SESSION 5

Circulatory course
 VENOUS THROMBOSIS,
DEEP VEIN THROMBOSIS (DVT)
Superficial veins Deep veins
are thick-walled muscular structures that lie just are thin walled and have less muscle in the media.
under the skin. They run parallel to arteries and bear the same
names as the arteries.

Deep and superficial veins have valves that permit unidirectional flow back to the heart.

This arrangement permits the valves to open without coming into contact with the wall of the vein,
permitting rapid closure when the blood starts to flow backward.

• Other kinds of veins are known as perforating veins

Cont`
• Formation of a thrombus frequently accompanies thrombophlebitis, which is an
inflammation of the vein walls.
• When a thrombus develops initially in the veins as a result of stasis or
hypercoagulability but without inflammation, the process is referred to as
phlebothrombosis.
• Venous thrombosis can occur in any vein but occurs more in the veins of the lower
extremities.
• superficial and deep veins of the extremities may be affected
 upper extremity venous thrombosis is more
common in patients with :
• intravenous catheters in patients with an underlying disease that causes
hypercoagulability.
• Internal trauma to the vessels may result from pacemaker leads,
chemotherapy ports, dialysis catheters…
• Effort thrombosis of the upper extremity is caused by repetitive motion,
such as experienced by competitive swimmers, tennis players, and
construction workers, that irritates the vessel wall, causing inflammation
and subsequent thrombosis.
Cont`
• Venous thrombi are aggregates of platelets attached to
the vein wall, along with a tail-like appendage
containing fibrin, white blood cells, and many red blood
cells.
• The “tail” can grow or can propagate in the direction of
blood flow as successive layers of the thrombus form.
• Video
DEEP VEINS

• With obstruction of the deep veins comes edema and swelling of the extremity
because the outflow of venous blood is inhibited
• If both extremities are swollen, a size difference may be difficult to detect. The
affected extremity may feel warmer than the unaffected extremity, and the
superficial veins may appear more prominent.
• Tenderness, which usually occurs later, is produced by inflammation of the vein
wall and can be detected by gently palpating the affected extremity.
• Homans’ sign (pain in the calf after the foot is sharply dorsiflexed) is not specific
for deep vein thrombosis because it can be elicited in any painful condition of the
calf.
• In some cases, signs of a pulmonary embolus are the first indication of deep vein
thrombosis
 SUPERFICIAL VEINS

• Thrombosis of superficial veins : produces pain or tenderness, redness, and

warmth in the involved area.
• The risk of the superficial venous thrombi becoming dislodged or fragmenting into
emboli is very low because most of them dissolve spontaneously.
This condition can be treated at home with bed rest, elevation of the leg,
analgesics, and possibly anti-inflammatory medication
 Assessment and Diagnostic Findings

• history of varicose veins, hypercoagulation, neoplastic disease, cardiovascular

• high risk
• When performing the nursing assessment
• Homans’ sign (pain in the calf as the foot is sharply dorsiflexed) has been used
historically to assess for DVT. It is not a reliable or valid sign for DVT and has no
clinical value in the assessment of a patient for DVT
Prevention

• application of elastic compression stockings,

• the use of intermittent pneumatic compression devices,
• special body positioning and exercise
• A further method to prevent venous thrombosis in surgical patients

administration of subcutaneous unfractionated or low molecular weight heparin

Complication of venous thrombosis
Chronic venous occlusion
Pulmonary emboli from dislodged thrombi
Valvular destruction
Chronic venous insufficiency
Increased venous pressure
Varicosities
Venous ulcers
Venous obstruction
Increased distal pressure
Fluid stasis
Edema
Venous gangrene
Medical Management

• prevent the thrombus from growing and fragmenting (risking pulmonary

embolism) and to prevent recurrent thrombo/emboli.
• Anticoagulant therapy
ANTICOAGULATION THERAPY
• Unfractionated Heparin
• Unfractionated heparin (heparin) is administered or by intermittent intravenous
infusion or continuous infusion for 5 to 7 days
• Oral anticoagulants, such as warfarin (Coumadin), are administered with heparin
therapy.
• Medication dosage is regulated by monitoring the partial thromboplastin time,
the international normalized ratio (INR), and the platelet count.
• Low-Molecular-Weight Heparin.
Thrombolytic Therapy.
• Unlike the heparins, thrombolytic (fibrinolytic) therapy causes the thrombus to
lyse and dissolve in 50% of patients.
SURGICAL MANAGEMENT
• Surgery is necessary for deep vein thrombosis when anticoagulant or thrombolytic
therapy is contraindicated
• The danger of pulmonary embolism is extreme, or the venous drainage is so
severely compromised that permanent damage to the extremity will probably
result.
• A thrombectomy (removal of the thrombosis) is the procedure of choice.
• A vena cava filter may be placed at the time of the thrombectomy; this filter traps
large emboli and prevents pulmonary emboli.
 Nursing Management+ care plan
• Assessment
• MONITORING AND MANAGING POTENTIAL COMPLICATIONS
• Medication administration and interaction
• Providing comfort
• APPLYING ELASTIC COMPRESSION STOCKINGS
• Position and Exercise
• USING INTERMITTENT PNEUMATIC COMPRESSION DEVICES
Venous insufficiency Resultant venous
results from Superficial and hypertension can occur
obstruction of the deep leg veins whenever there has been
venous valves in the can be a prolonged increase in
legs or a reflux of venous pressure, such as
involved. occurs with deep venous
blood back through
the valves. thrombosis.

Because the walls of veins are

thinner and more elastic the walls of
arteries, they distend readily when
venous pressure is consistently
elevated.
In this state, leaflets of the venous valves are stretched and prevented from closing completely, allowing a backflow or
reflux of blood in the veins. Duplex ultrasonography confirms the obstruction and identifies the level of valvular
incompetence.
Clinical Manifestations

• Edema
• altered pigmentation,
• pain, and stasis dermatitis.
• symptoms less in the morning and more in the evening.
• Obstruction or poor calf muscle pumping in addition to valvular reflux must be
present for the development of severe post thrombotic syndrome, which includes
stasis ulceration.
Cont`
• Superficial veins may be dilated. When these vessels rupture, red blood cells
escape into surrounding tissues and then degenerate, leaving a brownish
discoloration of the tissues.
• The pigmentation and ulcerations usually occur in the lower part of the extremity,
in the area of the medial malleolus of the ankle.
• The skin becomes dry, cracks, and itches; subcutaneous tissues fibrose and
atrophy.
 At night, the patient should sleep with the foot of the bed elevated about 15
cm (6 inches).
Elevating the legs decreases edema, promotes venous return, and provides
symptomatic relief. The legs should be elevated frequently throughout the day
Management
When sitting, the patient should avoid placing pressure on the popliteal spaces

Constricting garment should be avoided.

Elastic compression stockings are recommended for people with venous

insufficiency.

Prolonged sitting or standing still is detrimental; walking should be encouraged

Extremities with venous insufficiency must be carefully protected from trauma;

the skin is kept clean, dry, and soft.
Signs of ulceration are immediately reported to the health care provider for
treatment and follow-up