VENOUS DISORDERS
:PE
is an obstruction of a blood vessel in the lungs, usually
.due to a blood clot, which blocks a coronary artery
Surgery
Central venous catheter
Local vein damage
Venous Stasis- 2
Bed rest or immobilization
History of varicosities
Age (greater than 65 years)
Obesity
Spinal cord injury
Altered Coagulation- 3
Cancer
Pregnancy
Oral contraceptive use
Protein C deficiency
Protein S deficiency
Antiphospholipid antibody syndrome
Factor V Leiden defect
Prothrombin 20210A defect
Hyperhomocysteinemia
Elevated factors II, VIII, IX, XI
Antithrombin III deficiency
Polycythemia
Septicemia
Clinical Manifestations
Un common, phlegmasia cerulea dolens (massive iliofemoral
venous thrombosis), in which the entire extremity becomes
massively swollen, tense, painful, and cool to the touch
The affected extremity may feel warmer, and thesuperficial veins may appear more prominent
Tenderness, which usually occurs later, can be detected by. gently palpating the affected extremity
Homans sign (pain in the calf after the foot is sharplydorsiflexed) , but it is not a reliable sign for DVT
So
treated at home with bed rest, elevation of the leg, analgesic
agents, and possibly anti-inflammatory medication
:key concerns during nursing assessment includelimb pain, a feeling of heaviness, functional - 1
impairment, ankle engorgement, and edema
differences in leg circumference bilaterally from thigh - 2
to ankle
increase in the surface temperature of the leg, - 3
particularly the calf or ankle
areas of tenderness or superficial thrombosis (ie, cord- 4
Complications of VenousThrombosis
Valvular destruction
Chronic venous insufficiency
Increased venous pressure
Varicosities
Venous ulcers
Venous obstruction
Increased distal pressure
Fluid stasis
Edema
Venous gangrene
Prevention
Application of graduated compression stockings -1
Use of intermittent pneumatic compression devices - 2
Encouragement of early mobilization and leg exercises -3
For surgical patients, administration of subcutaneous - 4
un fractionated or low-molecular- weight heparin
(LMWH)
lifestyle changes as appropriate, which may include - 5
weight loss, smoking cessation, and regular exercise
Medical Management
:A- Pharmacologic Therapy
Unfractionated Heparin- 1
Subcutaneously to prevent development of DVTIntermittent or continuous IV infusion for 5 days toprevent the extension of a thrombus and the
development of new thrombi
Oral anticoagulants, such as warfarin, are administered with heparin therapy
Oral Anticoagulants- 3
Warfarin is a vitamin K antagonist that is indicated for
extended anticoagulant therapy , and have a slow
onset of action
Factor Xa Inhibitor- 4
given daily SC at a fixed dose, as Fondaparinuxhas a half-life of 17 hoursMust be used with caution in patients with renal insufficiency
Also effective in conjunction with warfarin-
Thrombolytic Therapy-5
catheter-directed thrombolytic (fibrinolytic) therapy lyses and.dissolves thrombi in at least 50% of patients
is given within the first 3 days after acute) eg, alteplase- (
thrombosis, if initiated more than 14 days it will be less
.effective
:The advantages
less long-term damage to the venous valves and a reducedincidence of post thrombotic syndrome and chronic
venous insufficiency
incidence of bleeding than heparin, so if bleeding can not
stopped, the thrombolytic agent is discontinued
Nursing Management
:A-Assessing and Monitoring Anticoagulant Therapy
unfractionated heparin is administered by continuous IV- 1
infusion using an electronic infusion device
Dosage calculations are based on the patients weight- 2
possible bleeding tendencies are detected by a- 3
pretreatment clotting profile
If renal insufficiency exists, lower doses of heparin are- 4
.required
Thrombocytopenia
A complication of heparin therapy may be heparin induced
thrombocytopenia (HIT)
It is a sudden decrease in the platelet count by at least30% of baseline levels
it is preferable not to use unfractionated heparin over the- 1
long term for the greatest risks
The administration of LMWH is less frequently associated- 2
with HIT
Beginning warfarin with unfractionated heparin can- 3
provide a stable INR or PT by day 5 of heparin treatment,
.at which time the heparin may be discontinued
:Drug Interactions
close monitoring of the patients medication schedule - 1
. is necessary
Check if any medications or supplements are - 2
contraindicated with warfarin, Many medications and
supplements inhibit oral anticoagulants
C- Providing Comfort
Elevation of the affected extremity- 1
graduated compression stockings, and analgesic- 2
.agents
Warm, moist packs applied to the affected extremity- 3
encouraged to walk once anticoagulation therapy has- 4
been initiated
instruct the patient that walking is better than - 5
standing or sitting for long periods
Bed exercises, such as repetitive dorsiflexion of the - 6
foot
NB
For ambulatory patients
graduated compression stockings are removed at
night and reapplied before the legs are
lowered from the bed to the floor in the
.morning
It is important to keep the foot dorsiflexed at a 90degree angle, thus avoiding excess pressure or
trauma to the anterior ankle area
Once the bandage dries, it provides a constant and consistent compression of the venous system, remain
in place for as long as 1 week
It
results from
obstruction
of the venous
Chronic
Venous
Insufficiency/
- valves3in the legs.or a reflux of blood through
valves
( Postthe
thrombotic
Syndrome)
Superficial and deep leg veins can be involved-
Gravity
Blood
pressure
Competent valves showing blood flow patterns when the valve is open (A) and
. closed (B), allowing blood to flow against gravity
C, With faulty or incompetent valves, the blood cannot move toward the heart
B- Infective Endocarditis
is a microbial infection of the endothelial surface of the
heart. It usually develops in people with prosthetic
heart valves or structural cardiac defects
Myocarditis- 2
inflammatory process involving the myocardium, can
cause heart dilation, thrombi on the heart wall (mural
thrombi), infiltration of circulating blood cells around
,the coronary vessels and between the muscle fibers
and degeneration of the muscle fibers themselves
Pericarditis- 3
inflammation of the pericardium, the membranous sac
. enveloping the heart
Primary illnessSecondary, it may develop during various medical and. surgical disorders
For example
After pericardectomy (opening of the pericardium) following
. cardiac surgery
also may occur 10 days to 2 months after acute myocardial
infarction (MI)
ARTERIAL DISORDERS
Arteriosclerosis and Atherosclerosis - 1
: Arteriosclerosis
is the most common disease of the arteries; the term
. means hardening of the arteries
It is a diffuse process whereby the muscle fibers and the
endothelial lining of the walls of small arteries and
arterioles become thickened
:Atherosclerosis
A different process, affecting the intima of the large and
.medium-sized arteries
These changes consist of the accumulation of lipids,
calcium, blood components, carbohydrates, and
fibrous tissue on the intimal layer of the artery. These
accumulations are referred to as atheromas or
.plaques
: It may be complicated by
hemorrhage, ulcerationcalcification, or thrombosisMyocardial infarction-
.stroke, or gangrene-
pain may be described as aching, cramping, or inducing fatigue or weakness that occurs with the same degree
.of exercise or activity and is relieved with rest
The pain commonly occurs in muscle groups distal to .the area of stenosis or occlusion
Elevating the extremity or placing it in a horizontal position increases the pain, whereas placing the
extremity in a dependent position reduces the pain
Raynauds Phenomenon
Is a form of intermittent arteriolar vasoconstrictionthat results in coldness, pain, and pallor of the
fingertips or toes
.There are two forms of this disorderPrimary or idiopathic (Raynauds disease) occurs in - 1
the absence of an underlying disease
Secondary Raynauds occurs in association with an - 2
underlying disease, usually a connective tissue disorder,
such as systemic lupus erythematosus, rheumatoid
arthritis, or scleroderma; trauma; or obstructive arterial
.lesions
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