Disorders of Venous Circulation

Venous Thrombosis, Chronic Venous Insufficiency,

Varicose Veins

(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 bloodThrombi can form in either arteries or veins; platelet aggregation is more likely due to the slower movement of blood

Factors Associated (See Box 33-5)

Bed restIV cathetersImmobilizationObesityMICHFCA of breast, pancreas, prostate, ovary

MSOral contraceptivesPregnancyChildbirthSurgery >age 40Altered coagulability states

Pathophysiology: Virchow’s Triangle

Statis of bloodIncreased blood coagulabilityInjury to vessel wall2 of 3 factors must be present for thrombi to form

A thrombus forms…..Trauma to the lining of the vein brings tissues in contact w/platelets that aggregateDeposit of fibrin, leukocytes & erythrocytes into the platelet clump causes a thrombusAt 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 vesselPieces may break loose & become traveling emboliFibroblasts invade thrombus, scar the vein, & destroy venous valves--permanent

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 veinsPE may be the first sign of DVT

DVT Manifestations

When clot is in formative stage, may notice no symptomsUsually profound tenderness; affected extremity may be larger (unilateral edema)Dull aching esp when walking: Most common Severe pain, esp when walkingCyanosis of extremitySlightly elevated tempGeneral malaise

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

Major Complications of Thrombophlebitis

Chronic venous insufficiencyPulmonary embolism

Superficial Vein Thrombosis (SVT)

Thrombi form primarily in upper extremitiesPrimary cause: trauma to venous wall assoc w/venous catheters, repeated venous punctures, use of strong IV solutions the produce inflammatory response

SVT Manifestations

Dull, aching pain over affected area: KEYMarked redness along veinIncreased warmth over area of inflammationPalpable cordlike structureMore immediate attention is required if edema, chills, high fever; suggests complications of inflammation

Collaborative Care: Thrombophlebitis

1. Tx focus: inflammatory process, prevention of further clotting, extension & restoration of blood flow

2. Must be differentiated from cellulitis, calf strain, contusion, lymphatic obstruction

3. Med tx: use of meds, treat inflammation/infection, dissolve clots

Lab & Diagnostics

Duplex venous ultrasonographyPlethysmography : lg & superficial veinsMagnetic Resonance ImagingAscending contrast venography (most accurate)Doppler ultrasound

Conservative Therapy: SVT

Prophylaxis: LMW HeparinPrevention is Key!: post op clients –leg exercises, TED’s, ambulate asap, no leg crossing, loose fitting clothes, exerciseFocus: relief of symptoms and reversal of inflammatory processApply warm, moist compresses over affected area & administer anti-inflammatory agents as prescribedSome clients may require antibiotics (therapeutic or prophylactic)

Conservative Therapy: DVT

Anticoagulants may be prescribed for severe casesStrict bedrest until symptoms of tenderness & edema resolve Legs elevated, knees slightly flexed, above heart level to promote venous return & discourage venous poolingTED’s or pneumatic compression devices

Medications

Anti-inflammatoriesAnticoagulants***

ThrombolyticsAntibiotics

Anti-inflammatories

NSAIDsIndomethacin (Indocin)Naproxen (Naprosyn)

When used w/warm, moist compresses, NSAIDs bring symptomatic relief to most clients w/SVT

AnticoagulantsFor DVT, most common tx to prevent propagation of thrombus & subsequent PEInitial 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 valueOral anticoagulation w/warfarin is started first week: important to overlap 4-5 days—full effect of warfarin is delayedWarfarin: PT should exceed normal value by 1.5-2.5 times/INR 2-3Oral anticoagulant tx may last from 2-6 months, depending on extent of disease (single occurrence vs PE)

Thrombolytics

Dissolve blood clots by imitating natural enzymatic processesHave been shown to destroy venous thrombi that are < 72 hrs oldMore rapid & efficient than heparin while also preventing additional damage to venous valvesSide effect of hemorrhage is more common than w/conventional heparinization

Antibiotics

Limited to specific tx of identified infectionsSVT; develop bacteremia, StaphlococcusIf blood cultures are positive, antibiotics are started to prevent systemic sepsis

SurgeryMost clients are tx w/meds and conservative txVenous thrombectomy; done when thrombi are lodged in femoral vein & excision of clots is required to prevent PE or to prevent gangreneAlso 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 problemsMost common filter used: Greenfield filter, assoc w/97% success rate in preventing the recurrence of PE

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

Nursing Diagnoses

PainIneffective Protection

Impaired Physical Mobility Risk for Ineffetive Tissue Perfusion:

Peripheral

Pain: r/t inflammation of vein caused by thrombotic process

Assess client level of pain on regular basis using 0-10 scaleMeasure diameter of calf & thigh of affected extremity on admission & QDApply warm, moist heat to extremity 4 x QD (compresses or Aqua-K pad)Maintain BR and teach client rationale

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 shiftElevate extremities; keep knees slightly flexed and legs above heart levelMaintain use of TEDs as ordered, remove only for short periods (30-60 min) during daily hygieneUse of mild soaps, lotions to clean leg/footAssess skin q shift Positioning aids: eggcrate /sheepskin

Ineffective Perfusion: Result of obstruction of blood flow & triggering of inflammatory response & subsequent swelling/pain

Administer & monitor effectiveness of analgesics, anticoagulants, thrombolytics, antibioticsBefore administering anticoagulants, check lab values (APTT/PTT)Position changes q 2 hrs while awake

Impaired Physical Mobility r/t prolonged bedrest (constipation, joint stiffening, muscle atrophy, boredom)

Encourage active or perform passive ROM exercises at least 1 x qshiftT, C, DB at least 4xshift while awakeIncrease fluid intake & dietary fiberProvide progressive ambulation within ordered guidelinesDiversional activities

Other Nursing Dx

Ineffective Protection r/t anticoagulant tx;Monitor lab results: INR (PT) aPTT, H & HAssess regularly of evidence of bleeding

Risk for Ineffective Tissue Perfusion: Cardiopulmonary

Frequent assessment of respiratory status: RRD, & O2 Sat

Chronic Venous Insufficiency

1. 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

Clinical Manifestions

Lower leg edemaItchingBrown pigmentation/Cyanosis of skin of lower leg/footFibrosis/hardness of subcutaneous tissuesStasis ulcers over ankle, most often medial

Complication: Ulcer development

Blood pools in lower limb and peripheral circulation slows; insufficient oxygen & nutrients to cellsCells die causing formation of venous stasis ulcersIn 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

Complication: Ulcer development

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

Assessment: Lab & Diagnostics

No specific labs or diagnostic tests Diagnosis is usually based on clinical findings

Interview dataFamily HxPast medical HxPhysical exam

Possible Nursing Diagnoses

Ineffective health maintenance r/t lack of knowledgeIneffective tissue perfusion: peripheral r/t incompetent venous valvesAnxiety r/t inability to control chronic diseaseDisturbed Body image r/t edema & statis ulcersRisk for infection r/t ulcerationsImpaired physical mobility r/t pain & lower leg edemaImpaired skin integrity r/t stasis ulcers

Nursing Interventions/Teaching

BR, w/feet elevated above heart levelAvoid long periods of standing –walk as much as possibleAvoid anything that pinches skin (knee-highs)While sitting, do not cross legs & avoid pressure behind kneesElastic support hose/TEDsFollow guidelines for care of legs & feet (p. 1219)

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

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

Evaluation…the client

Verbalizes s/s infection; remains free of infectionVerbalizes understanding of disease process, tx, regimen, limitations & is compliantDemonstrates improved perfusion AEB skin color & reduction/absence of edemaDisplays increasing tolerance to activityPain/discomfort relieved

Varicose Veins

Irregular, tortuous veins with incompetent valves

Varicose Veins

May develop anywhere in body, but most develop in lower extremitiesVein in legs most often affected: Long SaphenousOccur in 1 out of 5 people; more common females > 35; Whites > Blacks; familial tendencyCauses

Severe damage or trauma to saphenous veinEffects of gravity produced by long periods of standing

TypesPrimary: no deep veins involvedSecondary: caused by obstruction of deep veins (Most Common)

Pathophysiology

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

Normal vs Abnormal

Clinical Manifestations

Severe, aching pain in legLeg fatigue &/or heavinessItching over affected leg (stasis dermatitis)Feelings of heat in the legVisibly dilated veinsThin, discolored skin above anklesComplications: insufficiency, stasis ulcers, chronic stasis dermatitis, thrombophlebitis

Assessment: Labs & Diagnostics

No specfic labsDiagnostics

Doppler ultrasound flow tests & angiographic studies or Duplex Doppler ultrasoundTrendelenburg tests assists w/diagnosis

Collaborative Interventions

Conservative measures include antiembolism stockings and regular walking & leg elevationMild analgesics may relieve painCompression sclerotherapy & vein stripping are surgical techniques that may alleviate the major symptoms of varicose veins, however there is no cure

Nursing Process

Focus: Restore venous circulationRelieve symptomsPrevent complicationsPromote behaviors that minimize symptoms

Nursing Dx: chronic pain r/t prolonged interruption

in return of venous blood to heart & subsequent pooling of blood in extremity

Assess painTeach & reinforce methods for relieving pain that do not involve use of analgesicsEncourage discussion of possible relationships between pain and life stressorsCollaborate w/client to determine pain control planRegularly evaluate effectiveness of interventions used to minimize pain

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 edemaTeach client use of antiembolic stockings—remove daily for 30-60 minutesTeach to exercise extremities at regular intervalsTeach client to elevate affected extremities to reduce tissue congestion and promote return of venous blood to heart

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 breakdownTeach about daily skin hygieneTeach client to protect extremities from external forces that may cause skin breakdownEncourage adequate nutrition and fluid intake

Nursing Dx: Risk for peripheral neurovascular dysfunction

Assess circulation, sensation, & motion in lower extremitiesTeach to avoid flexing the extremity & to maintain positions that promote effective neurovascular functionTeach client/family to report and signs of impaired neurovascular function, such as numbness, coldness, pain, or tingling of extremityTeach about importance of maintaining safety and adhering to plan of care

Other Nursing Dx

Risk for infection r/t disruption incontinuity of skinImpaired home health maintenance r/t prescribed postural limitationsAnxiety r/t possible need for surgery

Evaluation

Skin is of normal color,temp, nontender, nonswollen, intactClient actively moves extremity; verbalizes reduced pain

Other info…

Home CareTeach clients how to adapt to accommodate prescribed health regimen (eg: daily walks, TEDs, elevate legs)

Older AdultFoster acceptance of interventionsSafety when walkingStrategies for minimizing standing & incorporating activity into the jobMay require home-based care