Presented by: Dave Jay S. Manriquez RN.
• are thin-walled vessels that transport deoxygenated blood from the capillaries
back to the right side of the heart
3 Layers – intima, media, adventitia
• there is little smooth muscle & connective tissue Ú makes the veins more
distensible Ú they accumulate large volumes of blood
• Major veins, particularly in the lower extremities, have one-way valves ---allow
blood flow against gravity
• Valves allow blood to be pumped back to the heart but prevent it from draining
back into the periphery
Venous Thrombosis (Superficial and Deep Vein Thrombosis), Thrombophlebitis,
Phlebothrombosis – the above terms do not necessarily represent an identical
pathology, for clinical purposes they are often used interchangeably.
Cause of Venous thrombosis remains unclear, three antecedents factors are believed to
play a significant role in its development: stasis of blood, injury to the vessel wall, and
altered blood coagulation.
Thrombophlebitis – is inflammation of the walls of the veins, often accompanied by the
formation of a clot. When a clot develops initially in the veins as a result of stasis or
hypercoagulability , but without inflammation, the process is referred to as
Venous thrombosis can occur in any vein but is most frequent in the veins of the lower
extremities. Both superficial and deep veins of the legs may be affected. Of the superficial
veins, the saphenous vein is most frequently affected. Of the deep leg veins, the
iliofemoral, popliteal, and small calf veins are most often involved.
Chronic Venous Insufficiency - Venous insufficiency is a disease state resulting from the
obstruction or reflux of venous valves in the legs. Both superficial and deep leg veins can
be involved. The resulting venous hypertension can occur whenever there has been a
prolonged increase in venous pressure, such as occurs with deep venous thrombosis. The
walls of veins are thinner and more elastic than walls of arteries, they distended readily
when venous pressure is consistently high. In this state, leaflets of the venous valves are
stretched and prevented from closing completely, thereby allowing a backflow or reflux
of blood in the veins.
When a deep veins in the legs have incompetent valves after a thrombus, postphlebitic
syndrome may develop. This result in edema, altered pigmentation, pain, stasis
dermatitis, and stasis ulceration.
Varicose Veins - abnormally dilated, tortuous, superficial veins cause by
incompetent venous valves.
alteration in the transport/flow of blood from the capillary back to the heart
changes in smooth muscle and connective tissue make the veins less distensible
with limited recoil capacity
valves may malfunction, causing backflow of blood
Virchow’s triad: blood stasis, vessel wall injury, and altered blood coagulation
inflammation of the veins caused by thrombus or blood clot
Factors assoc. with the devt. of Thrombophlebitis
venous stasis – occurs when blood flow is retarded, such as heart failure and
shock; when veins are dilated, such as after drug therapy; and when skeletal
muscle contraction is reduced, as with immobility, extremity paralysis, or
damage to the vessel wall – disruption of the intimal lining of blood vessel creates
a site for clot formation, such as after a fracture or dislocation, diseases of the
veins, and chemical irritation of the vein from intravenous drugs or solutions.
hypercoagulability of the blood – oral contraceptive use
common to hospitalized pts. , undergone major surgery (pelvic or hip surgery),
develops in both the deep and superficial veins of the lower extremity
deep veins – femoral, popliteal, small calf veins
superficial veins – saphenous vein
Thrombus – form in the veins from accumulation of platelets, fibrin, WBC and
Risk Factors for Thrombophlebitis
Previous Venous Insufficiency
Deep Vein Thrombosis (DVT)
tends to occur at bifurcations of the deep veins, which are sites of turbulent blood
a major risk during the acute phase of thrombophlebitis is dislodgment of the
thrombus Ú embolus
pulmonary embolus – is a serious complication arising from DVT of the lower
pain and edema of extremity – obstruction of venous flow
Û circumference of the thigh or calf
(+) Homan’s sign – dorsiflexion of the foot produces calf pain
Do not check for the Homan’s sign if DVT is already known to be present Ú Û
risk of embolus formation
* if superficial veins are affected - signs of inflammation may be noted – redness,
warmth, tenderness along the course of the vein, the veins feel hard and thready &
sensitive to pressure
The risk of dislodgement and embolization of superficial venous thrombi is very low
because the majority of them undergo spontaneous lysis, thus this condition can be
treated at home with rest, extremity elevation, analgesics, and possibly anti-
Noninvasive Techniques: - rely on the thrombus to create abnormalities of venous flow.
Doppler Ultrasonography – use of a Doppler probe placed over veins that are
obstructed. Nonexpensive, portable, simple, rapid, and noninvasive.
Duplex Venous Imaging – able to obtain anatomic information, as well as to
assess physiologic parameters.
Impedance Plethysmography – is used to measure changes in venous vlume, a
blood pressure cuff is applied to patient thigh inflated enough to impede venous
flow (50-60 mmHg), calf electrodes are used to measure electrical resistance that
results from venous volume changes.
Invasive Techniques: - rely on the injection of contrast media into the venous system,
which then bind with structural elements of the thrombus.
I-labeled Fibrinogen Scanning - a sensitive method for early detection of venous
thrombosis. The test relies on the fact that radioactive fibrinogen, when injected
intravenously, will concentrate in the forming clot. The level o radioactivity can then be
serially measured by an external counter, and the progression of the clot can be
Contrast Phlebography - involves the injection of radiographic contrast media into the
venous system through a dorsal foot vein.
bed rest with legs elevated
apply moist heat
NSAID’s ( Non – steroidal anti-inflammatory drugs) - aspirin
Deep vein thrombosis
bed rest w/ legs elevated to 15-20 degrees above heart level ( knees slightly
flexed, trunk horizontal, head may be raised) to promote venous return and help
prevent further emboli and prevent edema
application of warm moist heat to reduce pain, promotes venous return
elastic stocking or bandage
anticoagulants, initially with IV heparin then coumadin
fibrinolytic to resolve the thrombus
vasodilator if needed to control vessel spasm and improve circulation
prevent long periods of standing or sitting that impair venous return
elevate legs when sitting, dorsiflex feet at regular intervals to prevent venous
if edema occurs, elevate above heart level
regular exercise program to promote circulation
avoid crossing legs at the knees
avoid wearing constrictive clothing such as tight bands around socks or garters
use elastic stocking on affected leg
do leg exercises during periods of enforced immobility such as after surgery
Nursing Assessment - is invaluable in detecting early signs of venous disorders of the
lower extremities. Patients with history of varicose veins, hypercoagulation, neoplastic
disease, cardiovascular disease, or recent major surgery or injury, and the obese, the
elderly, and women taking oral contraceptives are in the high risk group.
characteristic of the pain
onset & duration of symptoms
history of thrombophlebitis or venous disorders
color & temp. of extremity
edema of calf of thigh - use a tape measure, measure both legs for comparison
Identify areas of tenderness and any thrombosis
if the thrombus is recurrent and extensive or if the pt. is at high risk for
pulmonary embolism - . Surgery for deep vein thrombosis is necessary
when: 1. anticoagulant or thrombolytic therapy is contraindicated. 2. the
danger of pulmonary embolism is extreme and 3. the venous drainage is
so severely compromised that permanent extremity damage will probably
Thrombectomy – incising the common femoral vein in the groin and extracting
Vena caval interruption – transvenous placement of a grid or umbrella filter in the
vena cava to block the passage of emboli
explain purpose of bed rest and leg elevation
use elastic stockings
monitor pt. on anticoagulant & fibrinolytic therapy for signs of bleeding
monitor for signs of pulmonary embolism – sudden onset of chest pain, dyspnea,
rapid breathing, tachycardia
Nsg. intervention often surgery of vena caval interruption
assess insertion site – bleeding, hematoma, apply pressure over site and inform
keep pt. on bed rest for 1st 24 hrs. then encourage ROM exercises to promote
assist pt. in ambulation when permitted, elevate legs when sitting
keep elastic bandage
avoid rubbing or massaging the affected extremity
give analgesic and anti-inflammatory agents to promote comfort
Anticoagulant Therapy for Thromboembolism:
- is the administration of a medication to delay the clotting time of blood, to prevent the
formation of a thrombus in postoperative patients, and to forestall the extension of a
thrombus once it has formed. Anticoagulants cannot dissolve a thrombus that has already
- Heparin is administered using a continuous pump infusion. To promptly reverse the
effects of heparin , the physician may prescribe intravenous injections of protamine
sulfate. For Coumadin it is Vitamin K.
- Intermittent intravenous injection is another means of administering heparin, in this
instance a dilute aqueous solution given every 4 hours.
- Oral anticougulants, such as Coumadin, are monitored by the prothrombin time.
Because Coumadin has a lag period of 3 to 5 days, it is usually administered in
conjunction with heparin until desired anticoagulation has been achieved.
Precaution and Nursing Assessment:
- The principal complication of anticoagulant therapy is the occurrence of spontaneous
bleeding anywhere in the body. A further possible complication of heparin therapy is that
of Heparin-induced thrombocytopenia which generally occurs 7 to 10 days after the
treatment has been started. Oral anticoagulants interact with many other medications. It
is advisory to study drug interactions for patients taking specific oral coagulants.
Patient Education About Oral Anticogulants:
- The patient should be informed about the medication, its purpose, and the need to take
the correct amount at the specific times prescribed, and should be aware that blood tests
are scheduled periodically to determine whether a change in medication dosage is
Chronic Venous Insufficiency
Results from obstruction of venous valves in legs or reflux of blood back through
Venous ulceration is serious complication – this is a result of inadequate
exchange of oxygen and other nutrients in the tissue, when the cellular
metabolism cannot maintain energy balance, cell death (necrosis) results.
Pharmacological therapy is antibiotics for infections
Debridement to promote healing
Topical Therapy may be used with cleansing and debridement
Management and Patient Education – management of the patient with venous
insufficiency is directed at reducing venous stasis and preventing ulcerations. Measures
that increases venous blood flow are antigravity activities and compression of superficial
veins with elastic stockings.
Elevation of the legs decreases edema, promote venous return. Elevations should be
performed frequently throughout the day (at least 30 minutes every 2 hours). At night, the
patient should sleep with the foot of the bed elevated for 6 inches. Prolonged sitting or
standing still detrimental, but walking should be encouraged. When sitting, patient
should avoid placing pressure on the popliteal spaces, such as occurs in leg crossing, or
sitting with the legs dangling over the side of the bed. Wearing of constricted garments
are also contraindicated.
Elastic stockings of the legs reduces pooling of venous blood and enhances venous return
to the heart. Prevent twisting of stockings causing tourniquet effect cause this will
worsens venous pooling. Extremities with venous insufficiency are conscientiously
protected from trauma. The skin is kept clean, dry, and soft. Signs of ulceration are
immediately reported to the nurse or physician for treatment and follow-up.
are abnormally dilated veins with incompetent valves, occurring most often in the
lower extremities, the saphenous veins, or the lower trunk however, it can occur
elsewhere in the body. Affect1 of 5 persons in the world. This condition is most
common in women and in persons in occupations requiring prolonged standing
such as salespeople, barbers, beauticians, elevator operators, nurses and dentist.
A hereditary weakness of the vein wall may contribute to the development of
varicosities, and it is not uncommon to see this condition occur in several
members of the same family.
• usually affected are woman 30-50 years old.
– congenital absence of a valve
– incompetent valves due to external pressure on the veins from pregnancy,
ascites or abdominal tumors
– sustained Û in venous pressure due to CHF, cirrhosis
– wear elastic stockings during activities that require long standing or when
– moderate exercise, elevation of legs
the great and small saphenous veins are most often involved
weakening of the vein wall does not withstand normal pressureäveins dilate , pooling of
bloodävalves become stretched and incompetentämore accumulation of blood in the
Primary varicosities – gradual onset and affect superficial veins, appearance of
dark tortuous veins. Affected persons may have no symptoms, but cosmetically the
appearance of the dilated vein is unappealing.
S/sx – dull aches, muscle cramps, pressure, heaviness or fatigue arising from reduced
blood flow to the tissues
Secondary Varicosities – affect the deep veins
occur due to chronic venous insufficiency or venous thrombosis
S/sx – edema, pain, changes in skin color, ulcerations may occur from venous stasis
A. Bordie-Trendelenburg test
assess competency of venous valves through measurement of venous filling time
the pt. lies down with the affected leg raised to allow for venous emptying
a tourniquet is then applied above the knee and the pt. stands. The direction and
filling time are recorded both before & after the tourniquet is removed
* Incompetent valves are evident when the veins fill rapidly from backward blood
B. Perthes’ test - is a diagnostic procedure that easily indicates whether the deeper
venous system and communicating veins are competent. A tourniquet is applied just
below the knee and the patient is asked to walk. If the varicose veins disappear, the deep
system and communicating vessels are competent. If the vessels do not empty and become
distended on walking, incompetency or obstruction is inferred.
C. Additional tests for the presence of Varicose Veins are the Doppler flow meter- detect
retrograde flow of blood in superficial veins with incompetent valves after compression
of the leg proximally., Phlebography – the injection of radiographic contrast media into
the leg veins so that vein anatomy can be visualized during various leg movements. , and
Plethysmography – allows measurement of changes in venous blood volume..
indicated or done for prevention or relief of edema, for recurrent leg ulcers or pain
or for cosmetic purposes
Vein ligation and stripping
the great sapheneous vein is ligated (tied) close to the femoral junction
the veins are stripped out through small incisions at the groin, above & below the
knee and at the ankles.
sterile dressing are placed over the incisions and an elastic bandage extending
from the foot to the groin is firmly applied
Ligation and stripping of the great and the small saphenous veins. (A) The tributaries of
the saphenous vein have been ligated, and the saphenous vein has been ligated at the
saphenofemoral junction . (B) Vein stripper has been inserted from the ankle superiorly
to the groin. The vein is stripped from above to downward. A number of alternate
incisions may be needed to remove separate varicosities masses. (C) The small
saphenous vein is stripped from its junction with the popliteal vein to a point posterior to
the lateral malleolus.
Sclerotherapy – an irritating chemical (Sotradecol) is injected into the vein, which
irritates venous endothelium and produces localized phlebitis and fibrosis, thereby
obliterating the lumen. This treatment may be performed alone for small varicosities or
may follow vein ligation and stripping. Sclerosing is a palliative not a curative treatment.
Nursing care after vein ligation & stripping
Monitor for signs of bleeding, esp. on 1st post-op day
if there is bleeding, elevate the leg, apply pressure over the wound and
notify the surgeon
Keep pt. flat on bed for first 4 hrs. after surgery, elevate leg to promote venous
return when lying or sitting
Medicate 30 mins. before ambulation and assist patient
Keep elastic bandage snug and intact, do not remove bandage