Venous DisorderDr Hitesh PatelAssociate professorSurgery DepartmentGMERS Medical College ,GotriVenous 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 heartmore 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 AssociatedBed restIV cathetersImmobilizationObesityMICHFCA of breast, pancreas, prostate, ovaryMSOral contraceptivesPregnancyChildbirthSurgery >age 40Altered coagulability states

Pathophysiology: Virchows TriangleStatis 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 veinsPulmonary Embolism may be the first sign of DVT

DVT ManifestationsWhen 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

Homans SignWas long considered classic manifestationthis 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 ThrombophlebitisChronic 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 ManifestationsDull, 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: ThrombophlebitisTx focus: inflammatory process, prevention of further clotting, extension & restoration of blood flowMust be differentiated from cellulitis, calf strain, contusion, lymphatic obstruction3. Med tx: use of meds, treat inflammation/infection, dissolve clots

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

Conservative Therapy: SVTProphylaxis: LMW HeparinPrevention is Key!: post op clients leg exercises, TEDs(compression stocking), 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: DVTAnticoagulants 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 poolingTEDs or pneumatic compression devices

MedicationsAnti-inflammatoriesAnticoagulants***ThrombolyticsAntibiotics

Anti-inflammatoriesNSAIDsIndomethacin (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 daysfull 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)

ThrombolyticsStreptokinase,urokinase,tpADissolve 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

AntibioticsLimited 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 cant 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 ProcessAddresses 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 DiagnosesPainIneffective Protection Impaired Physical Mobility Risk for Ineffetive Tissue Perfusion: Peripheral

Pain: r/t inflammation of vein caused by thrombotic processAssess 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/painAssess 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/painAdminister & 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 Range Of Motion exercises at least 1 x qshift

Increase fluid intake & dietary fiberProvide progressive ambulation within ordered guidelinesDiversional activities

Other Nursing DxIneffective Protection r/t anticoagulant tx;Monitor lab results: INR (PT) aPTT, Assess regularly of evidence of bleedingRisk for Ineffective Tissue Perfusion: CardiopulmonaryFrequent assessment of respiratory status: Respiratory distress, & O2 Sat

Chronic Venous InsufficiencyDisorder involving stasis of blood in lower extremities as result of obstruction & reflux of venous valves2. Assoc w/changes in venous circulation resulting from thrombophlebitis & valvular incompetence, varicose veins

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

Complication: Ulcer developmentBlood 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 developmentCongested 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 & DiagnosticsNo specific labs or diagnostic tests Diagnosis is usually based on clinical findingsInterview dataFamily HxPast medical HxPhysical exam

Possible Nursing DiagnosesIneffective 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/TeachingBR, 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

Other InterventionsUlcer may be treated w/semirigid boot applied to affected area; device may be made of Unnas 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 AntibioticsAcute weeping dermatitis: wet compresses w/boric acid, Burows 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

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

Varicose VeinsIrregular, tortuous veins with incompetent valves

Varicose VeinsMay 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 tendencyCausesSevere damage or trauma to saphenous veinEffects of gravity produced by long periods of standingTypesPrimary: no deep veins involvedSecondary: caused by obstruction of deep veins (Most Common)

PathophysiologyMajor 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 ManifestationsSevere, 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 & DiagnosticsNo specfic labsDiagnosticsDoppler ultrasound flow tests & angiographic studies or Duplex Doppler ultrasoundTrendelenburg tests assists w/diagnosis

Collaborative InterventionsConservative 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.

Nursing ProcessFocus: 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 extremityAssess 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 valvesAssess peripheral pulses, capillary refill time, skin temp, and degree of edemaTeach client use of antiembolic stockingsremove 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 valvesAssess 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 dysfunctionAssess 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 DxRisk for infection r/t disruption incontinuity of skinImpaired home health maintenance r/t prescribed postural limitationsAnxiety r/t possible need for surgery

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

Other infoHome 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

*L & B pp 1010 / (Olds)***The pathologic factors associated with thrombophlebitis are: increased blood coagulability, stasis of the blood, and:Occlusion of the vessel wallInjury to the vessel wallVasodilation of the vessel wallVasoconstriction of the vessel wall**Question: the most common site for the formation of thrombi seen in deep vein thrombosis are the deep veins of the:Groin areaThighAbdominal cavityCalf

*(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 cant stay on bedrest. The best response by the nurse is:Activity and exercise may cause life-threatening complications****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?ClostridiumStreptococcusStaphylococcusCandida**Question: Which examination is the most valuable in the detection of large and superficial veins:c. plethysmography*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 andA slingA rubber ball to do hand exercisesA warm compressAn ice bag*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 formationSit at a 60 degree angle to prevent further thrombus formationWear support hose to help prevent further thrombus formationBreak up long periods of sitting with short walks to prevent further thrombus formation.

So exercise is your best preventative measure!*********(Study Guide) With a venous occlusion of the calf, the most appropriate nursing intervention is to maintain bedrest and provide ROM exercises.**(Study Guide) Which APTT level indicates effective anticoagulation therapy for DVT:Control 20, client 48Control 22, client 28Control 24, client 60Control 18, client 36 ***(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 extremityCongestion of blood in the affected extremityPressure applied to the affected extremityIncreased temperature of the affected extremity*****(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. OKI should walk as little as possible. Not OKI should not wear anything that pinches my legs. OKI should keep the skin on my legs clean, soft, and dry. OK*************(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*****