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

1. Nursing Care of Clients with
Peripheral Vascular Disorders
Maria Carmela L. Domocmat, RN, MSN
Instructor
Northern Luzon Adventist College
Artacho, Sison, Pangasinan

2. VENOUS DISORDERS

3. VENOUS DISORDERS
Venous Thrombosis, Deep Vein Thrombosis (DVT),
Thrombophlebitis, and Phlebothrombosis
Chronic Venous Insufficiency
Leg Ulcers
Varicose Veins

4. Venous Thrombosis, Deep Vein
Thrombophlebitis,
Thrombosis (DVT), Thrombophlebitis,
and Phlebothrombosis

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. Types
Thrombophlebitis
Deep Vein Thrombophlebitis or Deep vein thrombosis
Phlebothrombus
Phlebitis

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 inflammation
Phlebitis
vein inflammation
associated with invasive procedures (IV therapy)

8. Etiology
exact cause unclear
Thrombus formation has been associated with Virchow's
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. 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

11. 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

12. Recent major surgery or injury ( most
common: hip surgery or open prostate
surgery)
Ulcerative colitis
Heart failure
Cardiovascular disease
Immobility: prolonged bedrest (ex: during
periop period)
Hypercoagulation

14. 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.

15. 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)

16. Deep vein thrombosis (DVT) in the calf of a patient.
http://www.the-hospitalist.org/details/article/574163/When_Should_an_IVC_Filter_Be_Used_to_Treat_a_DVT.html

18. positive Homan's 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!

19. 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

20. Deep vein thrombosis (DVT) in a
woman's thigh

21. 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!

22. 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

23. Upper extremity
Upper extremity venous Effort thrombosis of the
thrombosis 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.

24. Diagnostic tests
contrast venography
duplex ultrasonography
Doppler flow studies
Impedance plethysmography
Note: PE findings are often adequate for diagnosis.

26. MANAGEMENT
focus
prevent complications, such as pulmonary emboli
Prevent increase in size of thrombus.

27. MANAGEMENT
NONSURGICAL
MANAGEMENT SURGICAL MANAGEMENT
Rest Thrombectomy
drug therapy Inferior vena caval
preventive measures interruption

28. REST
bedrest and elevation of the extremity
intermittent or continuous warm, moist soaks to the affected
area.
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

29. 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

30. DRUG THERAPY
Anticoagulant 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).

31. Anticoagulants
Unfractionated 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.

33. Anticoagulants
Unfractionated 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

34. Anticoagulants
Low-
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

36. Anticoagulants
Low-
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

37. 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.

38. Anticoagulants
Warfarin 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

40. 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.
http://drugline.org/drug/medicament/24869/

42. 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.

43. 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.

44. SURGICAL MANAGEMENT
Thrombectomy
removal of thrombosis
Inferior vena caval interruption
may be placed at the time of the thrombectomy
this filter traps large emboli and prevents pulmonary emboli

45. 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
bird's-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

47. 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

48. 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.
http://www.the-
hospitalist.org/details/article/574163/When_Shoul
d_an_IVC_Filter_Be_Used_to_Treat_a_DVT.html

49. (A) Stainless-steel
Greenfield filter;
(B) modified-hook
titanium Greenfield
filter;
(C) bird’s nest filter;
(D) Simon nitinol filter;
(E) Vena Tech filter.

50. 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.

51. LIGATION OR EXTERNAL CLIPS

52. 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

53. MONITORING AND MANAGING
POTENTIAL COMPLICATIONS
Bleeding
Thrombocytopenia
Drug Interactions

54. MONITORING AND MANAGING
POTENTIAL 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

55. MONITORING AND MANAGING
POTENTIAL 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)

56. 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

57. 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.

59. PROVIDING COMFORT
Bed 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 embolization
elevation of the affected extremity
Warm, moist packs applied to the affected extremity : to
reduce discomfort
Mild analgesics
elastic compression stockings: when begin to ambulate
Walking is better than standing or sitting for long periods.
Bed exercises (ex: dorsiflexion of foot)

60. APPLYING ELASTIC COMPRESSION
STOCKINGS
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)

61. 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.

63. Applying INTERMITTENT PNEUMATIC
COMPRESSION 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

64. INTERMITTENT PNEUMATIC
COMPRESSION DEVICES
Watch
http://www.youtube.com/watch?v=pMf3e7mlaVY&featur
e=related

65. Preventive measures: Positioning the
body 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.

66. Preventive measures: Positioning the
body 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

67. 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

68. 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).

69. avoid potentially traumatic situations, such as participation in contact
sports.
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 of
one or two doses of the drug or by the administration of vitamin K.
In case of injury, clients are directed to apply pressure to bleeding
wounds and to seek medical assistance immediately.
The nurse encourages them to carry an identification card or wear a
medical alert bracelet that states that they are taking warfarin.
The nurse also instructs clients to inform their dentist and other health
care providers that they are taking warfarin before receiving treatment
or prescriptions.

70. Prothrombin times are affected by many prescription and over-the-counter
medications, such as antacids, antihistamines, aspirin, mineral oil, oral
contraceptives, 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, and
liver. Clients are therefore instructed to eat a well-balanced diet and to avoid
taking additional medications without consulting a health care provider. T
he nurse arranges for clients to have prothrombin time (PT) and International
Normalized Ratio (INR) determinations made 1 to 2 weeks after discharge.
Clients receiving subcutaneous LMWH injections at home need instruction on
self-injection. If family members or friends are administering the injections, the
nurse teaches the appropriate caregiver.
Clients who have experienced DVT may fear recurrence of a thrombus and may
also be concerned about treatment with warfarin and the risk for bleeding. The
nurse assures them that participation in the prescribed treatment frequently
helps in resolving this problem and that ongoing assessment of PTs and INRs
should minimize the risks of bleeding.

71. PATIENT EDUCATION
Taking 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.

72. PATIENT EDUCATION
Taking 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.

73. PATIENT EDUCATION
Taking 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.

74. Chronic Venous Insufficiency

75. 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.

76. 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.

77. Dx test
Duplex ultrasonography
Confirms obstruction and identifies the level of valvular
incompetence.

78. 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.

79. Clinical Manifestations
Stasis ulcers
pigmentation and ulcerations
Common: medial malleolus of the ankle.
Skin dry, cracks, and itches;
subcutaneous tissues fibrose and atrophy.

81. 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.

82. Management
Goal: reducing venous stasis and preventing ulcerations.
antigravity activities
measures that increase venous blood flow
1. Elevate leg
2. compression of superficial veins with elastic compression
stockings.

83. 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).

84. Avoid prolonged sitting or standing
Encourage walking
When 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)

85. Compression of the legs with elastic
compression 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.

87. 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

88. Leg Ulcers

89. 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

90. 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

91. 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).

92. 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

93. Medical Management
PHARMACOLOGIC THERAPY
Antibiotic therapy
DÉBRIDEMENT

94. Medical Management
PHARMACOLOGIC THERAPY: Antibiotic therapy
Oral antibiotics usually are prescribed
Topical antibiotics have not proven to be effective for leg ulcers.

95. usual method of wound cleaning : flush area with normal
saline 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.

96. 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

97. 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.

98. 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.

99. WOUND DRESSING
After the circulatory status has been assessed and determined to
be adequate for healing (ABI of more than 0.5), surgical dressings
can 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

100. 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.

101. Apligraf® is placed directly on Apligraf® is covered with The area is then
wound non-adherent dressing wrapped with final
dressings

102. A. Chronic wound on right hand palm.
B. Apligraf applied to the open wound.
C. One week after Apligraf is applied.

103. Varicose Veins

104. 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

106. 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

107. 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.

109. 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

110. 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.

111. 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.

112. 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

113. Management
Ligation and stripping
Endovenous Laser Treatment
Radiofrequency Ablation
Sclerotherapy

114. 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.

116. Ligation and stripping
Vein stripping: Postop care
Evaluate pulses
Elastic bandages
Elevate legs
Monitor extremities for edema, warmth , color , bleeding
Analgesics

117. 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.

118. 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.

119. SCLEROTHERAPY
Sclerotherapy ( Sodium murrhuate)
chemical is injected into vein, irritating venous endothelium
and producing localized phlebitis and fibrosis, thereby
obliterating the lumen of vein.
may be performed alone for small varicosities or may follow
vein ligation or stripping.
Sclerosing is palliative rather than curative.

120. SCLEROTHERAPY
After the sclerosing agent is injected
elastic compression bandages are applied to the leg; worn approx 5
days
The health care provider who performed sclerotherapy removes
the first bandages.
Elastic compression stockings are then worn for an additional 5
weeks.
After sclerotherapy, patients are encouraged to perform walking
activities 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 14-21
days

122. SCLEROTHERAPY

124. 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

125. PROMOTING COMFORT AND
UNDERSTANDING
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

126. may shower after the first 24 hours.
use patting technique rather than rubbing to dry
incisions with a clean towel
Avoid skin lotion until incisions are completely healed
to decrease chance developing infection.

127. 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.

128. Cellulitis

129. 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.
http://www.patient.co.uk/health/Cellulitis.htm

131. 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.

132. 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.

133. 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.

134. 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.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001858/

135. To prevent DVT, heparin may be given in low doses subcutaneously for
high-risk clients, especially after orthopedic surgery.
Other pharmacologic agents that may be used for prophylaxis are as
follows:
Ø Low-molecular weight heparin (e.g., enoxaparin [Lovenox])
Ø Dextran, an IV plasma expander
Ø 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 TED
stockings), and external intermittent or sequential compression devices
(SCDs) (Church, 2000). The nurse ensures that the compression devices
fit properly and do not restrict blood flow.

136. LYMPHATIC DISORDERS

137. LYMPHATIC DISORDERS
Lymphangitis and Lymphadenitis
Lymphedema and Elephantiasis

138. 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

139. 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

142. Lymphangitis and Lymphadenitis

143. 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

145. 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

146. Management
Antibiotics
After acute attacks, an
elastic compression
stocking or sleeve -
worn on affected extremity
for several months to
prevent long-term edema.
Recurrent episodes of
lymphangitis
often associated with
progressive lymphedema

147. Lymphangitis

148. Lymphangitis
is an acute inflammation of the lymphatic channels.
Cause: infection in an extremity.
hemolytic Streptococcus.

149. 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.

150. Management
Antibiotic
Post infection: wear elastic compression stocking or sleeve on
affected extremity for several months to prevent long-term
edema.

151. Lymphedema

152. Lymphedemas
classified
primary (congenital malformations)
secondary (acquired obstructions).
Tissue swelling occurs in extremities because of an increased
quantity of lymph that results from obstruction of lymphatic
vessels.

153. Types of lymphedema
Primary lymphedema
3 forms
congenital lymphedema
lymphedema praecox
lymphedema tarda

154. 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.

155. 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.

156. congenital lymphedema (lymphedema
praecox)
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.

157. Filariasis
most common cause
worldwide the direct
infestation of lymph nodes
by the parasite Wuchereria
bancrofti.
http://emedicine.medscape.com/article/191350-
treatment

160. 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

161. PHARMACOLOGIC THERAPY
diuretic furosemide (Lasix)
Prevent fluid overload that can result from mobilization of
extracellular fluid.
antibiotic therapy
For lymphangitis or cellulitis

162. SURGICAL MANAGEMENT
1. 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.

163. 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.

164. Three worms externalized