Transcript Thrombophlebitis (DVT) 842

Thrombophlebitis (DVT) 842
• Pathophysiology: Clot found either in deep large
veins of the leg. Venous thrombosis or
phlebothrombosis refers just to the clot itself. The
additional inflammation in the vein that
accompanies the clot makes it thrombophlebitis
• Risk factors: prolonged BR, sitting, inactivity,
incompetent valves, presence of catheters or wires,
pregnancy, BCP, lupus, dehydration, and clotting
disorders. Virchow’s triad refers to the
combination of venous stasis, hypercoagulation,
and damage.
Assessment of DVT
• 50% are asymptomatic unless the clot is in
the ileofemoral vein.
• Symptomatic patients and those with
ileofemoral clot have redness, pain, edema,
warmth, decreased movement, +Homan’s
sign (20% reliable).
• Dx Tests: venogram, venous US
Management of DVT
• Preventative:
–
–
–
–
–
–
TEDs
Venodynes
AEEs
SQLMWH (Lovenox)
Early ambulation
fluids
• Acute:
– BR or BRP
– Thrombolytics-may use up
to 3d after dx to dissolve
clot and reduce damage
– Heparin-bolus followed by
infusion with pump
– Warfarin, analgesics, heat
– PTT, PT, INR qam-heparin
and warfarin doses depend
on results
– Monitor for complications
(Pulm. embolism-50%,)
– Surgery-thrombectomy,
vena cava filter
Nursing Management of DVT
• Preventative measures for pts at risk
• Acute cases:
–
–
–
–
–
–
–
–
–
Monitor VS and NV status
Reinforce BR or BRP
Encourage fluids
Monitor IV and labs
Analgesics and heat
Restrict Vit K in diet
Monitor for complications-PE and hemorrhage
TEDs-family needs to know how to apply
Pt education-anticoag tx (845), activity, diet,
complications
Varicose Veins (849)
• Pathophysiology: congenital absence of valves
or acquired valve incompetence from heredity,
DVT, trauma, inflammation, obesity, pregnancy,
prolonged sitting or standing. Usually occurs in
legs and lower trunk in saphenous veins.
Superficial spider veins are called primary
varicosities; deep varicosities are called
secondary.
• S/S: aching, heaviness, itching, swelling,
unsightly appearance
Management of Varicose Veins
• Prevention: support hose, exercise,
elevation
• Sclerotherapy with sclerosing agent,
followed by elastic bandages and walking
• SDS: Vein stripping by tying off great
saphenous vein at saphenofemoral junction,
making incisions along leg, introducing
nylon wire, and pulling vein out.
Nursing Management of
Varicose Veins
• Teach prevention techniques
• Postop nursing care:
–
–
–
–
Maintain firm elastic pressure over whole limb
Regular movement and exercise of legs
FOB up 6-9” above heart level
Monitor for complications: hemorrhage, infection,
nerve damage, DVT
– Analgesics
– Pt education: meds, activity, MD will remove elastic
bandages, watch for bleeding
Leg Ulcers (846)
• Pathophysiology: 75% are venous from
venous insufficiency or severe varicosities.
Poor O2 supply causes necrosis and an open
necrotic lesion. Bacterial infection is a
common complication. Diabetics are
especially vulnerable.
Assessment of Leg Ulcers
• Venous stasis ulcers
– Irregular borders with
serous exudate
– Mild pain
– Ankle or medial or
lateral malleolus
• Arterial ulcers
– Definite border,
usually circular
– Painful
– Dorsal foot or toes
(usually medial hallux
or 5th toe)
– May be necrotic
Management of Leg Ulcers
• Goals are to promote skin integrity, increase
mobility, and provide good nutrition
– 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.
Wound Care Management of
Leg Ulcers
• Goal # 1: Keep wound moist to promote
healing-Tegaderm, hydrocolloids except for deep
or infected wounds
• Goal # 2: Keep wound clean-saline irrigation is
preferred. Necrotic tissue may be debrided with
wet to dry dsgs, enzyme ointments, Debrisan
beads, Ca++alginate, or surgery.
• Goal # 3: Prevent infection-clean or sterile
technique depending on depth of wound. Wound
cultures prn with antibiotic tx if needed.
Wound Care Management
(cont’d)
• Compression with Unna boots or TEDs and
elevation of the leg is needed for a venous
ulcer in order to decrease edema.
• New treatments:
– Apligraft, made from human skin, stimulates
production of growth factors
– Hyperbaric O2 increases O2 tension, which
increases production of fibroblasts and
stimulates collagen growth.
Nursing Management of Leg
Ulcers
• Assess location, size, color, odor, and drainage
• Follow order as to cleaning and dressing of
wound. Use appropriate technique and materials.
• Request wound cultures if needed
• Administer antibiotics and analgesics as ordered
• Teach and reinforce good skin and foot care,
proper diet, appropriate activity, avoidance of
trauma, S/S infection. May need to teach patient
and family dressing changes.
Medications for Peripheral
Vascular Diseases and Anemias
• Peripheral Arterial Occlusive Disease-Trental*
• Acute Arterial Occlusion-anticoagulants
(heparin), thrombolytics (streptokinase)
• Raynaud’s-Ca++channel blocker-(nifedipine*)
• HTN-diuretics-HCTZ*, Ablocker-phentolamine*,
ACEI-Vasotec*, ARB-Cozaar*, Ca++channel
blocker-(diltiazem), BBlocker(atenolol)
• DVT- (heparin), (warfarin)
• Fe Deficiency Anemia-ferrous sulfate*
• Pernicious Anemia-cyanocobalamin*
• Herbal supplement-ginkgo biloba*
Trental (pentoxifylline)
• Action: Decreases blood viscosity, increases
blood flow by increasing flexibility of RBCs
• Indication: Intermittent claudication
• Forms: po, po XR
• Side effects: HA, tremors, dizziness, indigestion,
NV, leukopenia
• Nursing Considerations: Watch BP if pt is on
antihypertensives. Assess for improvement in
activity with continued use.
HCTZ (hydrochlorothiazide)
• Action: Increases excretion of water, sodium,
chloride, and potassium in the distal tubule and
ascending limb of loop of Henle.
• Indications: Edema, HTN, diuresis, CHF
• Form: po
• Side effects: Dizziness, weakness, fatigue,
hypokalemia, NV, anorexia, hepatitis, aplastic
anemia, pancytopenia, glucosuria, allergic reaction
(sulfa)
• Nursing Considerations: Assess daily wts, I&O,
postural BPs, lytes, blood sugar
Regitine (phentolamine)
• Action: Binds to alpha adrenergic receptors,
dilating peripheral blood vessels, lowering
peripheral resistance. and lowering BP
• Indication:HTN secondary to pheochromocytoma
• Forms: IV, IM
• Side effects: Dizziness, hypotension, tachycardia,
angina, dysrhythmias, dry mouth, NVD,
cerebrovascular spasm
• Nursing Considerations: Postural BPs before tx
and q4h, daily wts, I&O
Vasotec (enalapril)
• Action: Suppresses renin-angiotensin-aldosterone
system; prevents conversion of angiotensin I to
angiotension II. Dilates arterial and venous
vessels.
• Indications: HTN, CHF
• Forms: po, IV
• Side effects: Insomnia, dizziness, hypotension,
dysrhythmias, proteinuria, renal failure,
agranulocytosis, neutropenia, dry cough
• Nursing Considerations: Monitor CBC, BP, P.
If pt is on diuretic tx, monitor for syncope
Cozaar (losartan)
• Action: Blocks the vasoconstrictor and
aldosterone-secreting effects of angiotensin II
• Indication: HTN, nephropathy in Type 2 DM
• Forms: po
• Side effects: Dizziness, insomnia, CVA, MI,
dysrhythmias, cough, diarrhea, indigestion, renal
failure, angioedema
• Nursing Considerations: BP, P. Monitor for
edema, lytes, hepatic and renal function before tx
begins
Feosol (ferrous sulfate)
• Action: Replaces iron stores needed for RBC
development, energy, and O2 transport
• Indications: Iron deficiency anemia
• Forms: po
• Side effects: Nausea, epigastric pain,
constipation, black stools
• Nursing considerations: Assess CBC qmo.
Vitamin B-12 (cyanocobalamin)
• Action: Needed for adequate nerve functioning,
protein and carbohydrate metabolism, normal
growth, RBC development, cell reproduction
• Indication: Pernicious anemia
• Forms: po, sq, IM
• Side effects: CHF, pulmonary edema, diarrhea,
anaphylaxis
• Nursing considerations: Check K+ levels q6mo,
folic acid and B-12 levels after 1 wk, reticulocyte
counts
Ginkgo (ginkgo biloba)
• Action: Relaxes blood vessels, inhibits platelet
aggregation, decreases ischemia and edema
• Indications: Peripheral artery disease,
intermittent claudication, to enhance circulation
• Form: po
• Side effects: HA, anxiety, restlessness, NV,
anorexia, diarrhea, rash
• Nursing considerations: Interacts with
anticoagulants, antiplatelets, and some
antidepressants (MAOIs). Don’t use during
pregnancy and lactation.