04.09 Venous Disorders (Chronic venous insufficiency, Deep venous thrombosis/DVT)

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Overview

  1. Venous disorders
    1. Veins not working right
    2. Damaged or missing valves

Nursing Points

General

  1. Insufficiency
    1. Absence of valves
    2. Venous hypertension–>too much pressure for valves to handle
      1. Venous walls damaged–>varicose veins
      2. Capillaries are damaged–>hyperpigmented skin
      3. Valves fail
      4. Reflux and pooling of blood
      5. Fluid leakage from blood stream–>swelling
      6. Lack of nutrients
        1. Cells die–>hard skin and formation of sore (venous ulcer)
    3. Inflammation
      1. Platelets stick to damaged walls–>clotting process initiated
  2. Risk factors
    1. Genetic
    2. Deep vein thrombosis (DVT)
      1. Clot blocks vein–>increased pressure behind clot damages vein and valves
    3. Standing long periods–>blood pooling, damaged valves

Assessment

  1. Presentation
    1. Pain or itching–>worse when standing
    2. Swelling–>worse when standing
    3. Burning or cramping
    4. Hard, flaky, discolored skin (from bursting of capillaries)
    5. Varicose veins–>rope-like
  2. Check pulses–>doppler
  3. Observe and palpate edema
    1. Pitting–>takes longer to bounce back
    2. Non pitting–>skin bounces back quickly

Therapeutic Management

  1. Nurse judgement
    1. Elevate patient feet
    2. Wound care
    3. Ambulation
  2. Doctor orders
    1. Compression stockings–>on 12 hours, off 12 hours
    2. Lymphedema pump–>compress from ankle and up leg
    3. Medications to prevent blood clots
    4. Vein stripping
    5. Vein bypass

Nursing Concepts

  1. Clotting–>DVTs can cause venous disorders
  2. Patient Education–>educate patient on care of legs
  3. Skin/Tissue Integrity–>Edema, hyperpigmentation, hard skin, venous ulcers

Patient Education

  1. Excercise
  2. Keep feet up–>avoid standing for long periods of time
  3. Wear stockings
  4. Quit smoking

Reference Links

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Video Transcript

Hey guys! Welcome to the lesson on venous disorders where we’re going to explore what causes disorder in the veins and what the results are. We will then discuss ways to care for patients that have venous disorders.

Before we get into details, remember that the veins bring the blood back to the heart after the blood perfused the organs. Venous disorders involve damaged valves in the veins that allow for blood backflow, damaging the venous walls and causing cell death and wound formation. Pressure is usually low in the veins. Next let’s talk about what happens when the pressure is high.  

When the pressure is high in the veins, it damages the valves and the walls. When the walls are damaged, varicose veins form, which are the big squiggly veins that sort of pop out of the leg. So the walls of the vein are damaged, and platelets begin to stick to them which causes the clotting process to begin. The patient is now going to develop blood clots that may further clot the veins increasing the pressure behind them. You will notice that these patients may have hyperpigmented skin on their legs. This is because the high pressure in the veins causes increased pressure in the capillaries, causing them to burst, leaving that dark purplish color under the skin.

The clotting, blockage, and increased pressure leads to cell death around those veins. The cells die off and the skin becomes hard and flaky. Venous ulcers form on the legs which are very difficult to heal with the lack of nutrients reaching the cells.

Our patients that have a family history of venous disorders are more likely to experience them as well. Those that have jobs where they are standing for long periods of time are more at risk because the blood pools and valves are damaged. Compression stockings can be helpful to prevent venous issues in those that must stand for long periods. DVTs get lodged in the vein and pressure increases behind the clot, causing damage to the walls and vessels.

Let’s think about what our patient will look like with venous disorders. The backing up of blood and increased pressure is going to allow fluid leakage outside of the vein causing edema in the legs. It’s worse when they’ve been standing because of gravity. The stretching and skin death cause hard, flaky, discolored skin that is painful and itchy. That discoloration is a dark purple color because of the bursting capillaries. Varicose veins are rope-like and usually stand out on the leg.

When we care for patients with venous disorders, we have to check their pulses and assess the edema in their legs. The edema may be pitting or non pitting. Pitting edema takes longer to bounce back, and non pitting bounces back quickly after pushing on the skin. The patient with severe edema may require a doppler if you are unable to feel the pulse with your fingers. The doppler allows you to hear the pulse when placed over the pulse location.

So, when we have a patient with venous disorders, it’s important to keep their legs elevated when they’re sitting to avoid further pooling of blood in the veins and increased edema and pain. Wound care is needed for those with venous ulcers to protect from infection. Although it may be more painful when up, we should encourage our patients to ambulate.

Something to help with the pain and swelling while ambulating is the use of compression stockings. These should be placed on the patient for twelve hours and then removed for twelve hours. A simple way to remember is on during the day and off at night. A lymphedema pump is a compression device that squeezes the blood upward from the ankle and up the leg to promote normal flow of blood. The doctor might order medications to prevent blood clots from forming to avoid further complications. Vein stripping to remove the problem veins and vein bypass to make a pathway around it may be an option as well, but these are surgical procedures that require a vascular specialist.

As the nurse, we should educate our patients to keep exercising while wearing their stockings. They should keep their feet up when sitting and avoid standing for long periods of time if possible. If the patient smokes, they should quit as it makes them at a higher risk for developing blood clots due to the vessel damage.

Alright guys, our nursing concepts for venous disorders are clotting, patient education, and skin/tissue integrity.

Okay, let’s review the key points from this lesson on venous disorders. First, venous hypertension causes increased pressure that weakens the valves and injures the vessel. The vein stretches from the pressure causing varicose veins, and the capillaries burst creating that dark purple color on their legs. Second, the lack of nutrients due to the back of of blood allows the cells to die. This creates hard skin and the forming of venous ulcers that are very difficult to heal. Third, the causes of venous disorders include DVTs, genetics, and standing for long periods of time. The patient with venous disorders will present with swollen, hyperpigmented legs. They may have varicose veins and ulcers on their legs, and pain especially when standing. Last, care and education of the patient includes keeping the legs up, wearing compression stockings, wound care, and exercise. The doctor may discuss vein removal or vein stripping if needed.

I’m so happy that you came here to learn about venous disorders. Feel free to check out the lesson on thrombophlebitis to learn more about problems that occur in the veins. Now go out and be your best self today, and as always, happy nursing!

Read more

  • Question 1 of 5

A client had a venous angioplasty and stent placement done. Which of the following education should the nurse provide to the client before discharge?

  • Question 2 of 5

A client with a history of venous disorders complains of severe pain in the leg. Which of the following is the priority nursing action?

  • Question 3 of 5

A client has had compression stockings on for 24 hours. Which of the following should the nurse do first?

  • Question 4 of 5

A client is admitted with a history of venous stasis and the lower extremities are edematous and discolored. The healthcare provider orders a doppler of the lower extremities, which shows that the left leg is positive for a clot. The nurse knows to implement which of the following orders first?

  • Question 5 of 5

The nurse knows that which signs and symptoms of a client indicate a venous disorder?