Venous Disorder

Dr Hitesh Patel
Associate professor
Surgery Department
GMERS Medical College ,Gotri

Venous Thrombosis, Chronic

Venous Insufficiency,
Varicose Veins

(Venous Thrombosis (Thrombophlebitis)

Condition in which a blood clot (thrombus)
forms on wall of vein and partially or
completely blocks flow of blood back to the
heartmore common
Usually due to slow movement of blood
Thrombi can form in either arteries or
veins; platelet aggregation is more likely
due to the slower movement of blood

Factors Associated
Bed rest
IV catheters
Immobilization
Obesity
MI
CHF
CA of breast,
pancreas, prostate,
ovary

MS
Oral contraceptives
Pregnancy
Childbirth
Surgery >age 40
Altered coagulability
states

Pathophysiology: Virchows Triangle

Statis of blood
Increased blood coagulability
Injury to vessel wall
2 of 3 factors must be present for
thrombi to form

A thrombus forms..
Trauma to the lining of the vein brings
tissues in contact w/platelets that
aggregate
Deposit of fibrin, leukocytes &
erythrocytes into the platelet clump
causes a thrombus
At first, the thrombus floats in the vein;
within 7-10 days it sticks to the vein wall,
but a portion may still float in the vessel
Pieces may break loose & become
traveling emboli
Fibroblasts invade thrombus, scar the
vein, & destroy venous valves--permanent

Deep Vein Thrombosis

(DVT)

Most likely to occur in deep

veins of the calf (80%)
25% of thrombi that occur in
calf will extend to the
popliteal & femoral veins
Pulmonary Embolism may be
the first sign of DVT

DVT Manifestations
When clot is in formative stage, may notice no
symptoms
Usually profound tenderness; affected extremity
may be larger (unilateral edema)
Dull aching esp when walking: Most common
Severe pain, esp when walking
Cyanosis of extremity
Slightly elevated temp
General malaise

Homans Sign
Was long considered classic manifestation
this is no longer true
Sign is not specific to DVT & can be
elicited by any condition of the calf
As calf muscles contract, there is risk of
detaching thrombus from the wall

Major Complications of
Thrombophlebitis
Chronic venous insufficiency
Pulmonary embolism

Superficial Vein Thrombosis

(SVT)

Thrombi form primarily in upper

extremities
Primary cause: trauma to venous wall assoc
w/venous catheters, repeated venous
punctures, use of strong IV solutions the
produce inflammatory response

SVT Manifestations
Dull, aching pain over affected area: KEY
Marked redness along vein
Increased warmth over area of
inflammation
Palpable cordlike structure
More immediate attention is required if
edema, chills, high fever; suggests
complications of inflammation

Collaborative Care:
Thrombophlebitis
1.
2.
3.

Tx focus: inflammatory process,

prevention of further clotting,
extension & restoration of blood flow
Must be differentiated from cellulitis,
calf strain, contusion, lymphatic
obstruction
Med tx: use of meds, treat
inflammation/infection, dissolve clots

Lab & Diagnostics

Duplex venous ultrasonography
Plethysmography : lg & superficial veins
Magnetic Resonance Imaging
Ascending contrast venography (most
accurate)
Doppler ultrasound

Conservative Therapy: SVT

Prophylaxis: LMW Heparin
Prevention is Key!: post op clients leg exercises,
TEDs(compression stocking), ambulate asap, no leg
crossing, loose fitting clothes, exercise
Focus: relief of symptoms and reversal of
inflammatory process
Apply warm, moist compresses over affected area
& administer anti-inflammatory agents as
prescribed
Some clients may require antibiotics (therapeutic
or prophylactic)

Conservative Therapy: DVT

Anticoagulants may be prescribed for severe
cases
Strict bedrest until symptoms of tenderness &
edema resolve
Legs elevated, knees slightly flexed, above heart
level to promote venous return & discourage
venous pooling
TEDs or pneumatic compression devices

Medications
Anti-inflammatories
Anticoagulants***
Thrombolytics
Antibiotics

Anti-inflammatories
NSAIDs
Indomethacin (Indocin)
Naproxen (Naprosyn)
When used w/warm, moist compresses,
NSAIDs bring symptomatic relief to most
clients w/SVT

Anticoagulants

For DVT, most common tx to prevent propagation of

thrombus & subsequent PE
Initial bolus of 7500 to 10,000 u of heparin, then
continuous heparin infusion started (via pump)
Daily dosage is calculated based on results of APTT
(activated partial thromboplastin time)
Desired: APTT is 1.5 to 2 times normal APTT value
Oral anticoagulation w/warfarin is started first
week: important to overlap 4-5 daysfull effect of
warfarin is delayed
Warfarin: PT should exceed normal value by 1.5-2.5
times/INR 2-3
Oral anticoagulant tx may last from 2-6 months,
depending on extent of disease (single occurrence vs
PE)

Thrombolytics

Streptokinase,urokinase,tpA
Dissolve blood clots by imitating natural enzymatic
processes
Have been shown to destroy venous thrombi that
are < 72 hrs old
More rapid & efficient than heparin while also
preventing additional damage to venous valves
Side effect of hemorrhage is more common than
w/conventional heparinization

Antibiotics
Limited to specific tx of identified
infections
SVT; develop bacteremia, Staphlococcus
If blood cultures are positive, antibiotics
are started to prevent systemic sepsis

Surgery

Most clients are tx w/meds and

conservative tx
Venous thrombectomy; done when
thrombi are lodged in femoral vein &
excision of clots is required to prevent
PE or to prevent gangrene
Also can insert filtering devices into
inferior vena cava via femoral or jugular
vein; used forpts who cant take
anticoagulants & are at risk for PE
or have recurrent problems
Most common filter used: Greenfield
filter, assoc w/97% success rate in
preventing the recurrence of PE

Nursing Process
Addresses clients responses to illness,
primarily in areas of pain mgt, education re:
disease process/med tx, & interventions to
reduce inflammation & prevent
complications. Prevention is very
important! Provide info re: causes to
venous thrombosis to all high risk clients

Nursing Diagnoses
Pain
Ineffective Protection
Impaired Physical Mobility
Risk for Ineffetive Tissue Perfusion:
Peripheral

Pain: r/t inflammation of vein caused by

thrombotic process

Assess client level of pain on regular basis

using 0-10 scale
Measure diameter of calf & thigh of
affected extremity on admission & QD
Apply warm, moist heat to extremity 4 x
QD (compresses or Aqua-K pad)
Maintain BR and teach client rationale

Ineffective Tissue Perfusion: r/t obstruction of

blood flow & triggering of inflammatory response
& subsequent swelling/pain
Assess peripheral pulses, skin integrity, capillary
refill times, & color of extremities at least once q
shift
Elevate extremities; keep knees slightly flexed
and legs above heart level
Maintain use of TEDs as ordered, remove only for
short periods (30-60 min) during daily hygiene
Use of mild soaps, lotions to clean leg/foot
Assess skin q shift
Positioning aids: eggcrate /sheepskin

Ineffective Perfusion: Result of obstruction of

blood flow & triggering of inflammatory response
& subsequent swelling/pain
Administer & monitor effectiveness of analgesics,
anticoagulants, thrombolytics, antibiotics
Before administering anticoagulants, check lab
values (APTT/PTT)
Position changes q 2 hrs while awake

Impaired Physical Mobility r/t prolonged bedrest

(constipation, joint stiffening, muscle atrophy,
boredom)
Encourage active or perform passive Range
Of Motion exercises at least 1 x qshift
Increase fluid intake & dietary fiber
Provide progressive ambulation within
ordered guidelines
Diversional activities

Other Nursing Dx
Ineffective Protection r/t anticoagulant tx;
Monitor lab results: INR (PT) aPTT,
Assess regularly of evidence of bleeding

Risk for Ineffective Tissue Perfusion:

Cardiopulmonary
Frequent assessment of respiratory status: Respiratory
distress, & O2 Sat

Chronic Venous Insufficiency

1.
2.

Disorder involving stasis of blood in

lower extremities as result of
obstruction & reflux of venous valves
Assoc w/changes in venous circulation
resulting from thrombophlebitis &
valvular incompetence, varicose veins

Clinical Manifestions
Lower leg edema
Itching
Brown pigmentation/Cyanosis of skin of lower
leg/foot
Fibrosis/hardness of subcutaneous tissues
Stasis ulcers over ankle, most often medial

Complication: Ulcer development

Blood pools in lower limb and peripheral circulation
slows; insufficient oxygen & nutrients to cells
Cells die causing formation of venous stasis ulcers
In attempt to heal stasis ulcer, body increases
supply of oxygen, nutrients, and energy to area;
but it does not reach the diseased tissues due to
impaired circulation = enlarged ulcers

Complication: Ulcer development

Congested venous circulation prevents
biochemicals from immune system to diseased
tissues, interfering w/normal inflammatory
response. Increases risk for wound infection
Area around stasis ulcers appear shiny, atrophic, &
cyanotic, w/brownish pigmentation. May have
eczema or stasis dermatitis, scar tissue
Slight trauma will result in serious tissue
breakdown

Assessment: Lab & Diagnostics

No specific labs or diagnostic tests
Diagnosis is usually based on clinical
findings
Interview data
Family Hx
Past medical Hx
Physical exam

Possible Nursing Diagnoses

Ineffective health maintenance r/t lack of
knowledge
Ineffective tissue perfusion: peripheral r/t
incompetent venous valves
Anxiety r/t inability to control chronic disease
Disturbed Body image r/t edema & statis ulcers
Risk for infection r/t ulcerations
Impaired physical mobility r/t pain & lower leg
edema
Impaired skin integrity r/t stasis ulcers

Nursing Interventions/Teaching
BR, w/feet elevated above heart level
Avoid long periods of standing walk as much as
possible
Avoid anything that pinches skin (knee-highs)
While sitting, do not cross legs & avoid pressure
behind knees
Elastic support hose/TEDs
Follow guidelines for care of legs & feet

Other Interventions
Ulcer may be treated w/semirigid boot applied to
affected area; device may be made of Unnas
paste or Gauzetex bandage. Changed q 1-2 wks
Surgery for large, chronic ulcers; Incompetent
veins ligated, ulcer excised, skin grafted

Medications: Topical Agents &/or

Antibiotics
Acute weeping dermatitis: wet compresses
w/boric acid, Burows soln, isotonic saline 4 x qd
for 1 hr intervals, followed w/topical ointments
(0.5% hydrocortisone cream)
Subsiding/Chronic: continue use of hydrocortisone
cream. Other: zinc oxide ointment, broadspectrum antifungal creams (clotrimizole/Lotrimin,
miconazole/Monistat)
Ulcerations: saline compresses to promote wound
healing or prepare for skin graft

Evaluationthe client
Verbalizes s/s infection; remains free of
infection
Verbalizes understanding of disease
process, tx, regimen, limitations & is
compliant
Demonstrates improved perfusion skin
color & reduction/absence of edema
Displays increasing tolerance to activity
Pain/discomfort relieved

Varicose Veins
Irregular, tortuous veins with
incompetent valves

Varicose Veins
May develop anywhere in body, but most develop in
lower extremities
Vein in legs most often affected: Long Saphenous
Occur in 1 out of 5 people; more common females >
35; Whites > Blacks; familial tendency
Causes
Severe damage or trauma to saphenous vein
Effects of gravity produced by long periods of standing

Types

Primary: no deep veins involved

Secondary: caused by obstruction of deep veins (Most
Common)

Pathophysiology
Major cause: sustained stretching of vascular wall
die to long-standing increased intravenous
pressure
Valves become incompetent because they cannot
close properly due to stretching
Prolonged standing, the force of gravity, lack of
lower limb exercise, & incompetent venous valves
all weaken muscle-pumping mechanism, & return of
venous blood to heart decreases
As client stands for long time, blood pools and
vessel wall continues to stretch, and valves
become increasingly incompetent

Normal vs Abnormal

Clinical Manifestations
Severe, aching pain in leg
Leg fatigue &/or heaviness
Itching over affected leg (stasis
dermatitis)
Feelings of heat in the leg
Visibly dilated veins
Thin, discolored skin above ankles
Complications: insufficiency, stasis ulcers,
chronic stasis dermatitis, thrombophlebitis

Assessment: Labs & Diagnostics

No specfic labs
Diagnostics
Doppler ultrasound flow tests &
angiographic studies or Duplex Doppler
ultrasound
Trendelenburg tests assists w/diagnosis

Collaborative Interventions
Conservative measures include
antiembolism stockings and regular walking
& leg elevation
Mild analgesics may relieve pain
Compression sclerotherapy & vein stripping
are surgical techniques that may alleviate
the major symptoms of varicose veins.

Nursing Process
Focus:
Restore venous circulation
Relieve symptoms
Prevent complications
Promote behaviors that minimize symptoms

Nursing Dx: chronic pain r/t prolonged interruption in

return of venous blood to heart & subsequent pooling of
blood in extremity

Assess pain
Teach & reinforce methods for relieving pain
that do not involve use of analgesics
Encourage discussion of possible
relationships between pain and life stressors
Collaborate w/client to determine pain
control plan
Regularly evaluate effectiveness of
interventions used to minimize pain

Nursing Dx: Ineffective tissue perfusion r/t

insufficient supply of nutrients/oxygen & incompetent

valves
Assess peripheral pulses, capillary refill time, skin
temp, and degree of edema
Teach client use of antiembolic stockingsremove
daily for 30-60 minutes
Teach to exercise extremities at regular intervals
Teach client to elevate affected extremities to
reduce tissue congestion and promote return of
venous blood to heart

Nursing Dx: Ineffective tissue perfusion r/t

insufficient supply of nutrients/oxygen & incompetent

valves
Assess skin on lower extremities for warmth,
erythema, moisture, signs of breakdown
Teach about daily skin hygiene
Teach client to protect extremities from external
forces that may cause skin breakdown
Encourage adequate nutrition and fluid intake

Nursing Dx: Risk for peripheral neurovascular

dysfunction
Assess circulation, sensation, & motion in lower
extremities
Teach to avoid flexing the extremity & to maintain
positions that promote effective neurovascular
function
Teach client/family to report and signs of
impaired neurovascular function, such as
numbness, coldness, pain, or tingling of extremity
Teach about importance of maintaining safety and
adhering to plan of care

Other Nursing Dx
Risk for infection r/t disruption
incontinuity of skin
Impaired home health maintenance
r/t prescribed postural limitations
Anxiety r/t possible need for surgery

Evaluation
Skin is of normal color,temp,
nontender, nonswollen, intact
Client actively moves extremity;
verbalizes reduced pain

Other info
Home Care

Teach clients how to adapt to accommodate

prescribed health regimen (eg: daily walks,
TEDs, elevate legs)

Older Adult

Foster acceptance of interventions

Safety when walking
Strategies for minimizing standing &
incorporating activity into the job
May require home-based care