Nursing Care of Clients with Peripheral Vascular Disorders Part 3 of 3


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Nursing Care of Clients with Peripheral Vascular Disorders Part 3 of 3:
Venous and Lymphatic System

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Nursing Care of Clients with Peripheral Vascular Disorders Part 3 of 3

  1. 1. Nursing Care of Clients withPeripheral Vascular Disorders Maria Carmela L. Domocmat, RN, MSN Instructor Northern Luzon Adventist College Artacho, Sison, Pangasinan
  3. 3. VENOUS DISORDERSVenous Thrombosis, Deep Vein Thrombosis (DVT),Thrombophlebitis, and PhlebothrombosisChronic Venous InsufficiencyLeg UlcersVaricose Veins
  4. 4. Venous Thrombosis, Deep Vein Thrombophlebitis,Thrombosis (DVT), Thrombophlebitis,and Phlebothrombosis
  5. 5. Venous Thrombosis:DVT, Thrombophlebitis, Phlebothrombosis Thrombophlebitis, for clinical purposes often used interchangeably But Note: they do not reflect identical disease processes Venous thrombosis is a blood clot (thrombus) that forms within a vein can occur in any vein; common lower extremities. superficial and deep veins of the extremities may be affected
  6. 6. Types Thrombophlebitis Deep Vein Thrombophlebitis or Deep vein thrombosis Phlebothrombus Phlebitis
  7. 7. Thrombophlebitis thrombus that is associated with inflammation most frequently occurs in deep veins of lower extremities.Deep vein thrombophlebitis commonly referred to as deep vein thrombosis (DVT) more serious than superficial thrombophlebitis because it presents a greater risk for pulmonary embolism (PE)Phlebothrombosis thrombus without inflammation hrombus develops initially in veins as result of stasis or hypercoagulability but without inflammationPhlebitis vein inflammation associated with invasive procedures (IV therapy)
  8. 8. Etiology exact cause unclear Thrombus formation has been associated with Virchows triad. (1) stasis of blood (venous stasis) (2) endothelial injury / vessel wall injury (3) hypercoagulability / altered blood coagulation Note: at least two of the factors seem to be necessary for thrombosis to occur.
  9. 9. Pathophysiology Venous stasis occurs when blood flow is reduced (e.g. HF or shock; when veins are dilated, as with some medication therapies) when skeletal muscle contraction is reduced (ex: immobility, paralysis of extremities, or anesthesia) bed rest reduces blood flow in the legs by at least 50%. Vessel wall injury Damage to the intimal lining of blood vessels creates a site for clot formation. Direct trauma to the vessels, as with fractures or dislocation, diseases of the veins, and chemical irritation of the vein from intravenous medications or solutions, can damage veins. Altered blood coagulation / hypercoagulability Abrupt withdrawal anticoagulant medications. Oral contraceptive use and several blood dyscrasias (abnormalities
  10. 10. Venous thrombi are aggregates of platelets attached to the vein wall, along with a tail-like appendage containing fibrin, WBCs , and RBCs. The “tail” can grow or can propagate in direction of blood flow as successive layers of thrombus form. A propagating venous thrombosis is dangerous because parts of thrombus can break off and produce an embolic occlusion of the pulmonary blood vessels. Fragmentation of thrombus can occur spontaneously as it dissolves naturally, or it can occur in association with an elevation in venous pressure, as occurs when a person stands suddenly or engages in muscular activity after prolonged inactivity. After an episode of acute deep vein thrombosis, recanalization of the lumen typically occurs. The time required for complete recanalization is an important determinant of venous valvular incompetence, which is one complication of venous thrombosis
  11. 11. Recent major surgery or injury ( mostcommon: hip surgery or open prostatesurgery)Ulcerative colitisHeart failureCardiovascular diseaseImmobility: prolonged bedrest (ex: duringperiop period)Hypercoagulation
  12. 12. Clinical Manifestations may have symptoms or may be asymptomatic. classic s/s of DVT calf or groin tenderness and pain, and sudden onset of unilateral swelling of the leg. phlegmasia cerulea dolens massive iliofemoral venous thrombosis entire extremity becomes massively swollen, tense, painful, and cool to the touch.
  13. 13. Clinical Manifestations limb pain a feeling of heaviness functional impairment ankle engorgement Edema differences in leg circumference bilaterally from thigh to ankle increase in surface temperature of leg, particularly the calf or ankle areas of tenderness or superficial thrombosis (ie, cordlike venous segment)
  14. 14. Deep vein thrombosis (DVT) in the calf of a patient.
  15. 15. positive Homans sign pain in calf on dorsiflexion of the foot appears in only 10% of clients with DVT and false-positive findings are common Therefore checking a Homan s sign is not advised!
  16. 16. Assessment Nurse shld examine area described as painful, and compare this site with the contralateral limb. observe for warmth, edema, and swelling of the extremity Coz outflow of venous blood is inhibited Determine amount of swelling: Measure circumference of affected extremity at various levels with a tape measure and comparing one extremity with the other at the same level to determine size differences (+) tenderness usually occurs later Due inflammation of vein wall pulmonary embolus in some cases first indication of DVT
  17. 17. Deep vein thrombosis (DVT) in awomans thigh
  18. 18. Assessment Note: Signs and symptoms may be absent (silent clinical findings) Be suspicious! Nurse must have a high index of suspicion for this disorder when caring for clients at high risk! Do not massage affected extremity!
  19. 19. Thrombosis SUPERFICIAL VEINS pain or tenderness, redness, and warmth risk of becoming dislodged or fragmenting into emboli is very low bcoz most dissolve spontaneously. Treatment Can be treated at home Bed rest Elevation of leg Analgesics Anti-inflammatory medication
  20. 20. Upper extremityUpper extremity venous Effort thrombosis of thethrombosis upper extremity not as common as lower extremity caused by repetitive motion, thrombosis. more common: with IV catheters or with underlying disease such as experienced by that causes hypercoagulability competitive swimmers, Internal trauma to the vessels may tennis players, and result from pacemaker leads, construction workers, that chemotherapy ports, dialysis catheters, or parenteral nutrition lines. irritates the vessel wall, The lumen of the vein may be causing inflammation and decreased as a result of catheter or subsequent thrombosis. from external compression, such as by neoplasms or extra cervical rib.
  21. 21. Diagnostic tests contrast venography duplex ultrasonography Doppler flow studies Impedance plethysmography Note: PE findings are often adequate for diagnosis.
  22. 22. MANAGEMENTfocus prevent complications, such as pulmonary emboli Prevent increase in size of thrombus.
  23. 23. MANAGEMENTNONSURGICALMANAGEMENT SURGICAL MANAGEMENT Rest Thrombectomy drug therapy Inferior vena caval preventive measures interruption
  24. 24. RESTbedrest and elevation of the extremityintermittent or continuous warm, moist soaks to the affectedarea.evaluate for signs and symptoms of pulmonary embolism(PE) SOB and chest pain Emboli may also travel to the brain or heart, but these complications are not as common as PE.Warm moist compress as prescribed
  25. 25. Medical Management drug therapy objectives of treatment for DVT Prevent the thrombus from growing and fragmenting (risking pulmonary embolism) Prevent recurrent thromboemboli. includes Anticoagulant therapy Unfractionated Heparin Low-Molecular-Weight Heparin Warfarin Thrombolytic Therapy
  26. 26. DRUG THERAPYAnticoagulant therapy drugs of choice for a client with DVT prevent the formation of a thrombus in postop patients forestall extension of a thrombus after it has formed IV unfractionated heparin (low-molecular weight heparin ) followed by oral anticoagulation with warfarin (Coumadin).
  27. 27. AnticoagulantsUnfractionated Heparin Therapy Route: IV unfractionated heparin (UFH; Hepalean) prevent formation of other clots, which often develop in the presence of an existing clot prevent enlargement of the existing clot. Check labs b4 administration baseline prothrombin time (PT), activated partial thromboplastin time (aPTT), International Normalized Ratio (INR), complete blood count (CBC) with platelet count, urinalysis, stool for occult blood, and creatinine level.
  28. 28. AnticoagulantsUnfractionated Heparin Therapy initially given in bolus IV dose (100 units/kg of body weight) followed by constant infusion. Use electronic infusion device. aPTTs are obtained daily (therapeutic levels 1-2 times the normal control levels. Assess s/s of bleeding (hematuria, frank or occult blood in the stool, ecchymosis (bruising), petechiae, an altered level of consciousness, or pain) The nurse ensures that protamine sulfate, the antidote for heparin, is available, if needed, for excessive bleeding
  29. 29. AnticoagulantsLow-Low-Molecular Weight Heparin (LMWH) Route: Subcutaneous enoxaparin (Lovenox) dalteparin (Fragmin) ardeparin (Normiflo) prevention and treatment of DVT Prevents extension of thrombus and development of new thrombi dosing schedule must be based on product used and protocol at each institution: coz there are several preparations Monitor INR and stools daily for occult blood
  30. 30. AnticoagulantsLow-Low-Molecular Weight Heparin (LMWH) Advantages Has longer half-life than unfractionated heparin doses can be given in 1 or 2 subq /day Doses are adjusted according to weight. is associated with fewer bleeding complications than unfractionated heparin. May be used safely in pregnant women patients may be more mobile and have an improved quality of life. Disadvantage cost is higher than for unfractionated heparin
  31. 31. Nursing respon:assess and monitor anticoagulant therapy frequently monitor PTT, PT, Hb, Hct , platelet count, and fibrinogen level. Monitor bleeding episodes if bleeding occurs, report STAT and DC anticoagulant therapy unfractionated heparin continuous IV infusion by electronic infusion device Coagulation tests and Hct level Therapeutic range : PTT 1.5 times the control intermittent IV injection dilute solution of heparin is administered q 4 hrs Can use Heparin lock, an IV catheter or a small, butterfly-type scalp vein needle with an injection site at end of tubing.
  32. 32. AnticoagulantsWarfarin Therapy Route : PO works in liver to inhibit synthesis of 4 vitamin K-dependent clotting factors and takes 3 to 4 days before it can exert therapeutic anticoagulation. Monitor PT or INR. effect is delayed for 3 to 5 days Clients usually receive warfarin for 3 to 6 months after an episode of DVT. Ensure that vitamin K, the antidote for warfarin, is available in case of excessive bleeding
  33. 33. Health teaching while in warfarin Do not change your eating habits without checking with your doctor. Eat a normal, balanced diet. Foods that have high levels of vitamin K (eg, green leafy vegetables, broccoli, liver, certain vegetable oils) may change the effect of Warfarin . Ask your doctor for a list of foods that may affect Warfarin . Tell your doctor if any foods on the list are a part of your diet. Do not eat cranberry products or drink cranberry juice while you are taking Warfarin . Tell your doctor if these products are already part of your diet. Do not take aspirin while you take Warfarin unless your doctor tells you to.
  34. 34. Thrombolytic Therapy effective in dissolving thrombi quickly and completely. effective dissolve clot or prevent new clots during 1st 24 hrs (Source: ignata) Streptokinase, recombinant tissue plasminogen activator (t-PA), platelet inhibitors such as abciximab (ReoPro) given within first 3 days after acute thrombosis (source: Smeltzer) tissue plasminogen activator [t-PA, alteplase, Activase], reteplase [r-PA, Retavase], tenecteplase [TNKase], staphylokinase, urokinase, streptokinase monitor closely for signs and symptoms of bleeding.
  35. 35. Thrombolytic Therapy advantages less long-term damage to venous valves reduced incidence of postthrombotic syndrome and chronic venous insufficiency disadvantage greater incidence of bleeding than heparin. If bleeding occurs and cannot be stopped, the thrombolytic agent is discontinued. Contraindications Postoperatively during pregnancy after childbirth, trauma, brain attacks, or spinal injuries.
  36. 36. SURGICAL MANAGEMENTThrombectomyremoval of thrombosisInferior vena caval interruption may be placed at the time of the thrombectomy this filter traps large emboli and prevents pulmonary emboli
  37. 37. INFERIOR VENA CAVAL INTERRUPTION Indicated for recurrent deep vein thrombosis (DVT) or pulmonary emboli that do not respond to medical treatment and for clients who cannot tolerate anticoagulation to prevent pulmonary emboli. popular Inferior vena caval interruption birds-nest filter Greenfield filter Stop anticoagulants, such as warfarin (Coumadin, Warfilone) or heparin (Hepalean) before therapy Use local anesthesia. surgeon inserts a filter device, or "umbrella," percutaneously into the inferior vena cava
  38. 38. INFERIOR VENA CAVAL INTERRUPTION trap emboli in inferior vena cava before they progress to the lungs. Holes in the device allow blood to pass through, thus not significantly interfering with the return of blood to the heart. Postop care Inspect incision on right side of chest for bleeding and signs or symptoms of infection
  39. 39. The drawings show the path of emboli from the lower extremities to the lung (left); Greenfield Filter placement in relation to the heart and lungs (above right); and emboli trapped in a Greenfield Filter.
  40. 40. (A) Stainless-steel Greenfield filter;(B) modified-hook titanium Greenfield filter;(C) bird’s nest filter;(D) Simon nitinol filter;(E) Vena Tech filter.
  41. 41. LIGATION OR EXTERNAL CLIPS If an inferior vena caval filter is not successful in preventing pulmonary emboli, or if the filter becomes blocked with thrombi Surgeon perform ligation or insert external clips on the inferior vena cava to prevent pulmonary emboli. In ligation: surgeon ties off inferior vena cava to block emboli. external clip, such as the Adams-DeWeese clip, narrows the inferior vena cava to four serrated transverse slits, 3 to 5 mm in diameter.
  43. 43. Nursing Management Assessing and monitoring anticoagulant therapy Monitoring and managing potential complications Providing comfort Applying elastic compression stockings Applying intermittent pneumatic compression devices Preventive measures
  44. 44. MONITORING AND MANAGINGPOTENTIAL COMPLICATIONS Bleeding Thrombocytopenia Drug Interactions
  45. 45. MONITORING AND MANAGINGPOTENTIAL COMPLICATIONS: Bleeding spontaneous bleeding anywhere in the body principal complication of anticoagulant therapy s/s bleeding from kidneys : detected by microscopic examination of urine; Often first sign of anticoagulant toxicity from excessive dosage. Bruises, nosebleeds, and bleeding gums
  46. 46. MONITORING AND MANAGINGPOTENTIAL COMPLICATIONS: Bleeding Antidotes! protamine sulfate Used to reverse effects of heparin (IV) Warfarin Reversing the effects vitamin K and possibly transfusion of fresh frozen plasma (FFP)
  47. 47. Heparin-Heparin-induced thrombocytopenia decrease in platelets s/s this serious complication results falling platelet count to less than in thromboembolic 100,000/mL manifestations decrease in platelet count exceeding 25% at one time At risk: need for increasing doses of those receive heparin for more heparin to maintain the than 5 days therapeutic level on readministration after a brief thromboembolic or hemorrhagic interruption of heparin therapy complications Prevention history of heparin sensitivity Begin warfarin concomitantly Treatment with heparin can provide a stable INR or prothrombin time by day Lab: platelet aggregation 5 of heparin treatment D/C heparin regular monitoring of platelet Administer protamine sulfate counts
  48. 48. Drug Interactions Meds and supplements that potentiate oral anticoagulants salicylates, anabolic steroids, chloral hydrate, glucagon, chloramphenicol, neomycin, quinidine, phenylbutazone (Butazolidin), coenzyme Q10, dong quai, garlic, gingko, ginseng, green tea, and vitamin E; Meds that decrease anticoagulant effect phenytoin, barbiturates, diuretics, estrogen, and vitamin C. Identify medication interactions for patients taking specific oral anticoagulants.
  49. 49. PROVIDING COMFORTBed rest depends on extent and location of a venous thrombosis 5 to 7 days after diagnosis: the time necessary for thrombus to adhere to vein wall, preventing embolizationelevation of the affected extremityWarm, moist packs applied to the affected extremity : toreduce discomfortMild analgesicselastic compression stockings: when begin to ambulateWalking is better than standing or sitting for long periods.Bed exercises (ex: dorsiflexion of foot)
  50. 50. APPLYING ELASTIC COMPRESSIONSTOCKINGS these stockings exert a sustained, evenly distributed pressure over the entire surface of the calves, reducing caliber of superficial veins in legs and resulting in increased flow in deeper veins. Types: knee-high, thigh-high, or panty hose. Thigh-high stockings Difficult to wear, because they have a tendency to roll down. roll of stocking further restricts blood flow rather than the stocking providing evenly distributed pressure over thigh NOTE: Any type of stocking can become a tourniquet if applied incorrectly (ie, rolled tightly at the top)
  51. 51. ELASTIC COMPRESSION STOCKINGS For ambulatory patients, elastic compression stockings are removed at night and reapplied before the legs are lowered from the bed to the floor in the morning. When stockings are off skin is inspected for signs of irritation calves are examined for possible tenderness. Any skin changes or signs of tenderness are reported Contraindication: severe pitting edema because they can produce severe pitting at the knee.
  52. 52. Applying INTERMITTENT PNEUMATICCOMPRESSION DEVICES can be used with elastic compression stockings to prevent DVT. can increase blood velocity beyond that produced by the stockings. Nursing measures Ensure that prescribed pressures are not exceeded Assess for patient comfort
  54. 54. Preventive measures: Positioning thebody and encouraging exercise Periodically elevate feet and lower legs above level of heart when bed rest allows superficial and tibial veins to empty rapidly and to remain collapsed. Active and passive leg exercises: increase venous flow. esp when not able to ambulate as frequently as necessary (ex: during long car, train, and plane trips) Early ambulation: most effective in preventing venous stasis.
  55. 55. Preventive measures: Positioning thebody and encouraging exercise Deep-breathing exercises produce increased negative pressure in the thorax, which assists in emptying the large veins. Avoid sitting for more than 2 hours at a time. elevate legs when sitting alternate standing with sitting at work or at home Walk at least 10 min q 1 to 2 hrs. regular exercise
  56. 56. Preventive measures Application of elastic compression stocking wear knee- or thigh-high compression or elastic stockings Avoid using the knee gatch or pillow under the knees Use of intermittent pneumatic compression devices Maintain IBW Administer heparin
  57. 57. HEALTH TEACHING stop or avoid smoking Avoid use of oral contraceptives Most are discharged on a regimen of warfarin (Coumadin, Warfilone) or low molecular weight heparin (LMWH).
  58. 58. avoid potentially traumatic situations, such as participation in contactsports.Provide written and oral information about s/s bleeding. report any of these manifestations to the health care provider immediately.The anticoagulant effect of warfarin may be reversed by the omission ofone or two doses of the drug or by the administration of vitamin K.In case of injury, clients are directed to apply pressure to bleedingwounds and to seek medical assistance immediately.The nurse encourages them to carry an identification card or wear amedical alert bracelet that states that they are taking warfarin.The nurse also instructs clients to inform their dentist and other healthcare providers that they are taking warfarin before receiving treatmentor prescriptions.
  59. 59. Prothrombin times are affected by many prescription and over-the-countermedications, such as antacids, antihistamines, aspirin, mineral oil, oralcontraceptives, and large doses of vitamin C.The action of warfarin is also affected by high-fat and vitamin K-rich foods,such as cabbage, cauliflower, broccoli, asparagus, turnips, spinach, kale, fish, andliver. Clients are therefore instructed to eat a well-balanced diet and to avoidtaking additional medications without consulting a health care provider. The nurse arranges for clients to have prothrombin time (PT) and InternationalNormalized Ratio (INR) determinations made 1 to 2 weeks after discharge.Clients receiving subcutaneous LMWH injections at home need instruction onself-injection. If family members or friends are administering the injections, thenurse teaches the appropriate caregiver.Clients who have experienced DVT may fear recurrence of a thrombus and mayalso be concerned about treatment with warfarin and the risk for bleeding. Thenurse assures them that participation in the prescribed treatment frequentlyhelps in resolving this problem and that ongoing assessment of PTs and INRsshould minimize the risks of bleeding.
  60. 60. PATIENT EDUCATIONTaking Anticoagulant Medications Take the anticoagulant at the same time each day, usually between 8:00 and 9:00 AM. Wear or carry identification indicating the anticoagulant beingtaken. Keep all appointments for blood tests. Because other medications affect the action of the anticoagulant, do not take any of the following medications or supplements without consulting with the primary health care provider: vitamins, cold medicines, antibiotics, aspirin, mineral oil, and anti- inflammatory agents, such as ibuprofen (Motrin) and similar medications or herbal or nutritional supplements. The primary health care provider should be contacted before taking any over- the-counter drugs.
  61. 61. PATIENT EDUCATIONTaking Anticoagulant Medications Avoid alcohol, because it may change the body’s response to an anticoagulant. Avoid food fads, crash diets, or marked changes in eating habits. Do not take warfarin (Coumadin) unless directed. Do not stop taking Coumadin (when prescribed) unless directed. When seeking treatment from physician, a dentist, a podiatrist, or another health care provider, be sure to inform the caregiver that you are taking an anticoagulant.
  62. 62. PATIENT EDUCATIONTaking Anticoagulant Medications Contact your primary health care provider before having dental work or elective surgery. If any of the following signs appear, report them immediately to the primary health care provider: Faintness, dizziness, or increased weakness Severe headaches or abdominal pain Reddish or brownish urine Any bleeding—for example, cuts that do not stop bleeding Bruises that enlarge, nosebleeds, or unusual bleeding from any part of the body Red or black bowel movements Rash Avoid injury that can cause bleeding. For women: Notify the primary health care provider if you suspect pregnancy.
  63. 63. Chronic Venous Insufficiency
  64. 64. Venous Insufficiency results from obstruction of venous valves in legs or a reflux of blood back through valves. Can involve superficial and deep leg veins The disorder is long-standing, difficult to treat, and often disabling.
  65. 65. Pathophy DVT prolonged increase in venous pressure Resultant venous hypertension Distension of veins due to consistent venous pressure elevation valvular reflux leaflets of venous valves are stretched and prevented from closing completely allowing a backflow or reflux of blood in the veins.
  66. 66. Dx test Duplex ultrasonography Confirms obstruction and identifies the level of valvular incompetence.
  67. 67. Clinical Manifestations postthrombotic syndrome chronic venous stasis, resulting in edema, altered pigmentation, pain, and stasis dermatitis stasis ulceration symptoms less in the morning and more in the evening. valvular reflux Superficial veins dilated.
  68. 68. Clinical Manifestations Stasis ulcers pigmentation and ulcerations Common: medial malleolus of the ankle. Skin dry, cracks, and itches; subcutaneous tissues fibrose and atrophy.
  69. 69. Complications 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.
  70. 70. Management Goal: reducing venous stasis and preventing ulcerations. antigravity activities measures that increase venous blood flow1. Elevate leg2. compression of superficial veins with elastic compression stockings.
  71. 71. Elevating the legs Effects: decreases edema, promotes venous return, and provides symptomatic relief. Legs elevated frequently throughout the day (at least 15 to 30 minutes every 2 hours). At night, patient should sleep with the foot of bed elevated about 15 cm (6 inches).
  72. 72. Avoid prolonged sitting or standingEncourage walkingWhen sitting: avoid placing pressure on popliteal spaces Ex: avoid crossing legs or sitting with legs dangling over side of bed.Avoid constricting garments (ex: panty girdles or tight socks)
  73. 73. Compression of the legs with elasticcompression stockings Effects: reduces pooling of venous blood and enhances venous return to heart. stocking should fit so that pressure is greater at foot and ankle and then gradually declines to a lesser pressure at the knee or groin. If the top of the stocking is too tight or becomes twisted, a tourniquet effect is created, which worsens venous pooling. Applied before standing or in the morning Stockings should be applied after legs have been elevated for a period, when amount of blood in the leg veins is at its lowest.
  74. 74. Other nursing care Protect extremities from trauma skin is kept clean, dry, and soft Signs of ulceration are immediately reported to the health care provider
  75. 75. Leg Ulcers
  76. 76. leg ulcer is an excavation of skin surface that occurs when inflamed necrotic tissue sloughs off. Causes 75% result from chronic venous insufficiency. 20% - due to arterial insufficiency 5% - burns, sickle cell anemia, and other factors
  77. 77. Pathophysiology Inadequate exchange of oxygen and other nutrients in tissue When cellular metabolism cannot maintain energy balance, cell death (necrosis) results. Alterations in blood vessels at arterial, capillary, and venous levels may affect cellular processes and lead to formation of ulcers
  78. 78. Clinical Manifestations Symptoms depend on whether the problem is arterial or venous in origin severity of the symptoms depends on the extent and duration of the vascular insufficiency. ulcer -open, inflamed sore may be draining or covered by eschar (dark, hard crust).
  79. 79. ARTERIAL ULCERS Chronic arterial disease intermittent claudication digital or forefoot pain at rest pain is unrelenting and rarely relieved even with opioid analgesics. small, circular, deep ulcerations on tips of toes or in the web spaces between toes. Often occur on medial side of the hallux or lateral fifth toe may be caused by a combination of ischemia and pressure
  80. 80. Medical Management PHARMACOLOGIC THERAPY Antibiotic therapy DÉBRIDEMENT
  81. 81. Medical Management PHARMACOLOGIC THERAPY: Antibiotic therapy Oral antibiotics usually are prescribed Topical antibiotics have not proven to be effective for leg ulcers.
  82. 82. usual method of wound cleaning : flush area with normalsaline solution.DÉBRIDEMENT removal of nonviable tissue from wounds. Removing the dead tissue is important, particularly in instances of infection. If this is unsuccessful, débridement may be necessary.
  83. 83. Types of debridement Sharp surgical débridement fastest method can be performed by a physician, skilled advanced practice nurse, or certified wound care nurse in collaboration with the physician. Nonselective débridement Apply isotonic saline dressings of fine-mesh gauze to the ulcer. When the dressing dries, it is removed (dry), along with the debris adhering to the gauze. Need pain management
  84. 84. Types of debridement Enzymatic débridement with the application of enzyme ointments ointment is applied to lesion but not to normal surrounding skin. Use of Débriding agents Dextranomer (Debrisan) beads : small, highly porous, spherical beads ; can absorb wound secretions. Calcium alginate dressings used when absorption of exudate is needed. should not be used on dry or nonexudative wounds.
  85. 85. TOPICAL THERAPY goals of treatment : remove devitalized tissue and to keep ulcer clean and moist while healing takes place. Treatment should not destroy developing tissue.
  86. 86. WOUND DRESSINGAfter the circulatory status has been assessed and determined tobe adequate for healing (ABI of more than 0.5), surgical dressingscan be used to promote a moist environment.Tegapore simplest method wound contact material (eg, Tegapore) next to wound bed and cover it with gauze. maintains a moist environment, can be left in place for several days, and does not disrupt the capillary bed when removed for evaluation.Hydrocolloids (eg, Comfeel, DuoDerm CGF, Restore, Tegasorb) promote granulation tissue and reepithelialization. provide a barrier for protection because they adhere to the wound bed and surrounding tissue. Not for deep wounds and infected wounds
  87. 87. STIMULATED HEALING Apligraf Tissue-engineered human skin equivalent along with therapeutic compression a skin product cultured from human dermal fibroblasts and keratinocytes. Application is not difficult, no suturing is involved, and the procedure is painless.
  88. 88. Apligraf® is placed directly on Apligraf® is covered with The area is thenwound non-adherent dressing wrapped with final dressings
  89. 89. A. Chronic wound on right hand palm.B. Apligraf applied to the open wound.C. One week after Apligraf is applied.
  90. 90. Varicose Veins
  91. 91. Varicose veins (varicosities) are abnormally dilated, tortuous, superficial veins caused by incompetent venous valves Most commonly occurs in lower extremities, saphenous veins, or lower trunk; can occur elsewhere in body (ex: esophageal varices) occur in up to 60% of adult population in US increased incidence correlated with increased age
  92. 92. Causes most common in women people whose occupations require prolonged standing (ex: salespeople, hair stylists, teachers, nurses, ancillary medical personnel, and construction workers) hereditary weakness of vein wall not uncommon to occur in several members of same family. Pregnancy may cause varicosities. leg veins dilate during pregnancy because of hormonal effects related to distensibility, increased pressure by the gravid uterus, and increased blood volume which all contribute to the development of varicose veins rare before puberty Risk factors - family history, prolonged standing/sitting, pregnancies, leg trauma
  93. 93. Pathophysiology Types: primary (without involvement of deep veins) secondary (resulting from obstruction of deep veins) A reflux of venous blood in the veins results in venous stasis. Vein walls weaken and dilate and valves become incompetent Saphenous vein- most commonly affected If only the superficial veins are affected, the person may have no symptoms but may be troubled by the appearance of the dilated veins.
  94. 94. Clinical Manifestations Distended protruding veins that appear darkened and tortuous Symptoms, if present, may take the form of dull aches, muscle cramps, and increased muscle fatigue in the lower legs. Heaviness or fullness in legs Ankle edema and a feeling of heaviness of the legs may occur. Nocturnal cramps are common (leg cramping that intensifies at night) (+) Trendelenburg test Brown discoloration of affected extremity Stasis ulcer When deep venous obstruction results in varicose veins, patients may develop s/s of chronic venous insufficiency: edema, pain, pigmentation, and ulcerations. Susceptibility to injury and infection is increased
  95. 95. Diagnostic Findings Duplex scan Documents anatomic site of reflux and provides a quantitative measure of the severity of valvular reflux. Air plethysmography Measures changes in venous blood volume. Venography Not routinely performed to evaluate for valvular reflux. When used, involves injecting x-ray contrast agent into leg veins so that vein anatomy can be visualized by x-ray studies during various leg movements.
  96. 96. Prevention avoid activities that cause venous stasis Avoid wearing tight socks or a constricting panty girdle Avoid Crossing legs at thigh Avoid sitting or standing for long periods. promote leg circulation Change position frequently Elevate legs as much as possible (20 mins) get up to walk for several minutes of every hour.
  97. 97. Prevention Encourage to walk 1 or 2 miles each day if there are no contraindications. Walking up the stairs rather than using the elevator or escalator is helpful in promoting circulation. Swimming : good exercise for the legs. Elastic compression stocking or antiembolic stockings, especially knee-high stocking. weight-reduction plan for overweight Avoid constrictive clothing
  98. 98. ManagementLigation and strippingEndovenous Laser TreatmentRadiofrequency AblationSclerotherapy
  99. 99. Ligation and stripping Ligation and stripping of the great and the small saphenous veins. Veins are removed if they are larger than 4 mm in diameter or if they are in clusters requires that the deep veins be patent and functional. saphenous vein - ligated and divided.
  100. 100. Ligation and stripping Vein stripping: Postop care Evaluate pulses Elastic bandages Elevate legs Monitor extremities for edema, warmth , color , bleeding Analgesics
  101. 101. Endovenous Laser Treatment thin fiber is inserted into damaged vein via a very small skin nick. Laser light energy is delivered to the targeted tissue, which reacts with the light, causing the vein to close and seal shut.
  102. 102. Radiofrequency Ablation Endovenous radiofrequency (RF) ablation insertion of a catheter with electrodes into the target vein and passage of RF energy (electricity) through the vein tissue.
  103. 103. SCLEROTHERAPYSclerotherapy ( Sodium murrhuate)chemical is injected into vein, irritating venous endotheliumand producing localized phlebitis and fibrosis, therebyobliterating the lumen of vein.may be performed alone for small varicosities or may followvein ligation or stripping.Sclerosing is palliative rather than curative.
  104. 104. SCLEROTHERAPYAfter the sclerosing agent is injected elastic compression bandages are applied to the leg; worn approx 5 daysThe health care provider who performed sclerotherapy removesthe first bandages.Elastic compression stockings are then worn for an additional 5weeks.After sclerotherapy, patients are encouraged to perform walkingactivities as prescribed to maintain blood flow in the leg.Walking enhances dilution of the sclerosing agent.Incision and drainage of trapped blood are performed after 14-21days
  106. 106. Nursing Management Surgery outpatient setting, or admitted to the hospital on the day of surgery and discharged the next day Bed rest 24 hours Then walking q 2 hrs for 5 to 10 minutes Elastic compression stockings used to maintain compression of the leg worn continuously for about 1 week after vein stripping. exercises and move the legs The foot of the bed should be elevated Standing still and sitting are discouraged
  107. 107. PROMOTING COMFORT ANDUNDERSTANDING Analgesics are prescribed to help patients move affected extremities more comfortably. inspect dressings for bleeding, particularly at the groin, where the risk of bleeding is greatest. alert for reported sensations of “pins and needles.” hypersensitivity to touch in the involved extremity may indicate a temporary or permanent nerve injury resulting from surgery, because the saphenous vein and nerve are close to each other in the leg
  108. 108. may shower after the first 24 hours.use patting technique rather than rubbing to dryincisions with a clean towelAvoid skin lotion until incisions are completely healed to decrease chance developing infection.
  109. 109. Post sclerotherapy burning sensation in the injected leg for 1 or 2 days. mild analgesic (eg, propoxyphene napsylate and acetaminophen [Darvocet N], oxycodone and acetaminophen [Percocet], oxycodone and acetylsalicylic acid [Percodan walking to provide relief.
  110. 110. Cellulitis
  111. 111. Cellulitis an infection of the deep layer of skin (dermis) and the layer of fat and tissues just under the skin (the subcutaneous tissues). most common infectious cause of limb swelling can occur as a single isolated event or a series of recurrent events. often misdiagnosed, usually as recurrent thrombophlebitis or chronic venous insufficiency. occurs when an entry point through normal skin barriers allows bacteria to enter and release their toxins in the subcutaneous tissues.
  112. 112. Clinical Manifestations acute onset of swelling localized redness pain systemic signs of fever, chills, and sweating. redness may not be uniform and often skips areas. Regional lymph nodes may also be tender and enlarged.
  113. 113. Medical Management Mild cases: oral antibiotic therapy. Severe: intravenous antibiotics for at least 7 to 14 days. key to preventing recurrent episodes 1. adequate antibiotic therapy for initial event 2. identify site of bacterial entry. The most commonly overlooked areas are cracks and fissures that occur in the skin between the toes. Other possible locations are drug use injection sites, contusions, abrasions, ulcerations, ingrown toenails, and hangnails.
  114. 114. Nursing Management elevate the affected area above heart level and apply warm, moist packs to the site every 2 to 4 hours. Individuals with sensory and circulatory deficits, such as diabetes and paralysis, should use caution when applying warm packs because burns may occur; it is advisable to use a thermometer or have a caregiver ensure that the temperature is not more than lukewarm. Education should focus on preventing a recurrent episode. The patient with peripheral vascular disease or diabetes mellitus should receive education or re-education about skin and foot care.
  115. 115. Prevention Whenever you have a break Protect skin by: in the skin: Keeping skin moist with lotions Clean the break carefully or ointments to prevent with soap and water. Apply an cracking antibiotic cream or ointment Wearing shoes that fit well and every day. provide enough room for feet Cover with a bandage and Learning how to trim nails to change it every day until a avoid harming the skin around scab forms. them Watch for redness, pain, Wearing appropriate protective equipment when participating drainage, or other signs of in work or sports infection.
  116. 116. To prevent DVT, heparin may be given in low doses subcutaneously forhigh-risk clients, especially after orthopedic surgery.Other pharmacologic agents that may be used for prophylaxis are asfollows:Ø Low-molecular weight heparin (e.g., enoxaparin [Lovenox])Ø Dextran, an IV plasma expanderØ Dihydroergotamine (DHE)Ø Warfarin (Coumadin, Warfilone)Ø Aspirin (ASA)Prevention of DVT also includes early ambulation and mobilization,thigh-high graduated compression elastic stockings (such as TEDstockings), and external intermittent or sequential compression devices(SCDs) (Church, 2000). The nurse ensures that the compression devicesfit properly and do not restrict blood flow.
  118. 118. LYMPHATIC DISORDERS Lymphangitis and Lymphadenitis Lymphedema and Elephantiasis
  119. 119. lymphatic system consists of a set of vessels that spread throughout most of the body. lymph capillaries drain unabsorbed plasma from the interstitial spaces unite to form the lymph vessels pass through lymph nodes empty into large thoracic duct that joins jugular vein
  120. 120. lymphatic system Lymph fluid drained from interstitial space by lymphatic system Flow depends on intrinsic contractions of lymph vessels, contraction of muscles, respiratory movements, and gravity. lymphatic system of abdominal cavity maintains a steady flow of digested fatty food (chyle) from the intestinal mucosa to the thoracic duct. other parts of body, the lymphatic system’s function is regional lymphatic vessels of head empty into clusters of lymph nodes located in neck lymphatic vessels of extremities empty into nodes of the axillae and the groin
  121. 121. Lymphangitis and Lymphadenitis
  122. 122. Lymphangitis an acute inflammation of the lymphatic channels. arises most commonly from a focus of infection in an extremity. Cause: hemolytic Streptococcus groin, axilla, or cervical region: Nodes most often involved
  123. 123. Clinical manifestations red streaks - extend up arm or leg from an infected wound acute lymphadenitis enlarged, red, and tender lymph nodes along course of lymphatic channels suppurative lymphadenitis necrotic and form an abscess
  124. 124. ManagementAntibioticsAfter acute attacks, anelastic compressionstocking or sleeve -worn on affected extremityfor several months toprevent long-term edema.Recurrent episodes oflymphangitis often associated with progressive lymphedema
  125. 125. Lymphangitis
  126. 126. Lymphangitis is an acute inflammation of the lymphatic channels. Cause: infection in an extremity. hemolytic Streptococcus.
  127. 127. Clinical manifestation red streaks that extend up the arm or the leg from an infected wound lymph nodes located along the course of the lymphatic channels also become enlarged, red, and tender (acute lymphadenitis). can also become necrotic and form an abscess (suppurative lymphadenitis). nodes involved most often are groin, axilla, or cervical region.
  128. 128. ManagementAntibioticPost infection: wear elastic compression stocking or sleeve onaffected extremity for several months to prevent long-termedema.
  129. 129. Lymphedema
  130. 130. Lymphedemasclassified primary (congenital malformations) secondary (acquired obstructions).Tissue swelling occurs in extremities because of an increasedquantity of lymph that results from obstruction of lymphaticvessels.
  131. 131. Types of lymphedema Primary lymphedema 3 forms congenital lymphedema lymphedema praecox lymphedema tarda
  132. 132. Types of lymphedema Secondary lymphedema has an identifiable cause that destroys or renders inadequate the otherwise normal lymphatics. results from damage or removal of regional lymph nodes through surgery, radiation, infection, or tumor invasion or compression. Filariasis vein stripping peripheral vascular surgery Lipectomy Burns burn scar excision insect bites.
  133. 133. Clinical Manifestations Tissue swelling extremities Especially when in a dependent position. (1) edema is soft, pitting, and relieved by treatment. (2) edema becomes firm, nonpitting, and unresponsive to treatment.
  134. 134. congenital lymphedema (lymphedemapraecox)praecox) most common primary type caused by hypoplasia of the lymphatic system of the lower extremity. usually seen in women and first appears between ages 15 and 25.
  135. 135. Filariasis most common cause worldwide the direct infestation of lymph nodes by the parasite Wuchereria bancrofti.
  136. 136. Medical Management goal :reduce and control edema & prevent infection Active and passive exercises assist in moving lymphatic fluid into the bloodstream. External compression devices milk the fluid proximally from the foot to the hip or from the hand to the axilla. When ambulatory, custom-fitted elastic compression stockings or sleeves are worn; those with the highest compression strength (exceeding 40 mm Hg) are required. strict bed rest with the leg elevated
  137. 137. PHARMACOLOGIC THERAPYdiuretic furosemide (Lasix) Prevent fluid overload that can result from mobilization of extracellular fluid.antibiotic therapy For lymphangitis or cellulitis
  138. 138. SURGICAL MANAGEMENT1. excision of affected subcutaneous tissue and fascia, with skin grafting to cover defect.2. surgical relocation of superficial lymphatic vessels into the deep lymphatic system by means of a buried dermal flap to provide a conduit for lymphatic drainage.
  139. 139. Nursing Management: Postop care Prophylactic antibiotics may be prescribed for 5 to 7 days. Constant elevation of affected extremity Observe for complications flap necrosis Hematoma abscess under flap cellulitis inspect the dressing daily Inform patient loss of sensation in skin graft area. Avoid application of heating pads or exposure to sun to prevent burns or trauma to the area.
  140. 140. Three worms externalized