Table of Contents

The vascular system
y Also known as the circulatory


y Consists of arteries, veins and


y The heart is responsible for

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

more tense.Arteries vs. Veins y Arteries y Tougher. 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 .

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. .Examination and Diagnostics y Homans sign y Flex the patient s knee slightly y With the other hand. al 2011).

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 . 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. 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+.

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

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 .

y the consistency (thickness) of the blood y qualities of the vessel wall.DVT PATHOPHYSIOLOGY y Virchow's triad is a group of three factors known to affect clot formation: y rate of flow. .

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

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. 1 1 í2 1 1 1 1 Points 1 .<1 point: low risk (3%). 1 to 2 points: moderate risk (17%). Risk score interpretation (probability of DVT): 3 points: high risk (75%). paresis.Wells Clinical Prediction Rule for DVT Clinical feature Active cancer (treatment within 6 months. or palliation) Paralysis.

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

DVT Complications y chronic venous insufficiency y Postphlebitic syndrome y Pulmonary Embolism .

Treatment y Anticoagulants y Injectable heparin y Blood thinners .

Sequential Compression device .

The patient states I am really worried about what is wrong with me now. Why would my leg suddenly become red and swollen? . 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. When the nurse enters the room in the beginning at her shift.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.

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

her recent labwork includes a CBC and Hemoglobin and Hematocrit with no abnormal values reported. Her husband.History of Present Illness y One June 1. 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. the patient was ambulating in her home when she accidently tripped over her small dog and fell. There she had an x-ray which revealed a left femur fracture. y Since hospitalization. 2010. 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.

She recalls having had a tetanus shot several years ago. The client states she has been diagnoses with osteoarthrtis since 2004 which she takes medications for. endoscopy was in 2004. y The client recalls that she had no immunizations as a child and regularly receives a flu shot each year. scarlet fever or polio. y Obstetric history includes two pregnancies. The client has had several surgeries and hospitalizations. chicken pox. Her last flu shot was in september of 2009. rubella. She also has had GERD since her late 40 s which is treated with medications. Her last colonoscopy was in 2003. rheumatic fever. These include an appendectomy in 1950 and childbirth with hospital stay in 1979. All tests were reported as normal. one full term live births and one miscarriage. 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). She has had hypertension since age 56 treated with medications and diet.Past Medical History y The client states she does recall having measles as a child but does not recall having had mumps. her last mammogram was in August 2009 .

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

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 her hobbies are reading. The client reports a typical breakfast around 7:00 am is oatmeal. The client has an high school education. She states her caffeine consumption is 3 cups of coffee per day. the client reports she has pasta. puzzles. She reports she eats three meals a day. She reports she has been a homemaker most of her life but did teach Sunday school from the ages of 40-55 years. a salad and a glass of milk. 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. She states she has had a weight loss of approximately 5 lbs in the past 6 months. gardening and watching movies on TV. She then has a small evening snack around 7:00 pm of jello or low fat ice cream.Personal/Social/Functional History y The client denies use of tobacco in the past or present. She states she does not drink alcohol. The client reports she does not get any exercise except some gardening and household work. She states lunch is usually a turkey sandwich and an apple. sewing. 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. . an orange coffee. She has had no record of military service. She reports she is Methodist and attends church every Sunday. She states she does get out of breath if she does too much and needs to take breaks. She states she does not have difficulty falling or staying asleep. For dinner. The client states she has not traveled to any countries that she could have been exposed to any diseases. She then has a snack around 10:00 am graham crackers and milk.

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

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 .Medications (Cont.) y While hospitalized.

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

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

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

clean dry and intact with no signs or symptoms of infection . 2+ left lower extremity Pedal pulses 3+ right lower extremity. 9 cm Positive Homan s sign Left hip surgical incision has staples. 7 cm. temperature y y y y y y y y y y 99.Physical Examination y Alert and oriented to person. pulse 68. and time y Vital signs: blood pressure 140/70. 1+ left lower extremity Calf circumference: right. respirations 20 Oxygen saturation 95% on room air Lungs clear all lobes Bowel sounds are normoactive and present in all four quadrants Apical pulse: 68 Skin warm to touch bilateral lower extremities. slight erythema left lower extremity No edema right lower extremity. left. place.7º F.

Conclusions y Assessment y Mrs. 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 . M. redness and swelling in her left lower extremity. Based on her physican exam and history.D is a 65 year old female who presents with complaints of pain.

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.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 . M.

Inspect legs and feet and record findings q 8 hours. Assist with progressive ambulation when allowed. Spend time with Mrs. report values outside desired range.D: y y y y y y y y Elevate legs. Monitor laboratory values to assess effect of anticoagulant therapy.moist compresses to right leg using a 2-hour-on. .D to explain venous thrombosis and its treatment. Apply antiembolism stockings as ordered. Administer prescribed analgesics and evaluate effectiveness.Planning and implementation y The following interventions are planned and implemented for Mrs.maintaining slight knee flexion. Apply warm. M. remove for 30 minutes every 8 hours. while in bed. 2hour-off schedule around the clock. M.

M.Audience questions y What were some of the factors that may have contributed to Mrs.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 .