Perfusion 4 NSG 353 Venous Thromboembolism (VTE), Varicose Veins, Chronic Venous Insufficiency and Venous Leg Ulcers

Venous Thromboembolism (VTE)

- Involves formation of a thrombus in association with inflammation of the vein

- Blood clot forms in a vein

- Most common disorder of the veins

- two classifications

Superficial vein thrombosis (less serious)

- Has been considered a benign disorder

- However those who have superficial may also have deep vein thrombosis and pulmonary emboli

Deep Vein Thrombosis (DVT)

- Most common—iliac or femoral veins

- Venous thromboembolism (VTE) is preferred term

Venous Thromboembolism (VTE) Etiology Virchow's triad

- Venous stasis- (blood not moving)

- Damage of the endothelium (inner lining of vein)-

- Hypercoagulability of the blood - (blood clots easily)

DVT Clinical Manifestations

- May or may not have unilateral leg edema

- pain

- tenderness with palpation

- dilated superficial veins

- a sense of fullness in thigh or calf

- paresthesia

- warm skin

- erythema

- systemic temperature greater than 100.4

- If inferior vena cava involved, both legs may be edematous and cyanotic

- Not only lower extremities : Symptoms would be in arms, neck, back and face

Deep Venous Thrombosis Diagnosis

- Based on clinical assessment

- D-dimer testing

- Duplex ultrasound

Deep Venous Thrombosis Complications

- Pulmonary Emboli (PE)—most serious

- S/S depend upon size and extent of PE

- Dyspnea

- Tachypnea

- Slow onset or Sudden onset of chest pain

- Hypoxemia—mild to moderate

- Massive PE—sudden change in mental status, hypotension, impending doom--death

Deep Venous Thrombosis/VTE Interprofessional Care

- Prevention and prophylaxis

- Thromboprophylaxis policy

- Early and aggressive mobilization

- Up in chair for meals and walk 4-6 times per day

- Graduated compression stockings—fitted correctly

- Intermittent pneumatic compression devices

- Anticoagulant Therapy for VTE Prophylaxis

- Lab monitoring is not needed

DVT/VTE Treatment Thrombin inhibitors (direct or indirect)

- Heparin

- Enoxparin

- Not taken PO

- Heparin drip (IV)- blood monitoring for therapeutic level is aPTT or antifactor xa

- therapeutic is aPTT 46-70

-LOW (<46)-->Not enough anticoagulation--> ↑ increase drip

- NORMAL (46-70) --> Therapeutic-->Keep same rate

- >70 is considered critical

- HIGH (>70)--> Too much → bleeding risk-->↓ decrease or hold

- Protamine Sulfate- reversal

- Heparin also monitor platelet levels ( Thrombocytopenia)

DVT /VTE Vitamin K antagonists (Warfarin)

- INR therapeutic monitoring usually want 2-3 (sometime 3.5)

- Pt needs routine blood monitoring

- Have to be careful to eat the same amount of vit k in their diet every day

- VItamin K foods : Asparagus.; Broccoli, Brussels sprouts; Collard greens; Kale

- Better taken for when they go home

- can be given PO

- <2-->Not enough anticoagulation-->↑ increase dose

- 2-3-->Therapeutic-->keep same

- >3-->Bleeding risk-->↓ decrease

Venous Thromboembolism (VTE) risk factor

- Post op

- Oral contraceptives

- pregnancy

- bedrest. pt

Heparin-Warfarin Bridge

- Heparin: Works FAST (immediate)

- Warfarin: Works SLOW (takes days)

- you stop heparin in bridge therapy When INR is therapeutic (2–3)'

FACTOR Xa INHIBITORS

- Apixaban

- Rivaroxaban

- Benefit- no therapeutic monitoring of INR or aPTT

- expensive

- Reversal agent- Andexanet alfa

Deep Venous Thrombosis/VTE Interprofessional Care

- Surgical and Interventional Radiology Therapies

- Vena cava interruption devices (Greenfield filters)

- filter to trap clots ( PE)

- Percutaneous endovascular Interventional radiology

procedure

- with or without catheter directed thrombolytic

therapy

- severe symptoms" "need rapid treatment

Deep Venous Thrombosis/VTE. Nursing Interventions

- Maintenance of catheter systems

- Monitor for bleeding, embolization and impaired perfusion

- • VTE prevention teaching

Venous Thromboembolism (VTE) Acute Care

- Prevent emboli formation

- Reduce inflammation

- Coagulation teaching

- Monitor labs

- Monitor for and reduce risk of bleeding

- Early ambulation

- Teach patient and caregiver

Venous Thromboembolism (VTE) Ambulatory Care

- Modification of VTE risk factors

- Importance of monitoring labs

- Dietary and drug instructions

- Guidelines for follow-up

- Women—stop oral contraceptives or hormone therapy

Venous Thromboembolism (VTE) Teach patients

- Limit standing or sitting in a motionless, leg-dependent position

- Travel precautions

- Signs and symptoms of PE

- Drug therapy, actions, side effects,

- need for routine lab tests

- what symptoms need immediate attention

- Diet

- Overweight patients

- Exercise program

- Graduated pressure stockings

- might get discharged on levenox

Varicose Veins

- also known as varicosities

- Dilated, tortuous, superficial veins

- Can be small and harmless

- large and bulging

- Primary—idiopathic

- Weakness in vein wall

- More common in women

- Secondary—due to trauma or direct injury,

- previous VTE or excessive vein distension

Varicose Veins Clinical Manifestations

- - Discomfort varies among people

- Worsens with superficial vein thrombosis

- Heavy, achy feeling or pain with prolonged standing and sitting

- Pressure, itching, burning, restless or tired legs, nocturnal leg cramps

- Some symptoms may be relieved by walking or limb elevation

- Superficial vein thrombosis most frequent complication

Varicose Veins Conservative treatment:

- Rest with limb elevation

- Graduated compression stockings

- Leg-strengthening exercises

- Weight loss

- 3E's- elevation, exercise and elastic

Chronic venous insufficiency (CVI)

- Common problem in older adults

- Can lead to venous leg ulcers (sometimes called venous stasis ulcers)

- Usually not life-threatening

- Painful, slow to heal, debilitating and costly

- Adversely affects quality of life

- Blood pools in legs → long-term damage

Chronic Venous Insufficiency and Venous Leg Ulcers Clinical Manifestations

- Lower leg is leathery

- Brownish or brawny appearance

- Edema (persistent)

- Eczema

- Itching

- Pain especially in dependent position

Chronic Venous Insufficiency and Venous Leg Ulcers Complications

- Untreated, wound becomes wider and deeper, increasing risk of infection

- Osteomyelitis—severe infection of bone, bone marrow and surrounding soft tissue

- Malignant changes

- Rare occasions-need for amputation

venous ulcers

- Open sores from poor circulation

- Slow healing

- Wet wounds

- Located near ankles

Chronic Venous Insufficiency and Venous Leg Ulcers Interprofessional Care

- Compression therapy is essential for venous ulcer healing and prevention of recurrence

- Moist dressings are the basis of wound care

- Nutritional status evaluation

- Antibiotics not routinely used—if used must be guided by wound culture

- Grafts may be needed

Chronic Venous Insufficiency and Venous Leg Ulcers Nursing Care

- Teaching self care measures

- Compression therapy compliance and correct use

- Daily moisturizing

- Wound assessment

- Infection

- Improvements

- Activity guidelines

- Proper limb positioning

- Elevation above level of heart to reduce edema

- Daily walking program

- no ted hoes --> Ace wrap instead