VENOUS DISORDERS

Venous thrombosis/ DVT

= clotting in vein

Pathophysiology

  • Exact cause is unclear

  • genetics

    • hypercoagulability - Factor V

  • More common in lower extremities

Virchow Triad

  1. Stasis of blood: cause by immobility (Bed rest, prolonged standing/sitting, extensive travel)

  2. Vessel Wall injury (Endothelial injury): caused by trauma (Fractures, contusions), central venous catheterization, vascular devices (PICC, central lines, pacemaker wires), IV medications, cancer therapy (Hormonal, chemotherapy, or radiation)

  3. Altered coagulation: caused by estrogen-containing oral contraceptive or hormone replacement, cancer (Secretes procoagulants), smoking, dehydration, hypercoagulable states, late stages of pregnancy, and the postpartum period

Clinical Manifestations

  • difference in leg circumference

  • Erythema

  • Warmth to extremity

  • tenderness to touch

  • Low-grade fever

  • Induration of vessel wall

  • Dilated veins

Assessment / Risks

  • history of varicose veins

  • hypercoagulable states (covid-19)

  • cancer

  • cardiovascular disease

  • recent major surgery or injury

  • BMI > 35

  • immobility

  • Old age

  • women taking oral contraceptives or hormone replacement therapy

Prevention

  • compression stocking (TEDs)

  • intermittent compression devices (SCDs)

  • exercise (walking)

  • Anticoagulation medications

Medical Management

Goal:

  • prevent clot growth

  • reduce risk of dislodgement

  • prevent reoccurrence

Pharmacology:

  • heparin

    • unfractionated

    • Low-molecular-weight (LMWH)

  • Direct thrombin inhibitor

  • thrombolytic therapy

  • oral anticoagulants

Surgical:

  • thrombectomy - take clot out

  • IVC filter

Nursing Management

  • Monitor labs based on drugs prescribed

  • mild analgesic for pain control

  • Monitor for spontaneous bleeding

  • Promote ambulation

  • Adminster reversal agent if appropriate

  • TEDS with ambulation

  • Active and passive exercise

  • Monitor for thrombocytopenia

  • compression therapy

  • Elevate extremity

  • Avoid sitting for long periods

Inferior Vena Cava (IVC) Filter

  • saves from heart attack

  • filter sits in inferior vena cava

  • looks like a scalp scratcher

Varicose Veins

= dilation of superficial veins

Varicosities

Pathophysiology

  • primary

    • DOes not involve deep vein

    • Pt. may be asymptomatic

    • image disturbance

  • Secondary

    • result of an obstructed deep vein

Who’s who at Risk

  • hereditary weak veins

  • pregnant women

  • Prior DVT

  • Old age

  • BMI . 30

  • Multigravida woman

Clinical Manifestations

  • Dull aches

  • muscle cramps

  • Lower extremity muscle

  • fatigue

  • Ankle edema

  • “heavy” legs

  • NIght-time leg cramps

Assessment/Diagnosis

  • Venous Duplex Scan: for deep veins

    • locates reflux + measures severity

  • Air plethysmography: progressive

    • Measures changes in venous blood volume

Prevention

  • Avoid activities that increase venous hypertension

    • tight cloths

    • crossing legs

    • sitting or standing for long periods of time

  • Frequent position changes

  • Elevate legs

  • Promote Circulation

    • walking (heel-toe stepping)

  • weight reduction

Surgical/Medical Management

  • Ligation & Strippping

  • Sclerotherapy - for superficial veins

  • Ablation

    • ECT in the vein - gets ride of diseased veins

Postoperative Nursing Management

  • mobility is best to promote circulation

  • walk, increase activity as tolerated

  • compression stockings X 1-2 weeks

  • elevated foot of bed

  • Avoid strenuous activity

  • analgesics for pain management

  • monitor surgical dressings

  • patient teaching on incision care

  • nurse alert: nerve damage

Chronic Venous Insufficiency

= Veins are chronically incompetent

Postphlebitic syndrome

  • venous valve injury results in an incompetent valve and reverse venous flow

  • fluid, plasma, and red blood cells leak inot the interstitial tissue

  • edema forms around ankles and/or lower legs

  • staining of skin occurs as red bloods cells break down, releasing hemosiderin

  • subcutaneous tissue becomes firm and fibrotic

  • loss of elasticity in the skin and subcutaneous tissue results

  • tissue becomes vulnerable to trauma and ulcer formation

Clinical Manifestations & NUrsing Assessment

  • edema

  • hemosiderosis

  • varicosities

  • telangiectasias (spider-veins)

  • warmth

  • post-thrombolyic syndrome

    • chronic edema

    • altered pigmentation

    • pain

    • dermatosclerosis

    • aches & heaviness in evening

Management

  • leg elevation

  • compression stocking use

  • provide symptom relief

  • encourage walking

  • Avoid prolonged sitting & standing

Vascular ulcers

Patho

  • most severe complication of CVI

  • treatment is dependent on type of ulcer

  • result of:

    • increased venous pressure

    • external trauma

    • ischemia secondary to atherosclerosis

Clinical Manifestations & assessment

venous ulcers

  • located in gaiter area

  • small to large

  • superficial

  • excessive drainage

  • damage to surrounding skin

Arterial Ulcers

  • located on toe tips and in toe webs

  • small lesions

  • digital gangrene

Management

pharmacology

  • infected = antibiotics

would cleaning & debridement

  • arterial - keep dry, Do not debride

  • Venous (with necrosis) - clean & Debride

Wound dressings

stimulated healing

  • tissue-engineered human skin

  • stimulates growth factor

  • painless

hyperbaric oxygenation

  • adjunctive therapy

  • used when wound is not responding to standard treatment is not responding to tandard treatment

  • decreases edema, kills bacteria, increases oxygen to hypoxic wounds

compression

  • promote edema reduction

  • unna boot/compression bandages

Lymphatic disorders

Lymphangitis

  • acute inflammation

  • secondary to infection in extremity

  • red streaks extending from wound

Lymphadenitis

  • enlarged, red, tender lymph nodes

  • can necrose and develop into abscesses

  • commonly in groin, axilla, cervical region

Lymphedema/Elephanntiasis

patho

  • classification:

    • Primary - congenital malformation

    • Secondary - Acquired obstruction

  • increase in lymph secondary to a obstructed lymph vessel

    • axillary node dissection

    • varicose veins

    • chronic thrombophlebitis

    • chronic lymphangitis

  • soft & pitting progresses to firm, nonpitting & resistant to treatment

Clinical Manifestations & Assessments

  • early stage

    • soft, pliable tissue

  • late stage

    • thick, firm tissue

    • stemmer sign

  • diagnosis is made through symptom evaluation

  • Early diagnosis prevents tissue damage

Stemmer Sign

  • how to assess

    • try to pinch and lift a skin fold at the base of the second toe (or finger)

    • positive stemmer sign

      • you cannot lift/pinch a thin fold of skin, only a thick “pad, because the skin is irdurated.

    • negative stemmer sign

      • you can pinch and lift a normal think skin fold.

  • What it indicates

    • dermal and subcutaneous fibrosis

Medical management

Medical

  • pharmacologic therapy

    • AVOID diuretics

  • exercise & compression

    • active & passive ROM exercises

    • external compression devices

    • lymphatic drainage massage

  • surgical management

    • excision & Skin grafting

    • relocation of lymphatic vessels

Nursing

  • management of skin graft & flap

  • extremity elevation

  • frequent monitoring for complications:

    • Flap necrosis

    • hematoma

    • abscess

    • cellulitis

  • Patient Education

Cellulitis

Patho

  • breakdown in normal skin protective barrier allowing for entry of bacteria

Clinical Manifestations & Assessment

  • acute swelling

  • locak erythema

  • pain

  • fever

  • chills

  • sweating

  • skin dimpling

  • lymph node swelling

Medical Management

  • mild -oral antibiotic therapy

  • severe - IV antibiotics

  • Proper identification of entry point on skin

Nursing Management

  • extremity above heart level

  • warm and moist heat to site

  • Pt education on episode recurrence prevention