Transcript Varicose Veins

Peripheral Vascular
Disease:
“Venous” Disorders
NUR 1021
MTC
Spring 2016
Venous Disorders
•
•
•
•
Venous thromboembolism
Chronic venous insufficiency
Leg ulcers
Varicose veins
Venous Thromboembolism
• Venous thromboembolism (VTE)
– One of health care's greatest challenges
– Includes both thrombus & embolus
complications
– Millions of people in U S are affected by
DVT each year
– Many die from pulmonary embolism
Virchow triad- 3 conditions associated
with thrombus formation
– Vessel damage
• Damaged endothelium stimulates
platelet activation & initiates the
coagulation cascade
– Venous stasis
• Valves are dysfunctional or the muscles
of the extremities are inactive
– Increased blood coagulability
• Occurs in blood dyscrasias or sepsis
Predisposing Factors
– 1.
•
•
•
•
Vessel damage
Direct trauma
Post hip or knee replacement surgery
IV catheter>48 hr
Irritating meds
– 2. Stasis of blood
•
•
•
•
– 3.
•
•
•
Heart failure, shock
Immobility; prolonged sitting
Obesity, Pregnancy
Constrictive clothing
Hypercoagulability of blood
Oral Contraceptives
Malignant disease
Blood dyscrasia
Blood Flow and Function of Valves in Veins
Incompetent valves lead to venous stasis
Formation of thrombus
• Frequently accompanies phlebitis
– Venous thrombosis occurs more
frequently in veins of lower extremities
• Venous thrombi
– Aggregates of platelets attached to vein
wall
– “tail”like appendage of fibrin, WBC’s &
multiple RBC’s
Venous Thrombus Grows
• The “tail” can grow in direction of
blood flow
• Dangerous – parts of thrombus can
break off and occlude pulmonary
vessels
Signs and Symptoms of DVT
• Classic -calf or groin tenderness
• Pain and sudden onset of unilateral
swelling of the leg
• Pain in calf on dorsiflexion of the
foot (positive Homans’ sign)
– False-positive findings are common
• Functional impairment
Assessment
• Superficial vein
– Assess for induration (hardening) along
the blood vessel
– Warmth, edema, tenderness & redness
may also be present in superficial & DVT
• Deep Vein Thrombosis
– Edema in one extremity suggests DVT
• May measure and compare right and left calf
and thigh
Preventive interventions
• Prior hx of VTE- reoccurrence @ rate
of 25% within 5 yrs
–
–
–
–
–
TED hose; SCD’s; venous foot pumps
Leg exercise
Early ambulation post-op
Adequate hydration
Prophylactic Lovenox s/c
If DVT diagnosed:
•
•
•
•
•
Bedrest 5-7 days
Elevate leg
NO massage of leg ever
Warm moist compresses
Pain med
Diagnosis
• Venous duplex ultrasonography
– Noninvasive ultrasound -assesses flow of
blood in veins of the arms and legs
• Impedence Plethysmography
– assess venous outflow & detects most
DVTs above the popliteal vein
• MRI- useful in finding DVT in
proximal deep veins and inferior vena
cava or pelvic veins
D-dimer test -global marker
of coagulation activation
• Lab Test- Normal results: <250 ng/mL
– Measures fibrin degradation products
produced from fibrinolysis (clot
breakdown
– Used for the diagnosis of DVT when few
clinical signs
– Useful as adjunct to noninvasive testing
D-dimer – reasons for altered results
• Negative d-dimer test
– Can exclude a DVT without an ultrasound
• False negative: occurs if patient on
anticoagulant therapy
• False positive:
– Recent surgery, trauma, infection &
numerous other conditions can cause a
false positive
Lovenox
• Low molecular weight heparin, smaller
molecule size
• For sub-q use only- prefilled syringe
• Pt may learn self-injection for home
use.
• Inhibits thrombin formation
– Inhibits factors 11a & factor Xa
More on Lovenox
• Binds less to plasma proteins & has a
longer half-life & more predictable
response
• Routine coagulation tests typically
not required
• Monitor complete blood count at
regular intervals
Drug Therapy
• Anticoagulants used routinely for
VTE prevention and treatment
• Goal of drug therapy for VTE
prophylaxis
– Prevent clot formation
• Goal in treatment of confirmed VTE
– Prevent propagation of the clot &
development of any new thrombi
Prevent clot from breaking off and going to
lung → Pulmonary Embolus
Heparin
• Action: antagonist to thrombin.
– Does NOT dissolve clots
• Effect is immediate and short-lived.
– Inhibits Factor II
• Usually used for thromboembolic episodes
and vascular/cardiac surgeries, or for high
risk patients
– Adm. for 5 days to prevent extension of clot
– Then begin oral therapy – warfarin (Coumadin)
Medical Treatment
• Dosage of Heparin:
– Monitor aTTP Heparin IV: until
therapeutic PTT levels reached, then
Coumadin po.
• Antidote for Heparin: Protamine
sulfate (NCLEX likes to ask questions
like this)
Lab Tests for the Patient on
Heparin
• aPTT (Activated Partial Thromboplastin
Time) – Normal 30-40sec
– Therapeutic level is 1 1/2 to 2 1/2 times
control.
Care of the Patient on Heparin
• IV - slow drip, based on pts weight
and aPTT results.
• May give sub-q in abdomen
• Monitor for bleeding- No razors
• Care when brushing teeth
• Don’t take ASA products
• Monitor for hematuria & blood in
stool
NCLEX Challenge
• The client is receiving heparin therapy for a
venous thromboembolism (VTE). Which activated
partial thromboplastin time (aPTT) indicates that
anticoagulation is adequate?
• a. The client’s aPPT is half of the control value.
• b. The client’s aPPT is the same as the control
value.
• c. The client’s aPPT is twice the control value.
• d. The client’s aPPT is five times the control
value.
NCLEX Challenge
• A client who is receiving unfractionated heparin is
experiencing excessive bleeding. Which medication
will the nurse administer?
• a. Warfarin
• b. Vitamin K
• c. Enoxaparin
• d. Protamine sulfate
Coumadin (warfarin)
• Slows down liver’s
• PT (Prothrombin
production of Vit. K
Time) must be
1 1/2 to 2 times
• Long term therapy:
normal (11 - 13) to
3-6 months
be at a therapeutic
• Oral: 2-5mg/day
level.
• Use INR & PT to
• Antidote: Vitamin K
monitor therapy
injection
Food-Drug Interaction
• Patients on Coumadin
– Encouraged to limit dietary intake of green
leafy vegetables, i.e. spinach →contain a lot of
Vit K
• Knowing what we know about Vit K and the
synthesis of prothrombin, what is the
problem if the patient takes in a lot of Vit
K in foods?
INR – International Normalized
Ratio – What is it?
• A specific thromboplastin reagent
used to achieve clot formation
– affects the amount of time it takes to
form the clot.
• A patient on coumadin used to have
great variations in the Protimes when
done by different laboratories.
INR continued…
• To avoid these variations, the WHO
developed INR to standardize PT test
• Developed a thromboplastin from human
brain that became the standard
– Normal = 0.75-1.25
• Venous thromboembolism:
– Target INR range 2.0–3.0
Self-Monitoring of INR
• Self-monitoring
– Gold standard of
care
– Individuals using
self monitoring
remain within
therapeutic range
over 70% of the
time
Other Medical Therapy
• Aspirin 81 mg/day (antiplatelet)
• Fibrolytics: (dissolve clots)
– Catheter-directed thrombolytics
directly dissolve clot(s) & reduce the
acute symptoms
• Streptokinase
• TPA
• Urokinase
– Risk of bleeding
NCLEX Challenge
• The health care provider has prescribed the client
sodium warfarin (Coumadin) while he or she is still
receiving intravenous heparin. Which is the nurse’s
best action?
• a. Administer the medications as prescribed.
• b. Turn off the heparin drip for 1 hour before
administration of the warfarin.
• c. Discontinue the heparin drip completely
before warfarin administration.
• d. Hold the dose of warfarin.
Surgical Treatment
• Venous thrombectomy
– Removal of a thrombus through an
incision in the vein
– Done if massive occlusion does not
respond to medical therapy
– Thrombus if 1-2 days onset
– Care similar to having arterial surgery
Vena cava interruption device
(Greenfield filter)
• Inserted percutaneously
through right femoral or
right internal jugular veins.
• Sieve-type” obstruction
Filter device is opened
and spokes penetrate
the vessel walls
– Permits filtration of clots
without interruption of blood
flow
Venous Ulcers
• Venous insufficiency
– Occurs as result of prolonged venous
hypertension
• Stretches veins & damages valves
• Damaged valves in veins results in retrograde
blood flow→ pooling of blood in the legs
• Hydrostatic pressure in the veins increases
and serous fluid and RBCs leak from the
capillaries and venules into the tissue,
resulting in edema
Venous ulcers
• Stasis of blood over time results in
venous stasis ulcers, swelling and
cellulitis
– Enzymes in the tissue eventually break
down RBCs, causing the release
hemosiderin→ brownish discoloration
– Skin of the lower leg -thick, fibrous
(hard) subcutaneous tissue
Venous ulcers (cont.)
• Located above the
medial malleolus
• Often quite painful
particularly when
edema or infection
is present
• Pain may be worse
when the leg is in a
dependent position
Care for Venous Stasis Ulcers
• Compression-essential for CVI treatment,
venous ulcer healing, and prevention of
ulcer recurrence
• Variety of options for compression therapy
– Elastic wraps
– Custom-fitted graduated compression
stockings
– Paste bandage (Unna boot) with an
elastic wrap
Care for Venous Stasis Ulcers (cont.)
• Make sure that coexistent PAD is not
present before compression therapy begun
• Moist environment dressings - used in
conjunction with compression therapy
– More effective in hastening the healing
of venous leg ulcers than dry dressings
– Options include hydrocolloids, hydrogels,
foams, calcium alginates, etc.
Debridement with:
• Wet to dry NS dressings
• Enzymatic ointments (eg Silvadene,
Accuzyme) and N/S dressings
• Calcium alginate dressing (Sorbsan)
– From seaweed. Pulls drainage away from
the wound. Absorbs large amounts of
drainage associated with venous ulcers.
• Debrisan Beads
– Absorb wound secretions, turn yellow,
remove and replace q 24-48 hours.
Dressings for venous ulcers:
• Negative pressure dressings
– Wound Vac-↓ healing time in complex
wounds
• Hyperbaric oxygen-use if no healing
after 30 days
– Enhances phagocytosis
• Hydrocolloids popular choice (DUOderm) - leave on 3-5 days;
Compression Treatment:
• Compression Dressing or Hose
– compression increases velocity of blood
flow in deep veins and venous return to
the heart- underlying venous ulcer
problem.
– Unna’s Boot - moistened gauze (Zinc
Oxide) applied toes - knees, covered
with elastic wrap that hardens, changed
1x wk. per NP or Dr.
This leg looks pretty good yet!!
Varicose Veins
• Vein wall weakens & dilates
• Venous pressure increases
• Valves become incompetent
Etiology of Varicose Veins
•
•
•
•
•
Heredity
Pregnancy
Obesity
Extreme height
Heart disease
• Occupations with
prolonged standing
or sitting
– nurses, hair
stylists,
construction
workers, teachers,
office workers,
postal workers
Pathophysiology
• Vein wall weakens & dilates
–
–
–
–
Venous pressure increases
Valves become incompetent
Vessels dilate more
Veins become tortuous & distended
Signs and Symptoms
•
•
•
•
•
•
•
Distended, protruding veins
Muscle fatigue in lower legs
Feeling fullness in legs
Night cramps
Pain-most prominent when standing
Sx relieved by elevating legs
If untreated: Chronic venous
insufficiency
Prevention
•
•
•
•
Avoid wearing socks too tight@ top
Avoid crossing legs at thighs
Avoid sitting or standing for long periods
Elevate legs 3-6” higher than heart when
resting
• Walk 1-2 miles/day
• Compression stockings
• Weight reduction if obese
OK- This works to get the feet up!!
Medical Management
• Deep Veins: Must be patent in order
to operate on superficial veins.
• Vein Ligation and Stripping:
– Saphenous system
•
•
•
•
•
Incise at groin
Incision 2-3 cm below knee
Thread wire length of vein to ligation
Pull wire –stripping/removing vein
Pressure & elevation minimize bleeding
Post op Care
• FOB elevated
• ROM of legs q 1 hr
• Maintain firm
elastic stockings 1
week.
• Do circulation
checks
• Keep leg elevated
• Walk postop. 510min/q 1 hr first
24 hrs.
• DO NOT Sit or
Stand Still !
• Leg will look
bruised - warn pt.
• Pain control - mild
analgesics
A patient with visible varicose veins wants to have surgery to
remove them because of leg pain. What would be the most
appropriate response for the nurse to make to this patient?
a.
"Surgery will have a good cosmetic effect, but will not relieve
the discomfort associated with varicose veins."
b. "All varicose veins should be surgically removed to restore
adequate blood flow to your legs and prevent gangrene."
c. "Often measures such as elevating your legs and elastic
stockings can relieve the discomfort associated with varicose
veins."
d. "Surgery is never indicated unless the varicose veins are
interfering with circulation. Have you tried cosmetic measures
to cover them up?"
A patient is recovering from surgery for
varicose veins. What information should the
nurse include in this patient’s postoperative
teaching?
Select all that apply.
1. Elevate the extremities.
2. Increase ambulation gradually.
3. Sit for no more than 90 minutes at a time.
4. Avoid standing for more than 30 minutes.
5. Keep pressure stockings on continuously 1 week.
Sclerotherapy
• Cosmetic for Spider Veins
• Irritating chemical - inject into vein
to produce phlebitis and fibrosis.
• May use after postop vein stripping
• In MD office – does not require
sedation
• Use of foam sclerosant
– Studies showing more effective in
obliteration of varicose veins
• Use of mild
analgesic- minor
burning for 1-2
days
• Anti-embolism
hose- 5 days
• Then graduated
compression hose
x 5 wk.
• Encourage walking
Attitude is
a little thing
that makes a big
difference.
Winston Churchill