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323 Exam 2: Management of patients with PVD + Lymphatic disorders

Terms in this set (36)

Examples of different venous disorders
Venous thromboembolism, chronic venous insufficiency/post thrombotic syndrome, varicose veins and leg ulcers
VTE: Venous thrombus embolism-what two conditions make it up
DVT and PE
Superficial veins
Superficial veins (greater saphenous, lesser saphenous, cephalic, basilica, and external jugular veins) are thick walled muscular structures that lie just below the skin
Deep veins
Thin walled and have less muscle
Veins have valves that allow for
Unidirectional flow back to the heart
VTE (venous thromboembolism)

Includes both...

Results from a combination of.....

What 3 things remain the fundamental basis for our understanding of thrombosis?
Disease that includes both DVT and PE
Is common and can be lethal

Results from a combination of hereditary and acquired risk factors (aka thrombophilia or hypercoagulable states)

Vessel wall damage, venous stasis, and increased activation of clotting factors remain the fundamental basis for our understanding of thrombosis remain
the fundamental basis for our understanding of thrombosis
VTE prophylaxis core measures

(6 of them)
VTE-1: Venous Thromboembolism prophylaxis

VTE-2: Intensive care unit venous thromboembolism prophylaxis

VTE-3: Venous thromboembolism patients with anticoagulation overlap therapy

VTE-4: Venous thromboembolism patients receiving unfractionated Heparin with dosages/platelet count monitoring by protocol or nomogram

VTE-5: Venous thromboembolism Warfarin Therapy Discharge instructions

VTE-6: Hospital acquired potentially preventable venous thromboembolism
Preventing VTE: Strategies
and what pharmacologic agents are used
Maintain adequate hydration
Encourage Ambulation
Compression stockings
Anti-embolism stockings
Sequential compression device (SCDs)
Pharmacologic interventions

Low dose unfractured heparin
low molecular weight heparin
factor Xa inhibitor
vitamin k anticoagulants
Pharmacologic interventions: Prophylactic vs tx:
Low dose unfractionated heparin (LDUF)
-what is the dose, how is it given and how often
-what does it do
-what labs are needed

Low molecular weight heparin
-what is the dose, how often is it given, and where is it given
-what does it do
-what labs are required
LCUFH
Heparin 5000 u SQ every 8 hours given IV infusion for tx (higher dose)
Preventing clots
Lab: aPTT and INR

LMWH
Enoxaprin (lovenox)
10 mg daily SQ
Prevents development or extension of thrombus
Lab: INR but not required
Pharmacologic interventions: prophylactic vs tx

Vitamin K anticoagulants
-what drug
-what labs are needed

Factor Xa inhibitors
-what drugs
-what does it do
-what labs are needed
Vitamin K anticoagulants
-Warfarin (Coumadin)
-Lab: INR (2.0-3.0 therapeutic range)

Factor Xa inhibitory
-Fondaparinux (arixtra)
-directly target the enzymatic activity of thrombin and factor Xa
-Lad: none required but aPTT can be evaluated
Deep vein thrombosis define
A thrombus formation in one of the body's large veins-most commonly the lower leg (calf) causes partial or complete blockage of circulation
S/S of DVT
Pain, edema, tenderness, redness of the affected area
complications of DVT
PE, (s/s of chest pain, anxiety, and SOB)
Risk factors for DVT
Inheriting a blood-clotting disorder
Prolonged bed rest, such as during a long hospital stay or paralysis
Injury or surgery
HF
Pregnancy
Smoking
Cancer
Age
Being overweight or obese
Inflammatory bowel disease
Birth control pills or hormone replacement therapy
A personal or family hx of DVT or PE
Sitting for a long period of time, such as flying or driving
Medical management: Objective for tx to prevent the thrombus from growing and fragmenting (thus risking PE)
What type of therapy can help
Anticoagulant therapy which delays clotting time of blood, prevents thrombus formation and decreases thrombus extension once it is formed

Anticoagulants cannot dissolve clots!!
Thrombolytic therapy ay eliminate the clot
-examples
Streptokinase, urokinase, and recombinant tissue type plasminogen activator (r-tPA) aims to bring about clot lysis
DVT medication and management
Diagnosis
D Dimers: elevated in patients with DVT

Ultrasonography
DVT medication and management
Medications
LMWH: Enoxaprin (lovenox) LMWHs have gradually replaced UFH for most indications: fewer side effects

LDUF/Low Dose Unfractured Heparin-Heparin IV

Vitamin K antagonist: warfarin (coumadin)
Medication management
Lab for Heparin/Lovenox/Atrixtra
Explain what the two tests are
Explain the reference range
Explain critical values
Lab for Heparin/Lovenox/Atrixtra

Activated partial thromboplastin time and partial thromboplastin time: is the time in seconds for patient plasma to clot

Thromboplastin time (PTT) and activated partial thromboplastin time (aPTT) are used to test for the same functions; however, in aPTT an activator is added that speeds up the clotting time and results in a narrower reference range. The aPTT is considered a more sensitive version of the PTT and is used to monitor the patients response to heparin therapy.
-reference range of the aPTT is 30-40 seconds
-the reference range of he PTT is 60-70 seconds
-critical values that should prompt a clinical alert are as follows: aPTT more than 70 seconds-signifies spontaneous bleeding and an aPTT more than 100 seconds signifies spontaneous bleeding
Medication management: Labs for Warfarin (Coumadin/Tantoven)
Warfarin is an effective medicine to prevent...
Warfarin Lab
Warfarin is an effective medicine to prevent new blood clots and to keep existing ones from getting bigger. Warfarin does not dissolve existing clots

Lab: INR
-patients must go for their blood test once a month or at the health care patients discretion. When first starting Warfarin it could be once a week for the INR
-know what target INR is supposed to be: 2.0-3.0; 2.5-3.5 or even higher
-if number is too high: risk for bleeding
-if number is too low: risk for clots
Teachable moment for patients
Warfarin meds come in different _______________
Avoid taking other meds that can make you bleed such as ______________
Read all your medications to make sure they don't contain _______
What is usually okay to take but make sure to check with provider
If you miss a dose of warfarin what do you do?
Warfarin medications come in different colors-color coated by strength
-If you get a different color: ask your pharmacist

Avoid taking other medications that can make you bleed: ASA/Motrin/Aleve

Read all your medication labels to make sure they don't contain ASA

Tylenol is usually okay to take; check with your health care practitioner

If you miss a dose of warfarin do not take an extra pill to catch up
What are different medication complications
Bleeding: skin, urine, stools, lab work

Thrombocytopenia
-a decline in platelets or a low platelet count 4-14 days after starting on heparin
-platelets (thrombocytes): colorless blood cells help blood clot by clumping and forming plugs in blood vessel injuries
-normal platelet count is 150,000-300,000

Drug interactions: many drugs and herbal nutritional supplements interact
Nursing management
what anticoagulant therapies need to be monitored
what else needs to be monitored
what comfort needs to be provided
Monitor anticoagulant therapy: aPTT, prothrombin time, INR, platelet count, hemoglobin, hematocrit

Monitor for bleeding, thrombocytopenia, drug interactions

Providing comfort
-elevate affected extremity. analgesic agents (adjuvant), warm moist packs to affected areas, graduated compression stockings
-graduated compression therapy
Nursing management
what are positioning
and what kind of care needs to be promoted
Positioning the body and encouraging exercise
-with bedrest position legs above heart periodically to rapidly empty superficial and tibial veins, active and passive ROM, and deep breathing
-early ambulation, 10 minutes every 1-2 hours with compression stockings on

Promoting home and community based care
-decrease risk factors of new clot
VENOUS INSUFFICIENCY
Incompetent valves
Obstruction of the venous vales in the legs or a reflux of blood through the valves
Prolonged venous HTN that damages valves
-when standing (and during pregnancy) gravity exerts a downward pull on the blood inside the veins. One by one, as the valves break the pressure on the next valve below it increases. Eventually, with most of all of the valves breaking inside the vein, the pressure rises to very high levels. This is called venous HTN
-edema
-venous stasis ulcer
-cellulitis
Incompetent valves risk factors
Standing/sitting in one position for long periods of time (need to ambulate)
Pregnancy
Obesity
Hx of thrombus/thrombophlebitis
Common symptoms of venous insufficiency
Swelling of the legs or ankles (edema)
Pain that gets worse when standing and subsides when legs are raised
Leg cramps, aching, throbbing, or a feeling of heaviness in legs
Itchy, weak legs
Thickening of the skin on legs or ankles
Skin that is changing color, especially around the ankles
Leg ulcer
Varicose veins
A feeling of tightness calves
Medical management of vascular insufficiency: educating patients
Keep legs elevated whenever possible
Wear compression stockings to apply pressure to lower legs
Keep legs uncrossed when seating
Exercise regularly
Stop smoking; don't sit or stand in one place for long periods of time
Medications
-diuretics: to reduce edema
-anticoagulants: already discussed
-pentoxifyline(trental): already discussed
Surgical management: vascular insufficiency
Surgical repair of veins or valves
Removal (stripping) the damaged vein
Minimally invasive endoscopic surgery to clip and tie off veins
Vein bypass
Sclerotherapy
Venous ulcers: medical management
Are venous stasis ulcers or arterial ulcers more common?
Describe how venous stasis ulcers look, feel, where they usually appear and what does the individual frequently develop as a result

What are pharmacologic agent examples
Venous stasis ulcers are 5 to 7 times more common than arterial ulcers associated with peripheral arterial insufficiency
-shallow superficial irregular shape
-small to large
-painful related to edema, phlebitis or infection
-usually appear on the lower leg or ankle
-frequently the individual develops contact dermatitis

Pharmacologic agents: antisepsis, silver wound products, antibiotics if infected
Venous ulcers: medical management
Compression therapy: a leg ulcer is much less likely to recur if compression stockings are worn regularly
Debridement
Topical therapy
Wound dressing
Stimulated hearing
Hyperbaric oxygenation
Negative pressure wound therapy
Varicose veins
Varicose veins are gnarled, enlarged veins-any vein may become varicose, but the veins most commonly affected are those in your legs and feet. That's because standing and walking upright increases the pressure in the veins of your lower body
-vein wall weakens
-venous pressure increases
-valves become incompetent
Varicose veins tx
Ligation and stripping, thermal ablation, sclerotherapy
Graduated compression stockings post ligation and stripping
Varicose veins prevention
Avoid activities that cause venous stasis (wearing socks that are too tight at the top of that leave marks on the skin, crossing the legs at the thighs, and sitting or standing for long periods)
Elevate the legs 3-6 in higher than heart level
Walk for several minutes of every hour to promote circulation and 1 to 2 miles each day if there are no contraindications
Wear graduated compression stockings
Overweight patients should be encouraged to begin weight reduction plans
Nursing Dx for vascular insufficiency
Impaired skin integrity r/t vascular insufficiency

Impaired physical mobility r/t activity restrictions of the therapeutic regimen and pain

Imbalanced nutrition less than body requirements r/t increased need for nutrients that promote wound healing
Determine what symptom is associated with venous and arterial peripheral disease
Gangrene
Pain when extremity is elevated
Pain when extremity dependent
Lower extremity rubor
Ankle discoloration (brown)
Diminished pedal pulse
Treated with compression stockings
Pain relieved when legs elevated
Intermittent claudication
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