Chapter 40: Nursing Management Vascular Disorders

Superficial Vein Thrombosis

Typically, superficial leg veins (e.g., varicosities); occasionally, superficial arm veins

Tenderness, rubour, warmth, pain, inflammation and induration along the course of the superficial vein

Vein appears as palpable cord.

Edema rarely occurs.

If left untreated, clot may extend to deeper veins and VTE may occur.

Venous Thromboembolism

Deep veins of arms (e.g., axillary, subclavian), legs (e.g., femoral), and pelvis (e.g., iliac or inferior or superior vena cava) and pulmonary system

Tenderness to pressure over involved vein, induration of overlying muscle, venous distension

Edema

Mild to moderate pain possible

Deep rubour in area caused by venous congestion

Systemic temperature possibly greater than 38°C

Note: Some patients may have no obvious physical changes in the affected extremity.

Embolization to lungs (pulmonary embolism) may occur and may result in death.∗

Pulmonary hypertension and post-thrombotic syndrome with or without venous leg ulceration may develop.

Risk Factors for Venous Thromboembolism

Venous Stasis

• Advanced age

• Atrial fibrillation

• Bed rest

• Chronic heart failure

• Fractured leg or hip

• Long trips without adequate exercise

• Obesity

• Orthopedic surgery (especially lower extremity)

• Pregnancy and postpartum period

• Prolonged immobility

• Spinal cord injury or limb paralysis

• Stroke

• Varicose veins

Hypercoagulability of Blood• Antiphospholipid antibody syndrome• Antithrombin III deficiency• Dehydration or malnutrition• Elevated (clotting) factor VIII or lipoprotein (a) level• Erythropoiesis-stimulating medications (e.g., epoetin alfa [Eprex])• Factor V Leiden or prothrombin gene mutation• High altitudes• Hormone replacement therapy

• Hyperhomocysteinemia

• Malignancies (especially breast, brain, hepatic, pancreatic, and gastrointestinal)

• Nephrotic syndrome

• Oral contraceptives, especially in women >35 yr of age who use tobacco

• Polycythemia vera

• Pregnancy and postpartum period

• Protein C deficiency

• Protein S deficiency

• Sepsis

• Severe anemia

• Tobacco use

Endothelial Damage• Abdominal and pelvic surgery (e.g., gynecological or urological surgery)• Caustic or hypertonic intravenous medications• Fractures of pelvis, hip, or leg• History of previous venous thromboembolism (VTE)• In-dwelling, peripherally inserted central vein catheter• Intravenous drug misuse• Trauma

Venous Thromboembolism (definition)

a blood clot that originates in a vein

Superficial Vein Thrombosis (Definition)

formation of a thrombus in a superficial vein, usually the greater or lesser saphenous vein

Deep Vein Thrombosis

blood clot forms in a large vein, usually in a lower limb

Post-thrombotic syndrome

characterized by chronic persistent pain & edema and ulceration of limb that had DVT

Manifestations of PTS typically begin within 2 years of a VTE. Sequential compression devices may be used for patients with severe PTS.

Phlegmasia cerulea dolens

(swollen, blue, painful leg), a very rare complication, may develop in the advanced stages of cancer. It results from one or more severe lower extremity VTEs that involve the major leg veins, causing near-total occlusion of venous outflow.

typically experience sudden, massive swelling, deep pain, and intense cyanosis of the extremity. If untreated, the venous obstruction causes arterial occlusion and gangrene and necessitates amputation.

ACT, aPTT, INR, bleeding time, Hb, Hct, platelet count

Alterations if patient has underlying blood dyscrasia (e.g., increased Hb and Hct in patient with polycythemia)

D-dimer (nonspecific)

Fragment of fibrin is formed as result of fibrin degradation and clot lysis. Elevated results suggest venous thromboembolism (VTE).

Normal results: 3.0 mmol/L (<50 ng/mL)

Fibrin monomer complex

Forms when concentration of thrombin exceeds that of antithrombin.

Presence is evidence of thrombus formation and suggests VTE.

Normal results: <10 mg/dL (<10 mcg/mL)

Venous compression ultrasonography

Evaluation of deep femoral, popliteal, and posterior tibial veins

Normal finding: Veins collapse with application of external pressure.

Abnormal finding: Veins fail to collapse with application of external pressure; failure to collapse suggests a thrombus.

Duplex ultrasonography

Combination of compression ultrasonography with spectral and colour flow Doppler study. Veins are examined for respiratory variation, compressibility, and intraluminal filling defects to help determine location and extent of thrombus (most widely used test to diagnose VTE).

Computed tomography venography (CTV)

Spiral CT used to evaluate veins in the pelvis, thighs, and calves after injection of venous-phase contrast material; involves less contrast material than does traditional venography; may be performed simultaneously with CT angiography of pulmonary vessels for patients being evaluated for VTE

Magnetic resonance venography

MRI with specialized software to evaluate blood flow through veins; can be performed with or without contrast material; highly accurate for pelvic and proximal veins; less accurate for calf veins; can distinguish acute and chronic thrombus

Contrast venography (phlebography)

Radiographic determination of location and extent of clot with contrast media to outline filling defects; identifies the presence of collateral circulation; once the gold standard of invasive venous studies but currently rarely performed

Sequential compression devices (SCDs)

are inflatable garments wrapped around the legs that apply intermittent external pressure to the lower extremities. They are often used in combination with graduated compression stockings. The nurse needs to ensure correct fit by accurately measuring the extremities. SCDs will not provide effective VTE prophylaxis if they are not applied correctly, if the fit is incorrect, or if the patient does not wear the device continuously while at rest. VTE prevention is enhanced if SCDs are used along with anticoagulation.

Three major classes of anticoagulants are available:

(1) vitamin K antagonists,

(2) thrombin inhibitors (both indirect and direct), and

(3) factor Xa inhibitors

Vitamin K antagonists

Anticoagulant

Warfarin (Coumadin)

PO

INR is used for monitoring therapeutic levels. Medications are administered at the same time each day. Variations of certain genes (e.g., CYP2CP, VKORC1) may influence response to the medication.

Antidote: Vitamin K

Unfractionated heparin

Thrombin Inhibitors: Indirect

Heparin sodium

Continuous IV

Subcut

Therapeutic effects are measured at regular intervals by the aPTT or ACT. CBC is monitored at regular intervals. If administered subcutaneously, medication should be injected deep into subcutaneous tissue (preferably into the abdominal fatty tissue or above the iliac crest), inserting the entire length of the needle. Skinfold is held during injection but released before needle is removed. The nurse should not aspirate, not inject intramuscularly, and not rub site after injection. Sites should be rotated.

Antidote: Protamine

Low-molecular-weight heparin (LMWH)

Thrombin Inhibitors: Indirect

Enoxaparin

Tinzaparin

Dalteparin

Nadroparin

Enoxaparin

Dalteparin

Subcut

Routine coagulation tests are typically not required. CBC is monitored at regular intervals. Air bubble should not be expelled before medication is administered subcutaneously. The nurse should follow remaining administration guidelines as described for unfractionated heparin. Dosage should be reduced in patients with renal impairment. Extreme caution should be used in patients with a history of HIT.

Antidote: Protamine

Hirudin derivatives

Lepirudin

IV or subcut

IV

Bivalirudin

IV or subcut

Therapeutic effect is measured by ACT or aPTT. Used in patients with HIT when anticoagulation is still required.

Antidote: None

Synthetic thrombin inhibitors

Thrombin Inhibitors: Direct

Argatroban

IV

Dabigatran

Subcut

Therapeutic effect is measured by aPTT. Used in patients at risk for or with HIT.

Antidote: None

Factor Xa Inhibitors

Fondaparinux

Subcut and IV

Rivaroxaban

Apixaban

PO

Routine coagulation tests are not required. CBC and creatinine are monitored at regular intervals. Air bubble should not be expelled before medication is administered. The nurse should follow remaining administration guidelines as described for unfractionated heparin.

Approved for VTE prophylaxis and treatment. For patients undergoing surgery, initial dose should be given no earlier than 6 hr postoperatively.

Should be administered with caution in older patients and in patients with impaired renal function.

May cause thrombocytopenia. If uncontrollable bleeding occurs, treatment with recombinant factor VIIa may be effective.

Antidote: None

International normalized ratio (INR)

• Vitamin K antagonists (e.g., warfarin [Coumadin])

Normal Value

0.75–1.25

Therapeutic Value

2–3 (for PAD)

Activated partial thromboplastin time (aPTT)

• Unfractionated heparin (e.g., heparin)

• Hirudin derivatives (e.g., bivalirudin [Angiomax])

• Synthetic thrombin inhibitors (e.g., argatroban; dabigatran [Pradaxa])

Normal Value

25–35sec

Therapeutic Value

46–70sec

Activated clotting time (ACT)

• Unfractionated heparin

• Hirudin derivatives

• Synthetic thrombin inhibitors

Normal Value

70–20sec∗

Therapeutic Value

>300sec

Anti-factor Xa

• Low-molecular-weight heparin (e.g., enoxaparin)

Normal Value

0U/mL

Therapeutic Value

U/mL

Anti-factor Xa

• Factor Xa inhibitors (e.g., apixaban; rivaroxaban)

Normal Value

0U/mL

Therapeutic Value

No therapeutic level monitored for dosing

heparin-induced thrombocytopenia (HIT).

HIT is an immune reaction to heparin in which the platelet count diminishes severely and suddenly, along with a paradoxical increase in venous or arterial thrombosis. HIT is diagnosed by measurements for the presence of heparin antibodies in the blood. Treatment requires immediately stopping heparin therapy and, if further anticoagulation is required, using a nonheparin anticoagulant

Anticoagulation Therapy for Prevention of Venous Thromboembolism

low-dose unfractionated heparin, LMWH, or fondaparinux is used. If the patient is at low VTE risk, medication prophylaxis is not needed.

Patients with moderate VTE risk (e.g., general, gynecological, or urological surgery) should receive either unfractionated heparin or LMWH.

Patients with high VTE risk (e.g., trauma) should receive unfractionated heparin or LMWH until discharge.

Patients having abdominal or pelvic surgery for cancer or major orthopedic surgery (e.g., total knee or hip replacement) should receive VTE prophylaxis

Anticoagulant Therapy for Venous Thromboembolism Treatment

Patients with confirmed VTE should receive initial treatment with either LMWH, unfractionated heparin, or an oral factor Xa medication.

Oral vitamin K antagonist therapy may be an option. A therapeutic INR is maintained between 2.0 and 3.0 if vitamin K antagonist therapy is used.

treatment of VTE should continue for at least 3 months and may continue longer in some patients

Thrombolytic Therapy for Venous Thromboembolism Treatment

Another treatment option for patients with a thrombus is catheter-directed administration of a thrombolytic medication (e.g., urokinase, tissue plasminogen activator). It dissolves the clot(s), reduces the acute symptoms, improves deep venous flow, reduces valvular reflux, and may help to decrease the incidence of PTS.

Catheter-directed thrombolytic medications directly dissolve clots, reduce the acute symptoms, and decrease the incidence of postphlebitic vein complications.

Vena cava interruption devices

catch clots and prevents them from flowing into the pulmmonary artery

(e.g., inferior vena cava filters) can be inserted percutaneously through the right femoral or right internal jugular veins. The filter device is opened and the spokes penetrate the vessel walls

Vena cava interruption device complications

Complications after insertion of the device are rare but include air embolism, improper placement, migration of the filter, and perforation of the vena cava with retroperitoneal bleeding. Over time, venous congestion can occur from accumulation of trapped clots, requiring filter removal and replacement.

A filter device is recommended with acute PE or proximal VTE of the leg in patients with active bleeding or if anticoagulant therapy is contraindicated.

Percutaneous endovascular interventional radiology procedures

can be used along with catheter-directed thrombolytic therapy, especially for severely symptomatic patients with iliocaval or iliofemoral obstruction (Hattab et al., 2017).

The interventional radiology procedures are like those used in the treatment of lower extremity PAD. The difference is accessing an occluded vein instead of an artery.

Options include mechanical thrombectomy, pharmacomechanical devices, and post-thrombus extraction, angioplasty, and/or stenting.

Anticoagulation therapy is recommended after an iliofemoral interventional radiology procedure. Postprocedure nursing care focuses on

(1) maintaining catheter systems (if continuous infusions);

(2) monitoring for bleeding, embolization, and impaired perfusion; and

(3) VTE prevention teaching

The overall goals for VTE should be reviewed with and agreed on with the patient and include

(a) pain relief,

(b) decreased edema,

(c) no skin ulceration,

(d) no bleeding complications, and

(e) no evidence of pulmonary embolism.

Anticoagulant Therapy Med Alert

• Patients should be instructed to avoid taking aspirin, NSAIDs, fish oil supplements, garlic supplements, ginkgo biloba, and certain antibiotics (e.g., sulfamethoxazole and trimethoprim).

• Patients should be instructed to report bleeding: black or bloody stools, bleeding gums, bloody urine or sputum, coffee-ground or bloody vomit, excessive bruising, nosebleeds, and excessive menstrual bleeding.

• The nurse should assess for signs of bleeding (e.g., hypotension, tachycardia, hematuria, melena, hematemesis, petechiae, ecchymosis).

Safety Alert

• The nurse should observe and teach the patient to observe closely for the following events:

• Any overt or occult bleeding

• Epistaxis and bleeding gingivae

• Blood (visible or occult) in emesis, urine, stool, and sputum

• Oozing or visible bleeding from trauma site or surgical incision

• Excessive menstrual bleeding

• The nurse should monitor vital signs for changes: decreased blood pressure, increased heart rate

• Intramuscular injections should be avoided

• The patient should be assessed for mental status changes, especially in the older patient, because they may indicate cerebral bleeding.

Nursing Interventions for Patients Receiving Anticoagulants

Assessment

• Evaluating appropriate laboratory coagulation tests for target therapeutic levels, if appropriate

• Evaluating lower extremity for ecchymosis/hematoma development if intermittent compression device is used

• Evaluating platelet count for signs of heparin-induced thrombocytopenia (HIT)

• Examining urine and stool for overt signs of blood

• Inspecting skin frequently, especially under any splinting devices

• Monitoring vital signs as indicated

• Notifying the health care provider of any abnormalities in assessments, vital signs, or laboratory values

• Performing assessment of risk for falling per institutional policy and implementing safety measures as needed

• Performing assessments frequently to observe for signs and symptoms of bleeding (e.g., hypotension, tachycardia), clotting, or both

Nursing Interventions for Patients Receiving Anticoagulants

Injections

• Applying manual pressure for at least 10min (or longer if needed) on venipuncture sites

• Avoiding intramuscular injections

• Minimizing venipunctures

• Using small-gauge needles for venipunctures unless ordered that therapy necessitates use of a larger gauge

Nursing Interventions for Patients Receiving Anticoagulants

Routine Care and Patient Education

• Administering stool softeners to avoid hard stools and straining

• Applying graduated compression stockings or sequential compression devices as ordered and with attention to proper size, application, and use

• Applying moisturizing lotion to skin

• Avoiding removal or disruption of established clots

• Avoiding restraints if possible; using only soft, padded restraints if needed

• Instructing patient not to forcefully blow nose

• Instructing patient to avoid restrictive clothing

• Instructing patient to use electric razors, not straight razors

• Instructing patient to use soft toothbrushes or foam swabs for oral care

• Limiting tape application; using paper tape as appropriate

• Lubricating tubes (e.g., suction catheter) adequately before insertion

• Performing physical care in a gentle manner

• Repositioning patient carefully at regular intervals

• Using humidified O2 source

• Using support pads, mattresses, and therapeutic beds as indicated

Varicose Veins

abnormally swollen, twisted veins with defective valves; most often seen in the legs

Primary Varicose Veins

Originate in the superficial saphenous veins. Prolonged standing or increased abdominal pressure

Secondary Varicose Veins

Result from impaired flow in the

deep venous channels

The most common varicose vein symptom is a

heavy, achy feeling or pain after prolonged standing, which is relieved by walking or limb elevation.

Some patients feel pressure or experience an itchy, burning, or cramplike sensation in the affected leg. Swelling or nocturnal leg cramps also may occur.

Superficial varicose veins can be diagnosed by

appearance.

Duplex ultrasonography is the gold standard to evaluate venous anatomy, valvular competence, and venous obstruction.

Sclerotherapy

involves the direct IV injection of a substance that obliterates venous telangiectasias, reticular veins, and small, superficial varicose veins 5 mm or larger in diameter

Commonly used sclerosing agents include detergents (e.g., hypertonic saline), as well as other agents such as foams (e.g., polidocanol) and cyanoacrylate. Direct IV injection of a sclerosing agent induces inflammation and results in eventual thrombosis of the vein.

Potential complications include itching, pain, blistering, edema, hyperpigmentation, necrosis, and recurrence of varicosities, SVT, visual disturbances, and VTE.

compression stocking is worn or an elastic bandage is applied to the leg for several days to maintain pressure over the vein. Long-term compression therapy is advised to help prevent the development of further varicosities.

Laser therapy can be used in

telangiectasias or in larger veins, including greater saphenous vein incompetence.

1. A 50-year-old woman weighs 95 kg and has a history of tobacco use, high blood pressure, high sodium intake, and sedentary lifestyle. When an individualized care plan is developed for this client, which of the following risk factors related to PAD would the nurse determine need to be modified?

a. Salt intake

b. Sedentary lifestyle

c. Tobacco use

d. Excess weight

c. Tobacco use

2. When teaching a patient about rest pain and PAD, what should the nurse explain as the cause of the pain?

a. Vasospasm of cutaneous arteries in the feet

b. Increase in retrograde venous perfusion of the lower legs

c. Decrease in arterial blood flow to the nerves of the feet

d. Decrease in arterial blood flow to the leg muscles during exercise

c. Decrease in arterial blood flow to the nerves of the feet

3. A client with infective endocarditis develops sudden left leg pain with pallor, paresthesia, and a loss of peripheral pulses. What should the nurse's initial action be?

a. Elevate the leg to promote venous return.

b. Start anticoagulant therapy with IV heparin.

c. Notify the health care provider of the change in perfusion.

d. Position the patient in reverse Trendelenburg position to promote perfusion.

c. Notify the health care provider of the change in perfusion.

4. Which clinical manifestations are seen in clients with both Buerger’s disease and clients with Raynaud’s phenomenon? (Select all that apply.)

a. Intermittent low-grade fevers

b. Sensitivity to cold temperatures

c. Gangrenous ulcers on fingertips

d. Colour changes of fingers and toes

e. Episodes of superficial vein thrombosis

b. Sensitivity to cold temperatures

c. Gangrenous ulcers on fingertips

d. Colour changes of fingers and toes

5. A client is admitted to the hospital with a diagnosis of abdominal aortic aneurysm. Which signs and symptoms would suggest that his aneurysm has ruptured?

a. Sudden shortness of breath and hemoptysis

b. Sudden, severe low back pain and bruising along his flank

c. Gradually increasing substernal chest pain and diaphoresis

d. Sudden, patchy blue mottling on feet and toes and rest pain

b. Sudden, severe low back pain and bruising along his flank

6. Which of the following are priority nursing measures 8 hours after an abdominal aortic aneurysm repair?

a. Assessment of cranial nerves and mental status

b. Administration of IV heparin and monitoring of aPTT

c. Administration of IV fluids and monitoring of kidney function

d. Elevation of the legs and application of graduated compression stockings

c. Administration of IV fluids and monitoring of kidney function

7. What is the first priority of interprofessional care of a client with a suspected acute aortic dissection?

a. Reduce anxiety.

b. Control blood pressure.

c. Monitor for chest pain.

d. Increase myocardial contractility.

b. Control blood pressure.

8. Which of the following clients has the highest risk for venous thromboembolism (VTE)?

a. A 62-year-old man with spider veins who is having arthroscopic knee surgery

b. A 32-year-old woman who smokes, takes oral contraceptives, and is planning a trip to Europe

c. A 26-year-old woman who is 3 days postpartum and received maintenance IV fluids for 12 hours during her labour

d. An active 72-year-old man at home recovering from transurethral resection of the prostate for benign prostatic hyperplasia

b. A 32-year-old woman who smokes, takes oral contraceptives, and is planning a trip to Europe

9. Which clinical findings should the nurse expect in a person with an acute lower extremity VTE? (Select all that apply.)

a. Pallor and coolness of foot and calf

b. Mild to moderate calf pain and tenderness

c. Grossly diminished or absent pedal pulses

d. Unilateral edema and induration of the thigh

e. Palpable cord along a superficial varicose vein

b. Mild to moderate calf pain and tenderness

d. Unilateral edema and induration of the thigh

10. What treatment should the nurse anticipate for an otherwise healthy person with no significant comorbid conditions?

a. IV argatroban while the person is an inpatient

b. IV unfractionated heparin as an inpatient

c. Subcutaneous unfractionated heparin as an outpatient

d. Subcutaneous low-molecular-weight heparin as an outpatient

d. Subcutaneous low-molecular-weight heparin as an outpatient

11. Which of the following is a key teaching instruction for the client who is receiving anticoagulant therapy?

a. Monitor for and report any signs of bleeding.

b. Do not take acetaminophen (Tylenol) for a headache.

c. Decrease your dietary intake of foods containing vitamin K.

d. Arrange to have blood drawn routinely to check medication levels.

a. Monitor for and report any signs of bleeding.

12. The nurse is planning care and teaching for a patient with venous leg ulcers. Which is the most important client action in healing and control of this condition?

a. Follow activity guidelines.

b. Using moist environment dressings.

c. Taking horse chestnut seed extract daily.

d. Apply graduated compression stockings.

d. Apply graduated compression stockings.