Understanding Venous Thrombosis and Deep Vein Thrombophlebitis

1. The Cardiovascular System NRS 108-ECC Majuvy L. Sulse RN, MSN, CCRN Lola Oyedele RN, MSN, CTN

2. SITES FOR PALPATING PERIPHERAL PULSES From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders

3. VEINS IN THE LEG From Jarvis, C. (2000). Physical examination and health assessment, ed 3, Philadelphia: W.B. Saunders

4. VENOUS THROMBOSIS • DESCRIPTION • Thrombus can be associated with an inflammatory process • When a thrombus develops, inflammation occurs that thickens the vein wall leading to embolization

5. TYPES OF VENOUS THROMBOSIS • THROMBOPHLEBITIS • A thrombus associated with inflammation • PHLEBOTHROMBUS • A thrombus without inflammation • PHLEBITIS • Vein inflammation associated with invasive procedures such as IVs • DEEP VEIN THROMBOPHLEBITIS (DVT) • More serious than a superficial thrombophlebitis because of the risk for pulmonary embolism

6. RISKS FACTORS FOR VENOUS THROMBOSIS • Venous stasis from varicose veins, heart failure, immobility • Hypercoagulability disorders • Injury to the venous wall from IV injections, fractures, trauma • Following surgery, particularly hip surgery and open prostate surgery • Pregnancy • Ulcerative colitis • Use of oral contraceptives

7. PHLEBITIS • ASSESSMENT • Red, warm area radiating up an extremity • Pain and soreness • Swelling • IMPLEMENTATION • Apply warm, moist soaks as prescribed to dilate the vein and promote circulation • Assess temperature of soak prior to applying • Assess for signs of complications such as tissue necrosis, infection, or pulmonary embolus

8. DEEP VEIN THROMBOPHLEBITIS (DVT) • ASSESSMENT • Calf or groin tenderness or pain with or without swelling • Positive Homans’ sign • Warm skin that is tender to touch

9. DEEP VEIN THROMBOPHLEBITIS (DVT) • IMPLEMENTATION • Provide bed rest • Elevate the affected extremity above the level of the heart as prescribed • Avoid using the knee gatch or a pillow under the knees • Do not massage the extremity • Provide thigh-high compression or antiembolism stockings as prescribed to reduce venous stasis and to assist in the venous return of blood to the heart

10. DEEP VEIN THROMBOPHLEBITIS (DVT) • IMPLEMENTATION • Administer intermittent or continuous warm, moist compresses as prescribed • Palpate the site gently, monitoring for warmth and edema • Measure and record the circumference of the thighs and calves • Monitor for shortness of breath and chest pain, which can indicate pulmonary emboli

11. DEEP VEIN THROMBOPHLEBITIS (DVT) • IMPLEMENTATION • Administer thrombolytic therapy (t-PA, tissue plasminogen activator) if prescribed, which must be initiated within 5 days after the onset of symptoms • Administer heparin therapy as prescribed to prevent enlargement of the existing clot and prevent the formation of new clots • Monitor APTT during heparin therapy • Administer warfarin (Coumadin) therapy as prescribed when the symptoms of DVT have resolved

12. DEEP VEIN THROMBOPHLEBITIS (DVT) • IMPLEMENTATION • Monitor PT and INR during warfarin (Coumadin) therapy • Monitor for the hazards and side effects associated with anticoagulant therapy • Administer analgesics as prescribed to reduce pain • Administer diuretics as prescribed to reduce lower extremity edema • Provide client teaching

13. ASSESSING FOR PERIPHERAL EDEMA From Black, J., Hawks, J, and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders

14. DEEP VEIN THROMBOPHLEBITIS (DVT) • CLIENT EDUCATION • Hazards of anticoagulation therapy • Signs and symptoms of bleeding • Avoid prolonged sitting or standing, constrictive clothing, or crossing legs when seated • Elevate the legs for 10 to 20 minutes every few hours each day • Plan a progressive walking program

15. DEEP VEIN THROMBOPHLEBITIS (DVT) • CLIENT EDUCATION • Inspect the legs for edema and how to measure the circumference of the legs • Antiembolism stockings (hose) as prescribed • Avoid smoking • Avoid any medications unless prescribed by the physician • Importance of follow-up physician visits and laboratory studies • Obtain and wear a Medic Alert bracelet

16. ANTIEMBOLISM HOSE From Elkin MF, Perry AG, Potter PA: Nursing interventions and clinical skills, ed. 2, St. Louis, 2000, Mosby.

17. VENOUS INSUFFICIENCY • DESCRIPTION • Results from prolonged venous hypertension that stretches the veins and damages the valves • The resultant edema and venous stasis causes venous stasis ulcers, swelling, and cellulitis • Treatment focuses on decreasing edema and promoting venous return from the affected extremity • Treatment for venous stasis ulcers focuses on healing the ulcer and preventing stasis and ulcer recurrence

18. VENOUS INSUFFICIENCY • ASSESSMENT • Stasis dermatitis or discoloration along the ankles extending up to the calf • Edema • The presence of ulcer formation

19. PERIPHERAL VASCULAR DISEASE From Bryant RA (1992): Acute and chronic wounds: nursing management, St. Louis: Mosby. Courtesy of Abbott Northwestern Hospital, Minneapolis, MN.

20. VENOUS INSUFFICIENCY • WOUND CARE • Provide care to the wound as prescribed by the physician • Assess the client’s ability to care for the wound, and initiate home care resources as necessary • If an Unna boot (a dressing constructed of gauze moistened with zinc oxide) is prescribed, it will be changed by the physician weekly

21. VENOUS INSUFFICIENCY • WOUND CARE • The wound is cleansed with normal saline prior to application of the Unna boot; providone-iodine (Betadine) or hydrogen peroxide is not used because they destroy granulation tissue • The Unna boot is covered with an elastic wrap that hardens, to promote venous return and prevent stasis • Monitor for signs of arterial occlusion from an Unna boot that may be too tight • Keep tape off of the client’s skin

22. VENOUS INSUFFICIENCY • MEDICATIONS • Apply topical agents to wound as prescribed to debride the ulcer, eliminate necrotic tissue, and promote healing • When applying topical agents, apply an oil-based agent as petroleum jelly (Vaseline) on surrounding skin, because debriding agents can injure healthy tissue • Administer antibiotics as prescribed if infection or cellulitis occur

23. VENOUS INSUFFICIENCY • CLIENT EDUCATION • Wear elastic or compression stockings during the day and evening as prescribed • Put on elastic stockings upon awakening before getting out of bed • Put a clean pair of elastic stockings on each day and that it will probably be necessary to wear the stockings for the remainder of life

24. VENOUS INSUFFICIENCY • CLIENT EDUCATION • Avoid prolonged sitting or standing, constrictive clothing, or crossing legs when seated • Elevate the legs for 10 to 20 minutes every few hours each day • Elevate legs above the level of the heart when in bed

25. VENOUS INSUFFICIENCY • CLIENT EDUCATION • The use of an intermittent sequential pneumatic compression system, if prescribed; instruct the client to apply the compression system twice daily for 1 hour in the morning and evening • Advise the client with an open ulcer that the compression system is applied over a dressing

26. VARICOSE VEINS • DESCRIPTION • Distended protruding veins that appear darkened and tortuous • Vein walls weaken and dilate, and valves become incompetent • ASSESSMENT • Pain in the legs with dull aching after standing • A feeling of fullness in the legs • Ankle edema

27. NORMAL VEINS AND VARICOSITIES From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders

28. VARICOSE VEINS From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby

29. VARICOSE VEINS • TRENDELENBURG TEST • Place the client in a supine position with the legs elevated • When the client sits up, if varicosities are present, veins fill from the proximal end; veins normally fill from the distal end

30. TRENDELENBURG TEST From Jarvis, C. (2000). Physical examination and health assessment, ed 3, Philadelphia: W.B. Saunders

31. VARICOSE VEINS • IMPLEMENTATION • Assist with the Trendelenburg test • Emphasize the importance of antiembolism stockings as prescribed • Instruct the client to elevate the legs as much as possible • Instruct the client to avoid constrictive clothing and pressure on the legs • Prepare the client for sclerotherapy or vein stripping, as prescribed

32. SCLEROTHERAPY • DESCRIPTION • A solution is injected into the vein followed by the application of a pressure dressing • An incision and drainage of the trapped blood in the sclerosed vein is performed 14 to 21 days after the injection, followed by the application of a pressure dressing for 12 to 18 hours

33. VEIN STRIPPING • DESCRIPTION • Varicose veins are removed if they are larger than 4 mm in diameter or if they are in clusters • PREOPERATIVE • Assist the physician with vein marking • Evaluate pulses as a baseline for comparison postoperatively

34. VEIN STRIPPING • POSTOPERATIVE • Maintain elastic (Ace) bandages on the client’s legs • Monitor the groin and leg for bleeding through the elastic bandages • Monitor the extremity for edema, warmth, color, and pulses • Elevate the legs above the level of the heart

35. VEIN STRIPPING • POSTOPERATIVE • Encourage range-of-motion exercises of the legs • Instruct the client to avoid leg dangling or chair sitting • Instruct the client to elevate the legs when sitting • Emphasize the importance of wearing elastic stockings after bandage removal

36. PERIPHERAL ARTERIAL DISEASE (PAD) • DESCRIPTION • A chronic disorder in which partial or total arterial occlusion deprives the lower extremities of oxygen and nutrients • Tissue damage occurs below the level of the arterial occlusion • Atherosclerosis is the most common cause of PAD

37. ARTERIES IN THE LEG From Jarvis, C. (2000). Physical examination and health assessment, ed 3, Philadelphia: W.B. Saunders

38. PERIPHERAL ARTERIAL DISEASE (PAD) • ASSESSMENT • Intermittent claudication (pain in the muscles resulting from an inadequate blood supply) • Rest pain, characterized by numbness, burning or aching in the distal portion of the lower extremities, that awakens the client at night and is relieved by placing the extremity in a dependent position • Lower back or buttock discomfort

39. PERIPHERAL ARTERIAL DISEASE (PAD) • ASSESSMENT • Loss of hair and dry scaly skin on the lower extremities • Thickened toenails • Cold and gray-blue color of skin in the lower extremities • Elevational pallor and dependent rubor in the lower extremities • Decreased or absent peripheral pulses

40. PERIPHERAL ARTERIAL DISEASE (PAD) • ASSESSMENT • Signs of arterial ulcer formation occurring on or between the toes, or on the upper aspect of the foot, that are characterized as painful • Blood pressure measurements at the thigh, calf, and ankle are lower than the brachial pressure (normally BP readings in the thigh and calf are higher than those in the upper extremities)

41. ARTERIAL OBSTRUCTIONS AND CORRESPONDING AREAS OF CLAUDICATION From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders

42. ARTERIAL INSUFFICIENCY From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.

43. GANGRENE From Auerbach PS: Wilderness Medicine: Management of wilderness and environmental emergencies, ed. 3, St. Louis, 1995, Mosby.

44. PERIPHERAL ARTERIAL DISEASE (PAD) • IMPLEMENTATION • Assess pain • Monitor the extremities for color, motion and sensation, and pulses • Obtain BP measurements • Assess for signs of ulcer formation or signs of gangrene • Assist in developing an individualized exercise program that is initiated gradually and slowly increased

45. PERIPHERAL ARTERIAL DISEASE (PAD) • IMPLEMENTATION • Encourage prescribed exercise, which will improve arterial flow through the development of collateral circulation • Instruct the client to walk to the point of claudication, stop and rest, then walk a little further

46. PERIPHERAL ARTERIAL DISEASE (PAD) • IMPLEMENTATION • As swelling in the extremities prevents arterial blood flow, instruct the client to elevate his or her feet at rest, but to refrain from elevating them above the level of the heart, because extreme elevation slows arterial blood flow to the feet • In severe cases of PAD, clients with edema may sleep with the affected limb hanging from the bed or they may sit upright in a chair for comfort

47. PERIPHERAL ARTERIAL DISEASE (PAD) • CLIENT EDUCATION • Avoid crossing the legs, which interferes with blood flow • Avoid exposure to cold (causes vasoconstriction) to the extremities and to wear socks or insulated shoes for warmth at all times • Never to apply direct heat to the limb such as with a heating pad or hot water, because the decreased sensitivity in the limb may result in burning

48. PERIPHERAL ARTERIAL DISEASE (PAD) • CLIENT EDUCATION • Inspect the skin on the extremities daily and to report any signs of skin breakdown • Avoid tobacco and caffeine because of their vasoconstrictive effects • Use of hemorrheologic and antiplatelet medications as prescribed • Importance of taking all medications prescribed by the physician

49. PERIPHERAL ARTERIAL DISEASE (PAD) • PROCEDURES TO IMPROVE ARTERIAL BLOOD FLOW • Percutaneous transluminal angioplasty • Laser-assisted angioplasty • Atherectomy • Bypass surgery (aortofemoral or femoral-popliteal)

50. RAYNAUD’S DISEASE • DESCRIPTION • Vasospasms of the arterioles and arteries of the upper and lower extremities • Vasospasm causes constriction of the cutaneous vessels • Attacks are intermittent and occur with exposure to cold or stress • Affects primarily fingers, toes, ears, and cheeks