Table of Contents

The vascular system

y Also known as the circulatory

system

y Consists of arteries, veins and

capillaries

y The heart is responsible for

pumping blood through this network of blood vessels through the following two systems:
y Pulmonary y Systemic

Arteries vs. Veins

y Arteries y Tougher, more tense, and less distensible y Veins y Less sturdy and more passive y Contain valves to keep blood flowing in one direction y Veins can expand for extra blood

Assessment for Venous obstruction and Sufficiency

y Signs and symptoms

will vary and will be dependent upon the rapididity with which the obstruction develops and the degree of localization (Seidel et. al 2011).

Venous obstruction
y One of the first symptoms is constant pain occurring

simultaneously with the following:

y Swelling and tenderness over the muscles y Engorgement of superficial veins y Erythmia and/or cyanosis

Examination and Diagnostics

y Examine the patient in both standing and supine

positions for the following:

y Homans sign y Edema

Examination and Diagnostics

y Homans sign y Flex the patient s knee slightly y With the other hand, dorsoflex the foot y Assess patient for calf pain
Positive results: May indicate venous thrombosis
*The absence of homan s sign still may not mean the patient does not have thrombosis (Seidel et. al 2011).

Examination and Diagnostics

y Edema accompanied by thickening and ulceration of the skin is frequently

associated with deep venous obstruction or venous valvular incompetence (Seidel et. al 2011). y The Severity of edema can be characterized by grading 1+ through 4+:
y 1+ Slight pitting with no visible distortion and disappears rapidly y 2+ A deeper pit than 1+, disappears within 10-15 seconds y 3+ Deep pit lasting more than a minute with the extremity looking

deeper and more swollen y 4+Very deep pit that may last 2 to 5 minutes with a grossly distorted extremity

Examination and Diagnostics

y Ultrasound doppler studies y According to Seidel et. al (2011), thrombosis cannot be confirmed on physical examination alone

POSSIBLE FINDINGS R/T THROMBOSIS

y DEEP VEIN THROMBOSIS
y The formation of a blood

clot (thrombosis) in a deep vein y commonly affects the leg veins or deep veins of the pelvis

DVT PATHOPHYSIOLOGY
y Virchow's triad is a group of

three factors known to affect clot formation:

y rate of flow, y the consistency

(thickness) of the blood y qualities of the vessel wall.

DVT Risk Factors

increasing age prolonged immobility Surgery Trauma malignancy Pregnancy estrogenic medications (e.g., oral contraceptive pills, hormone therapy) y congestive heart failure y diseases that alter blood viscosity (e.g., polycythemia, sickle cell disease, multiple myeloma) y inherited thrombophilias.
y y y y y y y

Wells Clinical Prediction Rule for DVT

Clinical feature Active cancer (treatment within 6 months, or palliation) Paralysis, paresis, or immobilization of lower extremity Bedridden for more than 3 days because of surgery (within 4 weeks) Localized tenderness along distribution of deep 1 veins Entire leg swollen Unilateral calf swelling of greater than 3 cm (below tibial tuberosity) Unilateral pitting edema Collateral superficial veins Alternative diagnosis as likely as or more likely than DVT Total points: DVT = deep venous thrombosis. Risk score interpretation (probability of DVT): 3 points: high risk (75%); 1 to 2 points: moderate risk (17%);<1 point: low risk (3%). 1 1 2 1 1 1 1 Points 1

DVT Classic Signs/Symptoms

y swelling, pain, and discoloration in the affected extremity. y Physical examination may reveal the palpable cord of a thrombosed vein, unilateral edema, warmth, and superficial venous dilation. y Classic signs of DVT, include Homans sign (pain on passive dorsiflexion of the foot), edema, tenderness, and warmth (Lewis et. al 2007).

DVT Complications
y chronic venous

insufficiency y Postphlebitic syndrome y Pulmonary Embolism

Treatment
y Anticoagulants y Injectable heparin y Blood thinners

Sequential Compression device

CASE STUDY
y A 65 year old while pleasant female is staying at an

acute rehabilitation hospital to undergo physical and occupational therapy after undergoing hip surgery related to a fall at home. When the nurse enters the room in the beginning at her shift, the patient complains of pain of a 7 on a scale of 1-10 in her left leg along with redness and swelling in her left lower leg. The patient states I am really worried about what is wrong with me now. Why would my leg suddenly become red and swollen?

Demographic Data
y a. Name: Mrs. M.D y b. Address: 1313 Horizon Lane, Spring Hill Fl 34608 y c. Age: 65 y d. Birth date: December 5, 1944 y e. Birthplace: St. Petersburg, FL y f. Gender: Female y g. Marital Status: Married y h. Race/Ethnic Origin: Caucasian/German y i. Occupation: Homemaker

History of Present Illness

y One June 1, 2010, the patient was ambulating in her home when she accidently tripped over her small dog and fell. Her husband, present at the time of the fall immediately called 911 and had her transported to the Oak Hill Hospital Emergency Room with complaints of severe left upper leg pain. There she had an x-ray which revealed a left femur fracture. She immediately had surgery for a left femur open reduction internal fixation. Her incision was closed with staples. 4 days later she was admitted to a rehabilitation hospital for physical and occupational therapy. y Since hospitalization, her recent labwork includes a CBC and Hemoglobin and Hematocrit with no abnormal values reported.

Past Medical History

y The client states she does recall having measles as a child but does not recall

having had mumps, chicken pox, rubella, rheumatic fever, scarlet fever or polio. She has had hypertension since age 56 treated with medications and diet. She also has had GERD since her late 40 s which is treated with medications. The client states she has been diagnoses with osteoarthrtis since 2004 which she takes medications for. The client has had several surgeries and hospitalizations. These include an appendectomy in 1950 and childbirth with hospital stay in 1979. y Obstetric history includes two pregnancies, one full term live births and one miscarriage. y The client recalls that she had no immunizations as a child and regularly receives a flu shot each year. Her last flu shot was in september of 2009. She recalls having had a tetanus shot several years ago. She did not receive a pneumonia or HINI vaccine. y The client reports her last physical exam was in September 2009 and that she had labwork for a complete blood count (CBC) and basic metabolic profile (BMP). All tests were reported as normal. Her last colonoscopy was in 2003, endoscopy was in 2004, her last mammogram was in August 2009

Family History
y The client reports that she is one of 2 children. She

states all of her four grandparents are deceased and she does not recall any history. The client also reports her parents are both deceased. Her father died at age 92 of a heart attack and her mother died at age 85 of a pneumonia. Her brother and sister are still alive and states are in good health. She reports she has no living aunts or uncles and does not know any history on the ones she had. The client has two daughter. She reports both are of average weight and are in good health.

Personal/Social/Functional History
y The client denies use of tobacco in the past or present. She states she does not drink alcohol. She reports she eats three meals a day. She states she has had a weight loss of approximately 5 lbs in the past 6 months. The client reports a typical breakfast around 7:00 am is oatmeal, an orange coffee. She then has a snack around 10:00 am graham crackers and milk. She states lunch is usually a turkey sandwich and an apple. For dinner, the client reports she has pasta, a salad and a glass of milk. She then has a small evening snack around 7:00 pm of jello or low fat ice cream. She states her caffeine consumption is 3 cups of coffee per day. The client reports she gets an average of 8 hours of sleep a night but wakes up 2-3 times a night to use the bathroom. She states she does not have difficulty falling or staying asleep. The client reports she does not get any exercise except some gardening and household work. The client has an high school education. She states her hobbies are reading, puzzles, sewing, gardening and watching movies on TV. She reports she has been a homemaker most of her life but did teach Sunday school from the ages of 40-55 years. The client states she has not traveled to any countries that she could have been exposed to any diseases. She has had no record of military service. She reports she is Methodist and attends church every Sunday. The client states she has good mobility and upper extremity function and is able to complete her housework and activities of daily living without problem. She states she does get out of breath if she does too much and needs to take breaks. The client reports she lives in a three bedroom home with her husband in a deed restricted community with a locked front entrance as well as medical emergency alarm pulls in her bedroom and bathroom.

Medications
y The client is allergic to Penicillin which causes a rash.

She states she is not allergic to any foods or other agents. y The client reports she has taken the following medications prior to being hospitalized:
y Lisinopril 5mg QD for her blood pressure y Omeprazole 20 mg QD for reflux y Calcium 500 mg QD and Vitamin D 1000 IU QD y Ecotrin 1 tablet QD for heart attack prevention y Optivite eye formula 1 tablet QD y Multivitamin once a day

Medications (Cont.)
y While hospitalized, she has been taking the following: y Lisinopril 5mg QD for her blood pressure y Omeprazole 20 mg BID for reflux y Calcium 500 mg QD and Vitamin D 1000 IU QD for osteoporosis y Ecotrin 1 tablet QD for heart attack prevention y Optivite eye formula 1 tablet QD y Multivitamin once a day y Miralax 1 packet (17 g) QD y Vicodin 1-2 tabs q 4 hours PRN pain y Tylenol 1-2 tabs q 4 hours PRN pain or fever

Review of systems
y y y y y y y

a. General The client states that she has gained 5 pound s in the last 6 months with a current weight of 140 and a height of 5 1. She states she would like to weigh 125. She reports she has been in her usual state of health for the past 5 years. b. Skin The client denies having any skin diseases, rashes, dryness, bruising or lesions. She denies any frequent bruising. She states she has no change in sensitivity to heat, pain, or cold c. Hair The client reports that she has not had any increased hair loss over the past 5 years or any change in texture other than the thinness. She also has no itching of the scalp. d. Nails The client states she has not had any changes in her nails and has not noticed any brittleness. e. Head The client reports that she has an occasional headache and dizziness which she treats by taking tylenol. She states she has not had any injuries. f. Neck The client denies any swelling, lumps or pain g. Eyes The client states she wears glasses for vision and has worn them since she was 15 years old. states that her vision has not worsened in the past several years. She reports no current problems with vision, redness, swelling or adjusting to stairs and states she has no history of glaucoma. She does report that she sometimes has blurring of her eyes when she is having problems with her sinuses. Her last exam was in 2009 and no changes were made at that time. h. Ears The client reports that she has not had any earaches, infections, discharge or tinnitus. She denies the use of hearing aides and denies any hearing difficulties. i. Nose and Sinuses The client denies any problems with her nose. She denies any discharge or nosebleeds. She states she does have some sinus drainage at night and has been told in the past it is allergies. She reports no history of hay fever. She has had 2 colds in the past year. j. Mouth and Throat The client denies any dental problems at this time. She denies any pain, bleeding gums, or toothaches. She does not wear dentures, brushes her teeth two times a day, and her last dental exam was 2009.

y y y

Review of systems (Cont.)

y p. Musculoskeletal y y y y

The client denies having gout. She denies having any swelling, limitations of movement, weakness, gait changes, difficulties with balance or deformities. She denies difficulty with stairs and does not use any assistive devices. She states she has osteoarthritis which causes pain in her knees occasionally and stiffness if she sits too long. She also reports to occasional cramps behind her knees. q. Neurologic The client denies any seizures, strokes, fainting, tics, tremors, paralysis or aphasia. r. Mental Status The client denies any memory problems, mood changes, suicidal or homicidal thoughts and Alzheimer s disease. She reports no problems with disorientation to time or setting. s. Hematologic The client denies any anemia or bleeding problems. t. Endocrine The client denies any symptoms that may depict DM or thyroid disease. She states she is not on any hormone therapy. She states that she used birth control for several years prior to having children.

Review of systems (cont.)

y y y y

k. Respiratory The client denies any infections. She reports a cough occasionally in the morning when she first awaken. She states she has occasional production of small amounts of sputum but cannot report on color. She also states she has some shortness of breath while walking distances of approximately 50 feet and doing housework or walking up and then down more than one flight of stairs. She denies a history of lung disease and her last chest x-ray was January2009and negative. She reports she has never had a PPD that she remembers. l. Cardiovascular The client denies any pain, palpitations, cyanosis, PND, edema, murmurs, or congenital defects. She reports she has some dyspnea on exertion when she ambulates, climbs stairs or does too much housework. She states she does have a history of hypertension which is controlled by medication. m. Peripheral vascular The client denies any coldness, tingling, edema, discoloration, or intermittent claudication. She denies wearing restrictive clothing and does not use TED hose. n. GI The client reports that she does not have any change in appetite. She states sometimes it is good and sometimes not so good. She enjoys all foods. She denies any pain, heartburn or nausea and vomiting. She denies any change in bowel habits or rectal bleeding but does state she has some flatulence and occasional constipation. Her usual pattern is one bowel movement every 1 -2 days. It is usually semi-soft and brown in color. She states she occassionally takes a stool softner or miralax. o. GU The client denies any frequency, pain, incontinence or straining. She states she has occasional urgency and has nocturia with waking 1-2 times a night

Physical Examination
y Alert and oriented to person, place, and time y Vital signs: blood pressure 140/70, pulse 68, temperature 99.7 F, respirations 20 y Oxygen saturation 95% on room air y Lungs clear all lobes y Bowel sounds are normoactive and present in all four quadrants y Apical pulse: 68 y Skin warm to touch bilateral lower extremities, slight erythema left lower extremity y No edema right lower extremity, 2+ left lower extremity y Pedal pulses 3+ right lower extremity, 1+ left lower extremity y Calf circumference: right, 7 cm; left, 9 cm y Positive Homan s sign y Left hip surgical incision has staples, clean dry and intact with no signs or symptoms of infection

Conclusions
y Assessment y Mrs. M.D is a 65 year old female who presents with complaints of pain, redness and swelling in her left lower extremity. Based on her physican exam and history, abnormal findings are consistent with Deep Vein Thrombosis. y Plan y Reports these findings to the doctor and recommend patient is given a doppler to confirm presence of DVT

Nursing Diagnoses
y Pain related to inflammatory response in affected vein y Anxiety related to unexpected hospitalization and

uncertainty about the seriousness of her illness y Ineffective tissue perfusion: Peripheral related to decreased venous circulation in the left leg y Risk for impaired skin integrity related to pooling of venous blood in the left leg

Expected outcomes
y The expected outcomes of the plan of care are that

Mrs. M.D will:

y Verbalize relief of left leg pain by day of discharge y Verbalize reduced anxiety by the end of the week y Demonstrate reduced left leg diameter by the end of the

week y Maintain intact skin in the left foot throughout the hospital stay y Verbalize an understanding of treatments

Planning and implementation

y The following interventions are planned and implemented for

Mrs. M.D:

y Elevate legs,maintaining slight knee flexion, while in bed. y Apply warm,moist compresses to right leg using a 2-hour-on, 2y y y y y y

hour-off schedule around the clock. Administer prescribed analgesics and evaluate effectiveness. Spend time with Mrs. M.D to explain venous thrombosis and its treatment. Apply antiembolism stockings as ordered; remove for 30 minutes every 8 hours. Monitor laboratory values to assess effect of anticoagulant therapy; report values outside desired range. Assist with progressive ambulation when allowed. Inspect legs and feet and record findings q 8 hours.

Audience questions
y What were some of the factors that may have

contributed to Mrs. M.D developing DVT? y What could have been done to have better prevented this from occurring? y What are some of the possible complications that could arise if the patient is not treated?

References