

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

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.

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

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.

Venous & Arterial Ulcers Arterial ulcer venous ulcer

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.

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.

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

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.

Collaborative Problems/Potential Complications Infection Gangrene

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

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

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

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

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.

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

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.

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

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

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

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

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