Name: Dave Jay S. Manriquez RN.
Subject: Adult Health Nursing Phase II
Professor: Mrs. Norma A. Hinoguin
Time: Thursday 6:00-9:00pm
- The exact cause of Venous thrombosis remains unclear, three antecedent factors are believed to
play a significant role in its development: stasis of blood, injury to the vessel wall, and altered
- Disruption of the intimal lining of blood vessels creates a site for clot formation. Direct vessel
trauma, such as after a fracture or dislocation, diseases of the veins, and chemical irritation of the
vein from intravenous drugs or solutions, can all damage veins. Increased coagulability of blood
occurs most commonly in patients for whom anticoagulant medications have been abruptly
withdrawn. Oral contraceptives and a number of blood dyscrasias can also lead to
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.
-a tail-like appendages containing fibrin, white blood cells, and many red blood cells. The “tail”
can grow larger or propagate in the direction of blood flow as successive layering of the clot
constituents occur. The danger associated with a propagating venous thrombosis is that parts of a
clot can become detached and produce an embolic occlusion of the pulmonary blood vessels.
- 50% of all patients with venous thrombosis of the lower extremities have no symptoms.
Obstruction of the deep veins of the legs produces edema and swelling of the extremity because
the outflow of venous blood is inhibited. The amount of swelling can be determined by
measuring extremity circumference at various levels with a tape measure. The skin over the
affected leg may become warmer, and superficial veins may become more prominent.
Tenderness, which usually occurs later, is produced by inflammation of the vein wall and can be
detected by gentle palpation by the extremity.
- Homan’s Signs, pain in the calf after sharp dorsiflexion of the foot, is not specific for deep
venous thrombosis because it can be elicited in any painful condition of the calf. In some cases,
signs of a pulmonary embolus are the first indication of a deep venous thrombosis.
- Thrombosis of superficial veins produces pain or tenderness, redness, and warmth of the
involved area. The risk of dislodgment and embolization of superficial venous thrombi is very
low because the majority of them undergo spontaneous lysis; thus, condition can be treated at
home with rest, extremity elevation, analgesics, and possibly anti-inflammatory agents.
- Patients with a history of varicose veins, hypercoagulation, neoplastic disease, cardiovascular
disease, or recent major surgery or injury, and the obese, the elderly, and women taking
oralcontraceptives are in high-risk group.
• Question the patient about the presence of leg pain, heaviness, any functional
impairement, or edema.
• Inspect the legs from the groin to the feet, noting asymmetry and measuring and
recording calf circumference.
• Note any increase in temperature in the affected leg.
• To identify areas of tenderness and any thromboses.
The noninvasive techniques are Doppler ultrasonography, impedence plethysmography, and
Doppler Ultrasonography – involves the use of a Doppler probe placed over veins that are
Duplex Venous Imaging – is able to obtain anatomic information, as well as to assess
Impedance Plethysmography – is used to measure changes in venous volume.
The invasive techniques are I-labeled fibrinogen and contrast phlebography.
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 monitored.
Contrast Phlebography – involves the injection of radiographic contrast media into the venous
system through a dorsal foot vein.
A. Elastic Stockings – are usually prescribed for patients on a regimen of restricted activity,
particularly those who are confined to bed.
B. Body Position and Exercise
The objective of medical treatment are to prevent propagation of the thrombus and the inherent
risk of pulmonary embolism and to prevent recurrent thromboemboli.
Heparin – administered for 10 to 12 days by intermittent intravenous infusion or continuous
infusion. The patient’s Prothrombin time, hemoglobin, and hematocrit are monitored frequently.
If bleeding occurs and cannot be stopped, the drug is discontinued.
- A Thrombectomy is the treatment of choice when surgery is necessary. 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 result.
- Bed rest, elevation of the affected extremity, elastic stockings, and analgesics for pain are
adjuncts to therapy.
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 formed.
- 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 required.
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.
- Venography confirms the presence of obstruction and identifies the level of valvular
- When the deep veins in the legs have incompetent valves after a thrombus, postphlebitic
syndrome may develop. This disorder is characterized by chronic venous stasis, resulting from
edema, altered pigmentation, pain, stasis dermatitis, and stasis ulceration. Superficial veins may
be dilated. The disorder is long-standing, difficult to treat, and often disabling.
- Venous ulceration is the most serious complication of chronic venous insufficiency and can be
associated with other conditions affecting the circulation of the lower extremities. The potential
complications and the principles of care, however, will be similar for all types.
Management and Patient Education:
- Management of the patient with venous insufficiency is directed at reducing venous stasis and
preventing ulcerations. Measures that increase venous blood flow are antigravity activities and
compression of superficial veins with elastic stockings.
- 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 abnormal dilated, tortuous, superficial veins caused by imcopetent venous valves, this
condition occurs in the lower extremities, the saphenous veins, or the lower trunk; however, it
can occur elsewhere in the body.
- affect one of five persons in the world, the condition is common in women and in persons in
occupations requiring prolonged standing, a hereditary weakness of the vein wall may contribute
to the development of varicosities.
Pathophysiology and Manifestations
- considered as primary and secondary, primary (without involvement of deep veins) or
secondary (resulting from obstruction of deep veins). A reflux of venous blood in the veins
results in venous stasis. If symptoms are present, they may take the form of dull aches, muscle
cramps, and increased fatigue of muscles in the lower leg. Ankle edema and a feeling of
heaviness of the legs may occur. Nocturnal cramps are a common symptom.
- when deep vein obstruction results in varicose veins, patients may demonstrate the signs and
symptoms of chronic venous insufficiency: edema pain, pigmentation, and ulceration.
Susceptibility to injury and infection is increased.
- most common diagnostic test is the Brodie-Trendelenburg test. It will demonstrate the
backward flow of blood through incompetent valves of the superficial veins and of the branches
that communicate with the deep veins of the leg.
- another is Perthes’ test is a diagnostic procedure that easily indicates whether the deeper venous
system and communicating veins are competent.
- additional tests for the presence of Varicose Veins are the Doppler flow meter, Phlebography,
Prevention and Health Education
- activities that cause venous stasis should be avoided, such as wearing tight garters or a
constricting panty girdle, crossing the legs at the thighs, and sitting or standing for long periods.
- changing position frequently, elevating the legs when they are tired, and getting up to walk for
several minutes of every hour promote circulation. Patient should be encouraged to walk 1 to 2
miles day if no contraindications. Walking upstairs rather than using the elevator or escalators.
Swimming is a good exercise. Support hose and elastic stockings are useful. The over-weight
patient should be assisted in a weight-reduction plan.
- surgery for varicose veins requires demonstrated patency of deep veins.
A. Ligation and Division of the Saphenous Vein – accomplished under general anesthesia, the
vein is ligated high in the groin where the saphenous vein meets the femoral vein. An incision is
then made in the ankle, and a metal or plastic wire is passed the full length of the vein,
“stripping” as it passes. Pressure and elevation keep bleeding at a minimum during surgery.
B. Sclerotherapy – an irritating chemical, such as 0.5% sodium tetradecyl sulfate (Sotradecol), is
injected into the vein, which irritates the 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 or stripping. Sclerosing is a palliative, not curative,
Suzanne C. Smeltzer and Brenda G. Bare. Brunner and Suddarth’s Textbook of Medical-
Surgical Nursing, 7th ed. Philadelphia: J.B. Lippincott Company , 1992. pp. 766-776