Disorders of Venous Circulation

1. Disorders of Venous Circulation Venous Thrombosis, Chronic Venous Insufficiency, Varicose Veins

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

3. Bed rest IV catheters Immobilization Obesity MI CHF CA of breast, pancreas, prostate, ovary MS Oral contraceptives Pregnancy Childbirth Surgery >age 40 Altered coagulability states Factors Associated (See Box 33-5)

4. Pathophysiology: Virchow’s Triangle • Statis of blood • Increased blood coagulability • Injury to vessel wall • 2 of 3 factors must be present for thrombi to form

5. A thrombus forms….. • Trauma to the lining of the vein brings tissues in contact w/platelets that aggregate • Deposit of fibrin, leukocytes & erythrocytes into the platelet clump causes a thrombus • At 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 vessel • Pieces may break loose & become traveling emboli • Fibroblasts invade thrombus, scar the vein, & destroy venous valves--permanent

6. 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 veins • PE may be the first sign of DVT

7. DVT Manifestations • When clot is in formative stage, may notice no symptoms • Usually profound tenderness; affected extremity may be larger (unilateral edema) • Dull aching esp when walking: Most common • Severe pain, esp when walking • Cyanosis of extremity • Slightly elevated temp • General malaise

8. 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

9. Major Complications of Thrombophlebitis Chronic venous insufficiency Pulmonary embolism

10. Superficial Vein Thrombosis (SVT) • Thrombi form primarily in upper extremities • Primary cause: trauma to venous wall assoc w/venous catheters, repeated venous punctures, use of strong IV solutions the produce inflammatory response

11. SVT Manifestations • Dull, aching pain over affected area: KEY • Marked redness along vein • Increased warmth over area of inflammation • Palpable cordlike structure • More immediate attention is required if edema, chills, high fever; suggests complications of inflammation

12. Collaborative Care: Thrombophlebitis Tx focus: inflammatory process, prevention of further clotting, extension & restoration of blood flow Must be differentiated from cellulitis, calf strain, contusion, lymphatic obstruction 3. Med tx: use of meds, treat inflammation/infection, dissolve clots

13. Lab & Diagnostics • Duplex venous ultrasonography • Plethysmography : lg & superficial veins • Magnetic Resonance Imaging • Ascending contrast venography (most accurate) • Doppler ultrasound

14. Conservative Therapy: SVT • Prophylaxis: LMW Heparin • Prevention is Key!: post op clients –leg exercises, TED’s, ambulate asap, no leg crossing, loose fitting clothes, exercise • Focus: relief of symptoms and reversal of inflammatory process • Apply warm, moist compresses over affected area & administer anti-inflammatory agents as prescribed • Some clients may require antibiotics (therapeutic or prophylactic)

15. Conservative Therapy: DVT • Anticoagulants may be prescribed for severe cases • Strict bedrest until symptoms of tenderness & edema resolve • Legs elevated, knees slightly flexed, above heart level to promote venous return & discourage venous pooling • TED’s or pneumatic compression devices

16. Medications Anti-inflammatories Anticoagulants*** Thrombolytics Antibiotics

17. Anti-inflammatories • NSAIDs • Indomethacin (Indocin) • Naproxen (Naprosyn) • When used w/warm, moist compresses, NSAIDs bring symptomatic relief to most clients w/SVT

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

19. Thrombolytics • Dissolve blood clots by imitating natural enzymatic processes • Have been shown to destroy venous thrombi that are < 72 hrs old • More rapid & efficient than heparin while also preventing additional damage to venous valves • Side effect of hemorrhage is more common than w/conventional heparinization

20. Antibiotics • Limited to specific tx of identified infections • SVT; develop bacteremia, Staphlococcus • If blood cultures are positive, antibiotics are started to prevent systemic sepsis

21. Surgery • Most clients are tx w/meds and conservative tx • Venous thrombectomy; done when thrombi are lodged in femoral vein & excision of clots is required to prevent PE or to prevent gangrene • Also 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 problems • Most common filter used: Greenfield filter, assoc w/97% success rate in preventing the recurrence of PE

22. 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

23. Nursing Diagnoses Pain Ineffective Protection Impaired Physical Mobility Risk for Ineffetive Tissue Perfusion: Peripheral

24. Pain: r/t inflammation of vein caused by thrombotic process • Assess client level of pain on regular basis using 0-10 scale • Measure diameter of calf & thigh of affected extremity on admission & QD • Apply warm, moist heat to extremity 4 x QD (compresses or Aqua-K pad) • Maintain BR and teach client rationale

25. 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 shift • Elevate extremities; keep knees slightly flexed and legs above heart level • Maintain use of TEDs as ordered, remove only for short periods (30-60 min) during daily hygiene • Use of mild soaps, lotions to clean leg/foot • Assess skin q shift • Positioning aids: eggcrate /sheepskin

26. Ineffective Perfusion: Result of obstruction of blood flow & triggering of inflammatory response & subsequent swelling/pain • Administer & monitor effectiveness of analgesics, anticoagulants, thrombolytics, antibiotics • Before administering anticoagulants, check lab values (APTT/PTT) • Position changes q 2 hrs while awake

27. Impaired Physical Mobility r/t prolonged bedrest (constipation, joint stiffening, muscle atrophy, boredom) • Encourage active or perform passive ROM exercises at least 1 x qshift • T, C, DB at least 4xshift while awake • Increase fluid intake & dietary fiber • Provide progressive ambulation within ordered guidelines • Diversional activities

28. Other Nursing Dx • Ineffective Protection r/t anticoagulant tx; • Monitor lab results: INR (PT) aPTT, H & H • Assess regularly of evidence of bleeding • Risk for Ineffective Tissue Perfusion: Cardiopulmonary • Frequent assessment of respiratory status: RRD, & O2 Sat

29. Chronic Venous Insufficiency 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

30. Clinical Manifestions • Lower leg edema • Itching • Brown pigmentation/Cyanosis of skin of lower leg/foot • Fibrosis/hardness of subcutaneous tissues • Stasis ulcers over ankle, most often medial

31. Complication: Ulcer development • Blood pools in lower limb and peripheral circulation slows; insufficient oxygen & nutrients to cells • Cells die causing formation of venous stasis ulcers • In 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

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

33. Assessment: Lab & Diagnostics • No specific labs or diagnostic tests • Diagnosis is usually based on clinical findings • Interview data • Family Hx • Past medical Hx • Physical exam

34. Possible Nursing Diagnoses • Ineffective health maintenance r/t lack of knowledge • Ineffective tissue perfusion: peripheral r/t incompetent venous valves • Anxiety r/t inability to control chronic disease • Disturbed Body image r/t edema & statis ulcers • Risk for infection r/t ulcerations • Impaired physical mobility r/t pain & lower leg edema • Impaired skin integrity r/t stasis ulcers

35. Nursing Interventions/Teaching • BR, w/feet elevated above heart level • Avoid long periods of standing –walk as much as possible • Avoid anything that pinches skin (knee-highs) • While sitting, do not cross legs & avoid pressure behind knees • Elastic support hose/TEDs • Follow guidelines for care of legs & feet (p. 1219)

36. 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

37. 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

38. Evaluation…the client • Verbalizes s/s infection; remains free of infection • Verbalizes understanding of disease process, tx, regimen, limitations & is compliant • Demonstrates improved perfusion AEB skin color & reduction/absence of edema • Displays increasing tolerance to activity • Pain/discomfort relieved

39. Varicose Veins Irregular, tortuous veins with incompetent valves

40. Varicose Veins • May develop anywhere in body, but most develop in lower extremities • Vein in legs most often affected: Long Saphenous • Occur in 1 out of 5 people; more common females > 35; Whites > Blacks; familial tendency • Causes • Severe damage or trauma to saphenous vein • Effects of gravity produced by long periods of standing • Types • Primary: no deep veins involved • Secondary: caused by obstruction of deep veins (Most Common)

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

42. Normal vs Abnormal

43. Clinical Manifestations • Severe, aching pain in leg • Leg fatigue &/or heaviness • Itching over affected leg (stasis dermatitis) • Feelings of heat in the leg • Visibly dilated veins • Thin, discolored skin above ankles • Complications: insufficiency, stasis ulcers, chronic stasis dermatitis, thrombophlebitis

44. Assessment: Labs & Diagnostics • No specfic labs • Diagnostics • Doppler ultrasound flow tests & angiographic studies or Duplex Doppler ultrasound • Trendelenburg tests assists w/diagnosis

45. Collaborative Interventions • Conservative measures include antiembolism stockings and regular walking & leg elevation • Mild analgesics may relieve pain • Compression sclerotherapy & vein stripping are surgical techniques that may alleviate the major symptoms of varicose veins, however there is no cure

46. Nursing Process Focus: Restore venous circulation Relieve symptoms Prevent complications Promote behaviors that minimize symptoms

47. Nursing Dx: chronicpain r/t prolonged interruption in return of venous blood to heart & subsequentpooling of blood in extremity • Assess pain • Teach & reinforce methods for relieving pain that do not involve use of analgesics • Encourage discussion of possible relationships between pain and life stressors • Collaborate w/client to determine pain control plan • Regularly evaluate effectiveness of interventions used to minimize pain

48. 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 edema • Teach client use of antiembolic stockings—remove daily for 30-60 minutes • Teach to exercise extremities at regular intervals • Teach client to elevate affected extremities to reduce tissue congestion and promote return of venous blood to heart

49. 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 breakdown • Teach about daily skin hygiene • Teach client to protect extremities from external forces that may cause skin breakdown • Encourage adequate nutrition and fluid intake

50. Nursing Dx: Risk for peripheral neurovascular dysfunction • Assess circulation, sensation, & motion in lower extremities • Teach to avoid flexing the extremity & to maintain positions that promote effective neurovascular function • Teach client/family to report and signs of impaired neurovascular function, such as numbness, coldness, pain, or tingling of extremity • Teach about importance of maintaining safety and adhering to plan of care