WELCOME

VARICOSE VEINPresented by

Aseem.B, MBA, MSc N, PGDHA, Assistant Professor in Nursing,

SP FORT College of Nursing, Thiruvananthapuramaseem.sapphire

Varicose vein aseem.sapphire

DEFINITION

Varicose veins are dilated tortuous subcutaneous veins most frequently found in the saphenous system.(Lewis Heitkemper).

Varicose veins are dilated, tortuous superficial veins that result from defective structure and function of the valves of the saphenous veins, from intrinsic weakness of the vein wall, from high intraluminal pressure, or rarely from arteriovenous fistulas.

Varicose vein is a dilated and twisted condition of the veins caused by structural changes in the walls or valves of the vessels.

aseem.sapphire

ETIOLOGY AND RISK FACTORS• PREGNANCY• AGE • GENDER• HERIDITARY• VENOUS OBSTRUCTION• OBESITY• PROLONGED STANDING• STRAINING• PRIOR SURGERY• TRAUMA

PROLONGED STANDING

pregnancy

heriditary

age

gender

obesity

straining

Prior surgery

PATHOPHYSIOLOGY

pathophysiology

Due to various Etiology and risk factors

Enlargement of vein in the leg

Streching of valves and it become incompetent

Back flow of blood

Increased back pressure Calf muscle pump fails

Venous distention and edema

TYPES

• PRIMARY : originate in the superficial system. More common in women and patients with strong family history.it is caused by the congental weakness of veins.(idiopathic varicosities)

• SECONDARY : it result from deep venous insufficiency or from deep venous occlution causing enlargement of superficial veins.it may occur in the esophagial varices, anorectal areas(haemorrhoids),AV fistulas.

CLINICAL MANIFESTATIONS

• Aching, heavy legs (often worse at night and after exercise).

• Appearance of spider veins (telangiectasia) in the affected leg.

• Ankle swelling.• A brownish-blue shiny skin discoloration near the

affected veins.• Redness, dryness, and itchiness of areas of skin -

termed stasis dermatitis or venous eczema, because of waste products building up in the leg.

CLINICAL MANIFESTATIONS continued• Cramps may develop especially when making a

sudden move as standing up.• Minor injuries to the area may bleed more than

normal and/or take a long time to heal.• In some people the skin above the ankle may shrink

(lipodermatosis) because the fat underneath the skin becomes hard.

• Whitened, irregular scar-like patches can appear at the ankles. This is known as atrophic blanche.

DIAGNOSIS

• HEALTH HISTORY• PHYSICAL EXAMINATION• OTHER STUDIES

DOPPLER ULTRASOUND

DUPLEX SCANNING

DUPLEX SCANNING

MAGNETIC RESONANCE VENOGRAPHY

MANAGEMENT

• Medical management• Surgical management• Nursing management• Conservative management

Medical management

Medical Management

• Drug Therapy, • Sclerotherapy, • Foam Sclerotherapy,• Endovenous Laser Therapy.

DRUG THERAPY

• Anti inflammatory drugs such as IBUPROFEN, ASPIRIN can be used for treatment of superficial thrombophlebitis

• Anti coagulation therapy is used in extensive thrombophlebitis

SCLEROTHERAPY• Commonly performed non surgical treatment• Medicine is injected into the veins to make them

shrink• Two techniques : 1. injection of a sclerosing agent

alone • 2.Injection of a mixture containing a sclerosing

and foaming agent.• Commonly used agents are hypertonic saline,

saline plus hypertonic dextrose, morruate sodium, ethanolamine oxalate.

SCLEROTHERAPY

• Direct IV induces inflammation and results in eventual thrombosis of the vein

• Performed in the clinical setting or office setting : minimal discomfort

• After injection leg is wrapped with elastic bandage for 24-72 hours

• Potential complication are itching, pian , blister, oedema, hyperpigmentation, thrombophlebitis and DVT

SCLERO AND FOAM AGENTS

After Sclerotherapy

FOAM THERAPY

• In this technique a sclerosing foam agent is used

• Foam has more surface area than liquid, which increases the likelihood that it will cling to its target area

• Foam irritates the vein and causes it to shrink more quickly.

Foam therapy

ENDOVENOUS LASER THERAPY• New technique• Uses laser to destroy the vein• Is a OP procedure with minimal discomfort• It takes around 30-45 mins• Small laser is passed in to the vein with the

guidance of ultrasound dupplex scanning• Mild bruising and numbing is the reported

complications

Endovenous laser therapy

RADIO FREQUENCY ABLATION• Newer technique• Uses heat to destroy the vein• Ultrasound sound guidance is there• Performed under local anesthesia• Takes around 30 mins

SURGICAL MANAGEMENT

SURGICAL MANAGEMENT

• Surgical Stripping and Ligation•Mini Phlebectomy

SURGICAL STRIPPING AND LIGATION

• Oldest method for treatment of varicose vein• Ussually used to remove the main superficial

vein( the long saphenous vein)• Strippers of various designs are used to pull out

the vein• General anaesthesia is given and connected to

ventillator• Performed in a hospital OT or equivalent

setting.

AFTER STRIPPING SURGERY

MINI PHLEBECTOMY

• Office surgical procedure• Performed under local anaesthesia• Faulty area is removed through minute

incisions

SIDE EFFECTS OF SURGERY

• Surgery can leave permanent scars.• Serious side effects are uncommon• with general anaesthesia, there always is a risk of cardiac

and respiratory complications.• Bleeding and congestion of blood can be a problem, but the

collected blood usually settles on its own and does not require any further treating.

• Wound infection, inflammation• swelling and redness can occur.• A very common complication is the damage of nerve fibres

around the veins which can lead to pain.

PRE OPERATIVE CARE

• Explain about the surgery its benefit, complication and after effects to the patient and concerned bystanders.

• High risk consent should be taken from the patient and bystanders.

• Blood investigations should be done• Surgery site should prepared• Patient should maintain NPO status.• IV should be administered before surgery• Emergency cart including lifesaving equipments

and drugs should be ready.• Input output chart should be maintained.

POST OPERATIVE CARE• Check vital signs• Elevate the drugs• Administer all the necessary drugs• Maintain inut output chart• Connect all the necessary monitors• Promote rest• Apply elastic bandage• Avoid or minimise visitors• Promote good nutrition• Encourage avoidance of leg crossing( it causes compression of vessels resulting

in venous stasis)• Encourage moderate amount of walking(it promotes venous return by

activating muscle pump).• Caution to avoid scratching or vigorous rubbing(it can cause skin abrasions and

bacterial invasions)• Encourage avoidance of constrictive clothing and accessories( It impede

circulation and promote venous stasis).• Include family others in teaching program.

NURSING MANAGEMENT

NURSING MANAGEMENT

The main aim of nursing management are :• Improving circulation• Relieving discomfort• Improving cosmetic appearance • Avoiding complications.ASSESSMENT1. Health history2. Physical examination

NURSING DIAGNOSIS

• Acute pain related to venous congestion, impaired venous return and inflammation

• Ineffective health maintenance related to lack of knowledge about disorder and its treatment

• Risk for impaired skin integrity related to altered peripheral tissue perfusion.

• Potential complication : bleeding related to anticoagulant therapy

• Potential complication : pulmonary embolism related to dehydration and immobility

NURSING INTERVENTIONS

• Restoring skin integrity• Promote rest• Improving Physical Mobility• Promoting Adequate Nutrition• Promoting Home and Community Based

Care

CONSERVATIVE MANAGEMENT• Leg elevation• Take rest• Wear compression stockings• Weight reduction• Avoid alcohol• Visit your health care provider• Do not cross legs when sitting• Take exercises

Dont

COMPLICATIONS• Pain, heaviness, inability to walk or stand for

long hours thus hindering work• Skin conditions / Dermatitis which could

predispose skin loss• Skin ulcers especially near the ankle, usually

referred to as venous ulcers.• Development of carcinoma or sarcoma in

longstanding venous ulcers. There have been over 100 reported cases of malignant transformation and the rate is reported as 0.4% to 1%.

• Severe bleeding from minor trauma, of particular concern in the elderly.

Complication continued

• Blood clotting within affected veins. Termed superficial thrombophlebitis. These are frequently isolated to the superficial veins, but can extend into deep veins becoming a more serious problem.

• Acute fat necrosis can occur, especially at the ankle of overweight patients with varicose veins. Females are more frequently affected than males.

• Tenderness in that region.• Restless legs syndrome: (RLS) appears to be a common

overlapping clinical syndrome in patients with varicose veins and other chronic venous insufficiency.

Restless leg syndrome

bibliography• Lewis Heitkemper Dirsksen O’brien Bucher “ Medical surgical nursing” seventh edition Elsevier

publications page number :917-919• • Joyce M Black Jane Hokanson Hawks “ Medical surgical Nursing ” 7th edition volume no 7

Elsevier publications page number :1539-1540.• • • Suzanne C Smeltzer Brenda Bare “ textbook of medical surgical nursing ” 10thedition

Lippincott Williams & Wilkins publications pagenumber :849-850.• • • Barbara F Weller “ Baillieres Nurses dictionary ”twenty third edition, Bailliere tindall

publication, London , UK page no : 410.• • Fahey VA, Schindler N “ Arterial reconstruction of lower extremities : Vascular Nursing ”ed4,

Philadelphia, Saunders publications 2004 page number 26-28.•

• www.wikipedia.com• • www.medicinenet.com• • www.webmd.com• • www.svs.vascularweb.org• • www.nhlbi.nih.gov• www.mayoclinic.org

Thank you