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Venous Thrombosis Venous Leg Ulcers

Venous Thrombosis Venous Leg Ulcers. Lewis, ch 38. Terminology. Sometimes called thrombophlebitis, phlebothrombosis, deep vein thrombosis Venous thrombosis refers to clot formation in a vein with inflammation Superficial—in small vein (INT site)

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Venous Thrombosis Venous Leg Ulcers

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  1. Venous ThrombosisVenous Leg Ulcers Lewis, ch 38

  2. Terminology • Sometimes called thrombophlebitis, phlebothrombosis, deep vein thrombosis • Venous thrombosis refers to clot formation in a vein with inflammation • Superficial—in small vein (INT site) • Deep—AKA: DVT—located in deep veins, usually iliac or femoral

  3. Etiology • Virchow’s triad: • Venous stasis • Damage of endothelium • Hypercoagulability

  4. Virchow’s Triad • Venous stasis—incompetent valves, inactivity for various reasons, obesity, heart failure, atrial fibrillation • Endothelial damage—major or minor trauma from various causes, external pressure • Hypercoagulability—blood disorders, sepsis, pregnancy, hormones, smoking

  5. Pathophysiology • When vein is traumatized, inflammation occurs and platelet aggregation and fibrin attract cells to form a thrombus • In venous stasis, clot forms at valve cusps or bifurcations. • If clot gets big enough to occlude vein, manifestations of DVT occur; if not, body will reabsorb it.

  6. Assessment of DVT • 50% are asymptomatic unless the clot is in the ileofemoral vein. • Symptomatic patients and those with ileofemoral clot have edema,redness, pain, warmth, decreased movement, +Homan’s sign (20% reliable). • Dx Tests: Duplex scanning, venogram, D-dimer blood test

  7. Preventative Management • Antiembolism stockings (TEDs) • Intermittent compression device (DVT boots, Venodynes) • Antiembolism exercises (AEEs) • SQLMWH (Lovenox) • Early ambulation • Increasing fluids

  8. Prevention—Surgical Care Improvement Project • Started in 1999 to identifyand implement ways to decrease postoperative complications • Research found that in all major surgical procedures that 25% of pts developed DVT and 7% developed pulmonary embolism • Recommendation was that patients receive prophylaxis within 24h before or after. • See Joint Commission or Institute for Healthcare Improvement websites for more information.

  9. Acute Management • Hospital or home?—depends on size of clot and presence of comorbidities • BR or some degree of ambulation?—EBP has shown no difference • Heat application • Extremity elevation

  10. Acute Pharmacologic Mgmt • IV Heparin—bolus followed by infusion with pump—dosage depends on established hospital protocol • SQ Lovenox q12h—EBP show results as good • PO Warfarin daily—dosage depends on PT, INR • Analgesics—not NSAIDs

  11. Acute Management cont’d • PTT, PT, INR qam—heparin and warfarin doses depend on results; not needed for Lovenox • Monitor for complications—50% develop pulmonary embolism • Surgery—thrombectomy, vena cava filter (915)

  12. Nursing Management of DVT • Practice prevention for at-risk pts. For acute cases: • Monitor VS and NV status • Maintain activity orders • Encourage fluids • Monitor anticoagulants meds and labs • Analgesics and heat • Monitor Vit K in diet • Monitor for complications-PE and hemorrhage

  13. Safety Issues—Anticoagulant Therapy • See Joint Commission’s National Patient Safety Goal #3: • “Reduce the likelihood of patient harm associated with the use of anticoagulant therapy” • There are 6 Elements of Performance that hospitals have to meet to put this safety measure in place.

  14. Patient Education • Anticoagulant therapy (917) • Activity for prevention • Dietary restrictions related to warfarin tx • Complications • How to give Lovenox at home • How to apply TEDs

  15. Venous Leg Ulcers (919) • Pathophysiology: 75% are venous from venous insufficiency or severe varicosities. Poor O2 supply causes necrosis and an open necrotic lesion. Bacterial infection and cellulitis is a common complication . • Patients with diabetes are especially vulnerable.

  16. Manifestations • Lower leg of patient usually has leathery texture with brown patches, edema, stasis dermatitis and pruritis. • Ulcers have irregular borders with serous exudate on ankle or medial or lateral malleolus. May extend into dermis. • Moderate pain—worse in dependent position

  17. Management of Leg Ulcers • Goals of care: • Promote skin integrity • Increase mobility • Provide good nutrition

  18. Management cont’d • Promoting skin integrity includes good foot care, avoiding trauma, avoiding pressure and standing for long periods. It also includes proper tx of existing ulcers. • Increase mobility as allowed and tolerated. • Good nutrition includes protein, Vits A & C, Fe, Zn, and weight control.

  19. Wound Care Management of Leg Ulcers • Compression tx—stockings, Unna boots, etc. Amount of compression depends on ABI index. • Keep wound moist—irrigate with saline, apply moisture-retentive dressings • Prevent infection using good technique; wound culture if indicated. • For persistent and unresponsive ulcers, VACs or skin grafts may be indicated.

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