Maria Carmela L. Domocmat, RN, MSN

Nursing Care of Clients with Nursing Care of Clients with Nursing Care of Clients with Nursing Care of Clients with

Peripheral Vascular DisordersPeripheral Vascular DisordersPeripheral Vascular DisordersPeripheral Vascular Disorders

Maria Carmela L. Domocmat, RN, MSN Instructor

Northern Luzon Adventist College Artacho, Sison, Pangasinan

VENOUS DISORDERS

VENOUS DISORDERS� Venous Thrombosis, Deep Vein Thrombosis (DVT),

Thrombophlebitis, and Phlebothrombosis

� Chronic Venous Insufficiency

� Leg Ulcers

� Varicose Veins� Varicose Veins

Venous Thrombosis, Deep Vein Venous Thrombosis, Deep Vein Venous Thrombosis, Deep Vein Venous Thrombosis, Deep Vein

Thrombosis (DVT), Thrombosis (DVT), Thrombosis (DVT), Thrombosis (DVT), ThrombophlebitisThrombophlebitisThrombophlebitisThrombophlebitis, , , ,

and and and and PhlebothrombosisPhlebothrombosisPhlebothrombosisPhlebothrombosis

Venous Thrombosis:Venous Thrombosis:Venous Thrombosis:Venous Thrombosis:DVT, DVT, DVT, DVT, ThrombophlebitisThrombophlebitisThrombophlebitisThrombophlebitis, , , , PhlebothrombosisPhlebothrombosisPhlebothrombosisPhlebothrombosis

� for clinical purposes often used interchangeably

� But Note: they do not reflect identical disease processes

� Venous thrombosis � is a blood clot (thrombus) that forms within a vein� is a blood clot (thrombus) that forms within a vein� can occur in any vein; common lower extremities. � superficial and deep veins of the extremities may be affected

Types� Thrombophlebitis

� Deep Vein Thrombophlebitis or Deep vein thrombosis

� Phlebothrombus

� Phlebitis

� Thrombophlebitis� thrombus that is associated with inflammation� most frequently occurs in deep veins of lower extremities.

� Deep vein thrombophlebitis� commonly referred to as deep vein thrombosis (DVT)� more serious than superficial thrombophlebitis because it presents a greater

risk for pulmonary embolism (PE)risk for pulmonary embolism (PE)

� Phlebothrombosis� thrombus without inflammation� hrombus develops initially in veins as result of stasis or hypercoagulability

but without inflammation� Phlebitis

� vein inflammation� associated with invasive procedures (IV therapy)

Etiology � exact cause unclear

� Thrombus formation has been associated with Virchow's triad. � (1) stasis of blood (venous stasis)� (2) endothelial injury / vessel wall injury� (2) endothelial injury / vessel wall injury� (3) hypercoagulability / altered blood coagulation� Note: at least two of the factors seem to be necessary for

thrombosis to occur.

PathophysiologyPathophysiologyPathophysiologyPathophysiology� Venous stasis

� occurs when blood flow is reduced (e.g. HF or shock; when veins are dilated, as with some medication therapies)

� when skeletal muscle contraction is reduced (ex: immobility, paralysis of extremities, or anesthesia)

� bed rest reduces blood flow in the legs by at least 50%.� Vessel wall injury � Vessel wall injury

� Damage to the intimal lining of blood vessels creates a site for clot formation.

� Direct trauma to the vessels, as with fractures or dislocation, diseases of the veins, and chemical irritation of the vein from intravenous medications or solutions, can damage veins.

� Altered blood coagulation / hypercoagulability� Abrupt withdrawal anticoagulant medications.� Oral contraceptive use and several blood dyscrasias (abnormalities

Venous thrombi � are aggregates of platelets attached to the vein wall, along with a tail-like

appendage containing fibrin, WBCs , and RBCs. � The “tail” can grow or can propagate in direction of blood flow as successive

layers of thrombus form. � A propagating venous thrombosis is dangerous because parts of thrombus can

break off and produce an embolic occlusion of the pulmonary blood vessels. � Fragmentation of thrombus can occur spontaneously as it dissolves naturally, or

it can occur in association with an elevation in venous pressure, as occurs when Fragmentation of thrombus can occur spontaneously as it dissolves naturally, or it can occur in association with an elevation in venous pressure, as occurs when a person stands suddenly or engages in muscular activity after prolonged inactivity.

� After an episode of acute deep vein thrombosis, recanalization of the lumen typically occurs.

� The time required for complete recanalization is an important determinant of venous valvular incompetence, which is one complication of venous thrombosis

� Recent major surgery or injury ( most common: hip surgery or open prostate surgery)

� Ulcerative colitis

� Heart failure� Heart failure

� Cardiovascular disease

� Immobility: prolonged bedrest (ex: during periop period)

� Hypercoagulation

Clinical ManifestationsClinical ManifestationsClinical ManifestationsClinical Manifestations� may have symptoms or may be asymptomatic.

� classic s/s of DVT � calf or groin tenderness and pain, and sudden onset of

unilateral swelling of the leg.

� phlegmasia cerulea dolens� phlegmasia cerulea dolens� massive iliofemoral venous thrombosis� entire extremity becomes massively swollen, tense, painful, and

cool to the touch.

Clinical ManifestationsClinical ManifestationsClinical ManifestationsClinical Manifestations� limb pain� a feeling of heaviness� functional impairment� ankle engorgement� Edema� Edema� differences in leg circumference bilaterally from thigh to

ankle� increase in surface temperature of leg, particularly the calf or

ankle� areas of tenderness or superficial thrombosis (ie, cordlike

venous segment)

� Deep vein thrombosis (DVT) in the calf of a patient.

http://www.the-hospitalist.org/details/article/574163/When_Should_an_IVC_Filter_Be_Used_to_Treat_a_DVT.html

� positive Homan's sign� pain in calf on dorsiflexion of the foot � appears in only 10% of clients with DVT� and false-positive findings are common � Therefore checking a Homan 's sign is not advised! � Therefore checking a Homan 's sign is not advised!

Assessment � Nurse shld examine area described as painful, and compare

this site with the contralateral limb. � observe for warmth, edema, and swelling of the extremity

� Coz outflow of venous blood is inhibited� Determine amount of swelling: Measure circumference of affected

extremity at various levels with a tape measure and comparing one extremity at various levels with a tape measure and comparing one extremity with the other at the same level to determine size differences

� (+) tenderness usually occurs later� Due inflammation of vein wall

� pulmonary embolus � in some cases� first indication of DVT

Deep vein thrombosis (DVT) in a Deep vein thrombosis (DVT) in a Deep vein thrombosis (DVT) in a Deep vein thrombosis (DVT) in a

woman's thighwoman's thighwoman's thighwoman's thigh

Assessment � Note: Signs and symptoms may be absent (silent clinical

findings)� Be suspicious!� Nurse must have a high index of suspicion for this disorder

when caring for clients at high risk!when caring for clients at high risk!

� Do not massage affected extremity!

Thrombosis SUPERFICIAL VEINS� pain or tenderness, redness, and warmth

� risk of becoming dislodged or fragmenting into emboli is very low bcoz most dissolve spontaneously.

� Treatment � Can be treated at home � Can be treated at home � Bed rest� Elevation of leg� Analgesics� Anti-inflammatory medication

Upper extremityUpper extremity venous Upper extremity venous Upper extremity venous Upper extremity venous

thrombosisthrombosisthrombosisthrombosis

Effort thrombosis of the Effort thrombosis of the Effort thrombosis of the Effort thrombosis of the

upper extremity upper extremity upper extremity upper extremity

� not as common as lower extremity thrombosis. more common: with IV catheters or with underlying disease that causes hypercoagulability

� caused by repetitive motion, such as experienced by competitive swimmers, tennis players, and � Internal trauma to the vessels may

result from pacemaker leads, chemotherapy ports, dialysis catheters, or parenteral nutrition lines.

� The lumen of the vein may be decreased as a result of catheter or from external compression, such as by neoplasms or extra cervical rib.

tennis players, and construction workers, that irritates the vessel wall, causing inflammation and

subsequent thrombosis.

Diagnostic tests � contrast venography

� duplex ultrasonography

� Doppler flow studies

� Impedance plethysmography

� Note: PE findings are often adequate for diagnosis.

MANAGEMENT� focus

� prevent complications, such as pulmonary emboli� Prevent increase in size of thrombus.

MANAGEMENTNONSURGICAL NONSURGICAL NONSURGICAL NONSURGICAL

MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENT SURGICAL MANAGEMENTSURGICAL MANAGEMENTSURGICAL MANAGEMENTSURGICAL MANAGEMENT

� Rest

� drug therapy

� preventive measures

� Thrombectomy

� Inferior vena cavalinterruption� preventive measures interruption

RESTRESTRESTREST� bedrest and elevation of the extremity

� intermittent or continuous warm, moist soaks to the affected area.

� evaluate for signs and symptoms of pulmonary embolism (PE)(PE)� SOB and chest pain� Emboli may also travel to the brain or heart, but these

complications are not as common as PE.

� Warm moist compress as prescribed

Medical ManagementMedical ManagementMedical ManagementMedical Management� drug therapy

� objectives of treatment for DVT � Prevent the thrombus from growing and fragmenting (risking

pulmonary embolism) � Prevent recurrent thromboemboli.� Prevent recurrent thromboemboli.

� includes� Anticoagulant therapy

� Unfractionated Heparin

� Low-Molecular-Weight Heparin

� Warfarin

� Thrombolytic Therapy

DRUG THERAPYDRUG THERAPYDRUG THERAPYDRUG THERAPY� Anticoagulant therapy

� drugs of choice for a client with DVT � prevent the formation of a thrombus in postop patients� forestall extension of a thrombus after it has formed� IV unfractionated heparin (low-molecular weight � IV unfractionated heparin (low-molecular weight

heparin ) followed by oral anticoagulation with warfarin(Coumadin).

Anticoagulants Anticoagulants Anticoagulants Anticoagulants

UnfractionatedUnfractionatedUnfractionatedUnfractionated Heparin TherapyHeparin TherapyHeparin TherapyHeparin Therapy

� Route: IV

� unfractionated heparin (UFH; Hepalean)

� prevent formation of other clots, which often develop in the presence of an existing clot

� prevent enlargement of the existing clot. � prevent enlargement of the existing clot.

� Check labs b4 administration � baseline prothrombin time (PT), activated partial

thromboplastin time (aPTT), International Normalized Ratio (INR), complete blood count (CBC) with platelet count, urinalysis, stool for occult blood, and creatinine level.

Anticoagulants Anticoagulants Anticoagulants Anticoagulants

UnfractionatedUnfractionatedUnfractionatedUnfractionated Heparin TherapyHeparin TherapyHeparin TherapyHeparin Therapy

� initially given in bolus IV dose (100 units/kg of body weight) followed by constant infusion. Use electronic infusion device.

� aPTTs are obtained daily (therapeutic levels 1-2 times the normal control levels.

� Assess s/s of bleeding (hematuria, frank or occult blood � Assess s/s of bleeding (hematuria, frank or occult blood in the stool, ecchymosis (bruising), petechiae, an altered level of consciousness, or pain)

� The nurse ensures that protamine sulfate, the antidote for heparin, is available, if needed, for excessive bleeding

Anticoagulants Anticoagulants Anticoagulants Anticoagulants

LowLowLowLow----Molecular Weight Heparin Molecular Weight Heparin Molecular Weight Heparin Molecular Weight Heparin (LMWH) � Route: Subcutaneous� enoxaparin (Lovenox)� dalteparin (Fragmin)� ardeparin (Normiflo)� prevention and treatment of DVT� prevention and treatment of DVT� Prevents extension of thrombus and development of new

thrombi � dosing schedule must be based on product used and protocol

at each institution: coz there are several preparations� Monitor INR and stools daily for occult blood

Anticoagulants Anticoagulants Anticoagulants Anticoagulants

LowLowLowLow----Molecular Weight Heparin Molecular Weight Heparin Molecular Weight Heparin Molecular Weight Heparin (LMWH)

� Advantages� Has longer half-life than unfractionated heparin

� doses can be given in 1 or 2 subq /day

� Doses are adjusted according to weight.

� is associated with fewer bleeding complications than unfractionated heparin.

� May be used safely in pregnant women� patients may be more mobile and have an improved quality of

life.

� Disadvantage � cost is higher than for unfractionated heparin

Nursing respon: assess and monitor anticoagulant therapy

� frequently monitor PTT, PT, Hb, Hct , platelet count, and fibrinogen level.

� Monitor bleeding episodes� if bleeding occurs, report STAT and DC anticoagulant therapy

� unfractionated heparinunfractionated heparin� continuous IV infusion by electronic infusion device

� Coagulation tests and Hct level� Therapeutic range : PTT 1.5 times the control

� intermittent IV injection � dilute solution of heparin is administered q 4 hrs� Can use Heparin lock, an IV catheter or a small, butterfly-type scalp vein

needle with an injection site at end of tubing.

Anticoagulants Anticoagulants Anticoagulants Anticoagulants

WarfarinWarfarinWarfarinWarfarin TherapyTherapyTherapyTherapy

� Route : PO

� works in liver to inhibit synthesis of 4 vitamin K-dependent clotting factors and takes 3 to 4 days before it can exert therapeutic anticoagulation.

� Monitor PT or INR. � Monitor PT or INR.

� effect is delayed for 3 to 5 days

� Clients usually receive warfarin for 3 to 6 months after an episode of DVT.

� Ensure that vitamin K, the antidote for warfarin, is available in case of excessive bleeding

Health teaching while in warfarin� Do not change your eating habits without checking with your

doctor. � Eat a normal, balanced diet. � Foods that have high levels of vitamin K (eg, green leafy

vegetables, broccoli, liver, certain vegetable oils) may change the effect of Warfarin .

� Ask your doctor for a list of foods that may affect Warfarin . Tell your doctor if any foods on the list are a part of your diet.

� Do not eat cranberry products or drink cranberry juice while you are taking Warfarin . Tell your doctor if these products are already part of your diet.

� Do not take aspirin while you take Warfarin unless your doctor tells you to.

http://drugline.org/drug/medicament/24869/

Thrombolytic TherapyThrombolytic TherapyThrombolytic TherapyThrombolytic Therapy� effective in dissolving thrombi quickly and completely.

� effective dissolve clot or prevent new clots during 1st 24 hrs (Source: ignata) � Streptokinase, recombinant tissue plasminogen activator (t-PA),

platelet inhibitors such as abciximab (ReoPro)platelet inhibitors such as abciximab (ReoPro)

� given within first 3 days after acute thrombosis (source: Smeltzer)� tissue plasminogen activator [t-PA, alteplase, Activase], reteplase

[r-PA, Retavase], tenecteplase [TNKase], staphylokinase, urokinase, streptokinase

� monitor closely for signs and symptoms of bleeding.

Thrombolytic TherapyThrombolytic TherapyThrombolytic TherapyThrombolytic Therapy� advantages

� less long-term damage to venous valves � reduced incidence of postthrombotic syndrome and chronic venous

insufficiency

� disadvantage� greater incidence of bleeding than heparin. � greater incidence of bleeding than heparin.

� If bleeding occurs and cannot be stopped, the thrombolytic agent is discontinued.

� Contraindications� Postoperatively� during pregnancy� after childbirth, trauma, brain attacks, or spinal injuries.

SURGICAL MANAGEMENTSURGICAL MANAGEMENTSURGICAL MANAGEMENTSURGICAL MANAGEMENT� Thrombectomy

� removal of thrombosis

� Inferior vena caval interruption� may be placed at the time of the thrombectomy� this filter traps large emboli and prevents pulmonary emboli � this filter traps large emboli and prevents pulmonary emboli

INFERIOR VENA CAVAL INTERRUPTIONINFERIOR VENA CAVAL INTERRUPTIONINFERIOR VENA CAVAL INTERRUPTIONINFERIOR VENA CAVAL INTERRUPTION� Indicated for recurrent deep vein thrombosis (DVT) or pulmonary

emboli that do not respond to medical treatment and for clients who cannot tolerate anticoagulation to prevent pulmonary emboli.

� popular Inferior vena caval interruption� bird's-nest filter � Greenfield filter

� Stop anticoagulants, such as warfarin (Coumadin, Warfilone) or heparin (Hepalean) before therapy

� Use local anesthesia.

� surgeon inserts a filter device, or "umbrella," percutaneously into the inferior vena cava

INFERIOR VENA CAVAL INTERRUPTIONINFERIOR VENA CAVAL INTERRUPTIONINFERIOR VENA CAVAL INTERRUPTIONINFERIOR VENA CAVAL INTERRUPTION

� trap emboli in inferior vena cava before they progress to the lungs.

� Holes in the device allow blood to pass through, thus not significantly interfering with the return of blood to the heart.

� Postop care� Inspect incision on right side of chest for bleeding and signs or

symptoms of infection

The drawings show the path of emboli from the lower extremities to the lung (left); Greenfield Filter Greenfield Filter placement in relation to the heart and lungs (above right); and emboli trapped in a Greenfield Filter.

http://www.the-hospitalist.org/details/article/574163/When_Should_an_IVC_Filter_Be_Used_to_Treat_a_DVT.html

(A) Stainless-steel Greenfield filter;

(B) modified-hook titanium Greenfield filter; filter;

(C) bird’s nest filter;

(D) Simon nitinol filter;

(E) Vena Tech filter.

LIGATION OR EXTERNAL CLIPSLIGATION OR EXTERNAL CLIPSLIGATION OR EXTERNAL CLIPSLIGATION OR EXTERNAL CLIPS� If an inferior vena caval filter is not successful in preventing

pulmonary emboli, or if the filter becomes blocked with thrombi

� Surgeon perform ligation or insert external clips on the inferior vena cava to prevent pulmonary emboli. inferior vena cava to prevent pulmonary emboli.

� In ligation: surgeon ties off inferior vena cava to block emboli.

� external clip, such as the Adams-DeWeese clip, narrows the inferior vena cava to four serrated transverse slits, 3 to 5 mm in diameter.

LIGATION OR EXTERNAL CLIPSLIGATION OR EXTERNAL CLIPSLIGATION OR EXTERNAL CLIPSLIGATION OR EXTERNAL CLIPS

Nursing ManagementNursing ManagementNursing ManagementNursing Management� Assessing and monitoring anticoagulant therapy

� Monitoring and managing potential complications

� Providing comfort

� Applying elastic compression stockings

Applying intermittent pneumatic compression devices� Applying intermittent pneumatic compression devices

� Preventive measures

MONITORING AND MANAGING

POTENTIAL COMPLICATIONS

� Bleeding

� Thrombocytopenia

� Drug Interactions

MONITORING AND MANAGING

POTENTIAL COMPLICATIONS: BleedingBleedingBleedingBleeding

� spontaneous bleeding anywhere in the body� principal complication of anticoagulant therapy

� s/s� bleeding from kidneys : detected by microscopic examination of

urine; Often first sign of anticoagulant toxicity from excessive urine; Often first sign of anticoagulant toxicity from excessive dosage.

� Bruises, nosebleeds, and bleeding gums

MONITORING AND MANAGING

POTENTIAL COMPLICATIONS: BleedingBleedingBleedingBleeding

Antidotes!

� protamine sulfate� Used to reverse effects of heparin (IV)

Warfarin� Warfarin� Reversing the effects� vitamin K and possibly transfusion of fresh frozen plasma (FFP)

HeparinHeparinHeparinHeparin----induced thrombocytopeniainduced thrombocytopeniainduced thrombocytopeniainduced thrombocytopenia� decrease in platelets� this serious complication results

in thromboembolicmanifestations

� At risk: � those receive heparin for more

than 5 days

� s/s� falling platelet count to less than

100,000/mL� decrease in platelet count

exceeding 25% at one time� need for increasing doses of

heparin to maintain the therapeutic levelthan 5 days

� on readministration after a brief interruption of heparin therapy

� Prevention� Begin warfarin concomitantly

with heparin can provide a stable INR or prothrombin time by day 5 of heparin treatment

� regular monitoring of platelet counts

therapeutic level� thromboembolic or hemorrhagic

complications� history of heparin sensitivity

� Treatment� Lab: platelet aggregation � D/C heparin� Administer protamine sulfate

Drug InteractionsDrug InteractionsDrug InteractionsDrug Interactions� Meds and supplements that potentiate oral anticoagulants

� salicylates, anabolic steroids, chloral hydrate, glucagon, chloramphenicol, neomycin, quinidine, phenylbutazone(Butazolidin), coenzyme Q10, dong quai, garlic, gingko, ginseng, green tea, and vitamin E;

� Meds that decrease anticoagulant effect � phenytoin, barbiturates, diuretics, estrogen, and vitamin C.

� Identify medication interactions for patients taking specific oral anticoagulants.

PROVIDING COMFORT� Bed rest

� depends on extent and location of a venous thrombosis� 5 to 7 days after diagnosis: the time necessary for thrombus to

adhere to vein wall, preventing embolization

� elevation of the affected extremity � Warm, moist packs applied to the affected extremity : to

reduce discomfort � Mild analgesics � elastic compression stockings: when begin to ambulate� Walking is better than standing or sitting for long periods. � Bed exercises (ex: dorsiflexion of foot)

APPLYING ELASTIC COMPRESSION

STOCKINGS� these stockings exert a sustained, evenly distributed pressure

over the entire surface of the calves, reducing caliber of superficial veins in legs and resulting in increased flow in deeper veins.

� Types: knee-high, thigh-high, or panty hose. Thigh-high stockings� Thigh-high stockings� Difficult to wear, because they have a tendency to roll down. � roll of stocking further restricts blood flow rather than the

stocking providing evenly distributed pressure over thigh

� NOTE: Any type of stocking can become a tourniquet if applied incorrectly (ie, rolled tightly at the top)

ELASTIC COMPRESSION STOCKINGS

� For ambulatory patients, elastic compression stockings are removed at night and reapplied before the legs are lowered from the bed to the floor in the morning.

� When stockings are off� When stockings are off� skin is inspected for signs of irritation� calves are examined for possible tenderness.� Any skin changes or signs of tenderness are reported

� Contraindication: severe pitting edema because they can produce severe pitting at the knee.

Applying INTERMITTENT PNEUMATIC

COMPRESSION DEVICES

� can be used with elastic compression stockings to prevent DVT.

� can increase blood velocity beyond that produced by the stockings.

� Nursing measures� Nursing measures� Ensure that prescribed pressures are not exceeded � Assess for patient comfort

INTERMITTENT PNEUMATIC

COMPRESSION DEVICES

� Watch http://www.youtube.com/watch?v=pMf3e7mlaVY&feature=related

Preventive measures: Preventive measures: Preventive measures: Preventive measures: Positioning the

body and encouraging exercise� Periodically elevate feet and lower legs above level of

heart when bed rest� allows superficial and tibial veins to empty rapidly and to

remain collapsed.

� Active and passive leg exercises: increase venous flow. Active and passive leg exercises: increase venous flow. � esp when not able to ambulate as frequently as necessary (ex:

during long car, train, and plane trips)

� Early ambulation: most effective in preventing venous stasis.

Preventive measures: Preventive measures: Preventive measures: Preventive measures: Positioning the

body and encouraging exercise

� Deep-breathing exercises � produce increased negative pressure in the thorax, which assists

in emptying the large veins.

� Avoid sitting for more than 2 hours at a time.

� elevate legs when sitting� elevate legs when sitting

� alternate standing with sitting at work or at home

� Walk at least 10 min q 1 to 2 hrs. � regular exercise

Preventive measures Preventive measures Preventive measures Preventive measures � Application of elastic compression stocking

� wear knee- or thigh-high compression or elastic stockings

� Avoid using the knee gatch or pillow under the knees

� Use of intermittent pneumatic compression devices

� Maintain IBW� Maintain IBW

� Administer heparin

HEALTH TEACHING HEALTH TEACHING HEALTH TEACHING HEALTH TEACHING � stop or avoid smoking

� Avoid use of oral contraceptives

� Most are discharged on a regimen of warfarin (Coumadin, Warfilone) or low molecular weight heparin (LMWH).

� avoid potentially traumatic situations, such as participation in contact sports.

� Provide written and oral information about s/s bleeding. � report any of these manifestations to the health care provider immediately.

� The anticoagulant effect of warfarin may be reversed by the omission of one or two doses of the drug or by the administration of vitamin K. one or two doses of the drug or by the administration of vitamin K.

� In case of injury, clients are directed to apply pressure to bleeding wounds and to seek medical assistance immediately.

� The nurse encourages them to carry an identification card or wear a medical alert bracelet that states that they are taking warfarin.

� The nurse also instructs clients to inform their dentist and other health care providers that they are taking warfarin before receiving treatment or prescriptions.

� Prothrombin times are affected by many prescription and over-the-counter medications, such as antacids, antihistamines, aspirin, mineral oil, oral contraceptives, and large doses of vitamin C.

� The action of warfarin is also affected by high-fat and vitamin K-rich foods, such as cabbage, cauliflower, broccoli, asparagus, turnips, spinach, kale, fish, and liver. Clients are therefore instructed to eat a well-balanced diet and to avoid taking additional medications without consulting a health care provider. T

� he nurse arranges for clients to have prothrombin time (PT) and International � he nurse arranges for clients to have prothrombin time (PT) and International Normalized Ratio (INR) determinations made 1 to 2 weeks after discharge.

� Clients receiving subcutaneous LMWH injections at home need instruction on self-injection. If family members or friends are administering the injections, the nurse teaches the appropriate caregiver.

� Clients who have experienced DVT may fear recurrence of a thrombus and may also be concerned about treatment with warfarin and the risk for bleeding. The nurse assures them that participation in the prescribed treatment frequently helps in resolving this problem and that ongoing assessment of PTs and INRs should minimize the risks of bleeding.

PATIENT EDUCATIONPATIENT EDUCATIONPATIENT EDUCATIONPATIENT EDUCATION

Taking Anticoagulant MedicationsTaking Anticoagulant MedicationsTaking Anticoagulant MedicationsTaking Anticoagulant Medications� Take the anticoagulant at the same time each day, usually between

8:00 and 9:00 AM.� Wear or carry identification indicating the anticoagulant

beingtaken.� Keep all appointments for blood tests.� Because other medications affect the action of the anticoagulant, � Because other medications affect the action of the anticoagulant,

do not take any of the following medications or supplements without consulting with the primary health care provider: vitamins, cold medicines, antibiotics, aspirin, mineral oil, and anti-inflammatory agents, such as ibuprofen (Motrin) and similar medications or herbal or nutritional supplements. The primary health care provider should be contacted before taking any over-the-counter drugs.

PATIENT EDUCATIONPATIENT EDUCATIONPATIENT EDUCATIONPATIENT EDUCATION

Taking Anticoagulant MedicationsTaking Anticoagulant MedicationsTaking Anticoagulant MedicationsTaking Anticoagulant Medications

� Avoid alcohol, because it may change the body’s response to an anticoagulant.

� Avoid food fads, crash diets, or marked changes in eating habits.

� Do not take warfarin (Coumadin) unless directed.� Do not take warfarin (Coumadin) unless directed.

� Do not stop taking Coumadin (when prescribed) unless directed.

� When seeking treatment from physician, a dentist, a podiatrist, or another health care provider, be sure to inform the caregiver that you are taking an anticoagulant.

PATIENT EDUCATIONPATIENT EDUCATIONPATIENT EDUCATIONPATIENT EDUCATION

Taking Anticoagulant MedicationsTaking Anticoagulant MedicationsTaking Anticoagulant MedicationsTaking Anticoagulant Medications� Contact your primary health care provider before having dental work or

elective surgery.� If any of the following signs appear, report them immediately to the

primary health care provider:� Faintness, dizziness, or increased weakness� Severe headaches or abdominal pain� Reddish or brownish urine� Reddish or brownish urine� Any bleeding—for example, cuts that do not stop bleeding� Bruises that enlarge, nosebleeds, or unusual bleeding from any part of the

body� Red or black bowel movements� Rash

� Avoid injury that can cause bleeding.� For women: Notify the primary health care provider if you suspect

pregnancy.

Chronic Venous InsufficiencyChronic Venous InsufficiencyChronic Venous InsufficiencyChronic Venous Insufficiency

Venous InsufficiencyVenous InsufficiencyVenous InsufficiencyVenous Insufficiency� results from obstruction of venous valves in legs or a reflux

of blood back through valves.

� Can involve superficial and deep leg veins

� The disorder is long-standing, difficult to treat, and often � The disorder is long-standing, difficult to treat, and often disabling.

Pathophy� DVT

� prolonged increase in venous pressure

� Resultant venous hypertension

� Distension of veins due to consistent venous pressure elevationelevation

� valvular reflux � leaflets of venous valves are stretched and prevented from

closing completely allowing a backflow or reflux of blood in the veins.

Dx test � Duplex ultrasonography

� Confirms obstruction and identifies the level of valvularincompetence.

Clinical Clinical Clinical Clinical ManifestationsManifestationsManifestationsManifestations� postthrombotic syndrome

� chronic venous stasis, resulting in edema, altered pigmentation, pain, and stasis dermatitis

� stasis ulceration

� symptoms less in the morning and more in the evening. � symptoms less in the morning and more in the evening.

� valvular reflux

� Superficial veins dilated.

Clinical ManifestationsClinical ManifestationsClinical ManifestationsClinical Manifestations� Stasis ulcers

� pigmentation and ulcerations � Common: medial malleolus of the ankle.

� Skin dry, cracks, and itches;

� subcutaneous tissues fibrose and atrophy.� subcutaneous tissues fibrose and atrophy.

ComplicationsComplicationsComplicationsComplications� Venous ulceration

� is the most serious complication of chronic venous insufficiency and can be associated with other conditions affecting the circulation of the lower extremities.

ManagementManagementManagementManagement� Goal: reducing venous stasis and preventing ulcerations. � antigravity activities

� measures that increase venous blood flow

1. Elevate leg

2. compression of superficial veins with elastic compression 2. compression of superficial veins with elastic compression stockings.

Elevating the legs � Effects: decreases edema, promotes venous return, and

provides symptomatic relief.

� Legs elevated frequently throughout the day (at least 15 to 30 minutes every 2 hours).

� At night, patient should sleep with the foot of bed elevated � At night, patient should sleep with the foot of bed elevated about 15 cm (6 inches).

� Avoid prolonged sitting or standing

� Encourage walking

� When sitting: avoid placing pressure on popliteal spaces� Ex: avoid crossing legs or sitting with legs dangling over side of

bed. bed.

� Avoid constricting garments (ex: panty girdles or tight socks)

Compression of the legs with elastic

compression stockings

� Effects: reduces pooling of venous blood and enhances venous return to heart.

� stocking should fit � so that pressure is greater at foot and ankle and then gradually

declines to a lesser pressure at the knee or groin. declines to a lesser pressure at the knee or groin.

� If the top of the stocking is too tight or becomes twisted, a tourniquet effect is created, which worsens venous pooling.

� Applied before standing or in the morning � Stockings should be applied after legs have been elevated for a

period, when amount of blood in the leg veins is at its lowest.

Other nursing care � Protect extremities from trauma

� skin is kept clean, dry, and soft

� Signs of ulceration are immediately reported to the health care provider

Leg UlcersLeg UlcersLeg UlcersLeg Ulcers

leg ulcer � is an excavation of skin surface that occurs when inflamed

necrotic tissue sloughs off.

� Causes � 75% result from chronic venous insufficiency. � 20% - due to arterial insufficiency � 20% - due to arterial insufficiency � 5% - burns, sickle cell anemia, and other factors

PathophysiologyPathophysiologyPathophysiologyPathophysiology� Inadequate exchange of oxygen and other nutrients in tissue

� When cellular metabolism cannot maintain energy balance,� cell death (necrosis) results.

� Alterations in blood vessels at arterial, capillary, and venous levels may affect cellular processes and lead to formation of levels may affect cellular processes and lead to formation of ulcers

Clinical Clinical Clinical Clinical ManifestationsManifestationsManifestationsManifestations� Symptoms depend on whether the problem is arterial or

venous in origin

� severity of the symptoms depends on the extent and duration of the vascular insufficiency.

� ulcer -open, inflamed sore� ulcer -open, inflamed sore� may be draining or covered by eschar (dark, hard crust).

ARTERIAL ULCERS� Chronic arterial disease

� intermittent claudication

� digital or forefoot pain at rest

� pain is unrelenting and rarely relieved even with opioid analgesics.analgesics.

� small, circular, deep ulcerations on tips of toes or in the web spaces between toes.

� Often occur on medial side of the hallux or lateral fifth toe

� may be caused by a combination of ischemia and pressure

Medical Management� PHARMACOLOGIC THERAPY

� Antibiotic therapy

� DÉBRIDEMENT

Medical Management� PHARMACOLOGIC THERAPY: Antibiotic therapy

� Oral antibiotics usually are prescribed � Topical antibiotics have not proven to be effective for leg ulcers.

� usual method of wound cleaning : flush area with normal saline solution.

� DÉBRIDEMENT� removal of nonviable tissue from wounds. Removing the dead

tissue is important, particularly in instances of infection. tissue is important, particularly in instances of infection. � If this is unsuccessful, débridement may be necessary.

Types of debridement � Sharp surgical débridement

� fastest method � can be performed by a physician, skilled advanced practice

nurse, or certified wound care nurse in collaboration with the physician.physician.

� Nonselective débridement� Apply isotonic saline dressings of fine-mesh gauze to the ulcer.� When the dressing dries, it is removed (dry), along with the

debris adhering to the gauze. � Need pain management

Types of debridement � Enzymatic débridement with the application of enzyme

ointments� ointment is applied to lesion but not to normal surrounding

skin.

� Use of Débriding agents� Use of Débriding agents� Dextranomer (Debrisan) beads : small, highly porous, spherical

beads ; can absorb wound secretions.

� Calcium alginate dressings � used when absorption of exudate is needed. � should not be used on dry or nonexudative wounds.

� TOPICAL THERAPY� goals of treatment : remove devitalized tissue and to keep ulcer

clean and moist while healing takes place. � Treatment should not destroy developing tissue.

WOUND DRESSING� After the circulatory status has been assessed and determined to

be adequate for healing (ABI of more than 0.5), surgical dressings can be used to promote a moist environment.

� Tegapore� simplest method � wound contact material (eg, Tegapore) next to wound bed and cover

it with gauze. it with gauze. � maintains a moist environment, can be left in place for several days,

and does not disrupt the capillary bed when removed for evaluation.� Hydrocolloids (eg, Comfeel, DuoDerm CGF, Restore, Tegasorb)

� promote granulation tissue and reepithelialization.� provide a barrier for protection because they adhere to the wound

bed and surrounding tissue. � Not for deep wounds and infected wounds

STIMULATED HEALING� Apligraf

� Tissue-engineered human skin equivalent along with therapeutic compression

� a skin product cultured from human dermal fibroblasts and keratinocytes. keratinocytes.

� Application is not difficult, no suturing is involved, and the procedure is painless.

Apligraf® is placed directly on wound

Apligraf® is covered with non-adherent dressing

The area is then wrapped with final dressings

A. Chronic wound on right hand palm. B. Apligraf applied to the open wound.C. One week after Apligraf is applied.

Varicose VeinsVaricose VeinsVaricose VeinsVaricose Veins

Varicose veins (varicosities) � are abnormally dilated, tortuous, superficial veins caused by

incompetent venous valves

� Most commonly occurs in lower extremities, saphenousveins, or lower trunk; can occur elsewhere in body (ex: esophageal varices)esophageal varices)

� occur in up to 60% of adult population in US

� increased incidence correlated with increased age

Causes � most common in women� people whose occupations require prolonged standing (ex:

salespeople, hair stylists, teachers, nurses, ancillary medical personnel, and construction workers)

� hereditary weakness of vein wall � not uncommon to occur in several members of same family. not uncommon to occur in several members of same family.

� Pregnancy may cause varicosities.� leg veins dilate during pregnancy because of hormonal effects related

to distensibility, increased pressure by the gravid uterus, and increased blood volume which all contribute to the development of varicose veins

� rare before puberty� Risk factors - family history, prolonged standing/sitting,

pregnancies, leg trauma

PathophysiologyPathophysiologyPathophysiologyPathophysiology� Types:

� primary (without involvement of deep veins) � secondary (resulting from obstruction of deep veins)

� A reflux of venous blood in the veins results in venous stasis.

� Vein walls weaken and dilate and valves become incompetent� Vein walls weaken and dilate and valves become incompetent

� Saphenous vein- most commonly affected

� If only the superficial veins are affected, the person may have no symptoms but may be troubled by the appearance of the dilated veins.

Clinical ManifestationsClinical ManifestationsClinical ManifestationsClinical Manifestations� Distended protruding veins that appear darkened and

tortuous� Symptoms, if present, may take the form of dull aches, muscle cramps,

and increased muscle fatigue in the lower legs. � Heaviness or fullness in legs� Ankle edema and a feeling of heaviness of the legs may occur. � Nocturnal cramps are common (leg cramping that intensifies at night)� Nocturnal cramps are common (leg cramping that intensifies at night)� (+) Trendelenburg test� Brown discoloration of affected extremity� Stasis ulcer� When deep venous obstruction results in varicose veins, patients may

develop s/s of chronic venous insufficiency: edema, pain, pigmentation, and ulcerations.

� Susceptibility to injury and infection is increased

Diagnostic Findings� Duplex scan

� Documents anatomic site of reflux and provides a quantitative measure of the severity of valvular reflux.

� Air plethysmography� Measures changes in venous blood volume.� Measures changes in venous blood volume.

� Venography� Not routinely performed to evaluate for valvular reflux.� When used, involves injecting x-ray contrast agent into leg

veins so that vein anatomy can be visualized by x-ray studies during various leg movements.

Prevention� avoid activities that cause venous stasis

� Avoid wearing tight socks or a constricting panty girdle� Avoid Crossing legs at thigh� Avoid sitting or standing for long periods.

� promote leg circulation� promote leg circulation� Change position frequently� Elevate legs as much as possible (20 mins)� get up to walk for several minutes of every hour.

Prevention� Encourage to walk 1 or 2 miles each day if there are no

contraindications.

� Walking up the stairs rather than using the elevator or escalator is helpful in promoting circulation.

� Swimming : good exercise for the legs.� Swimming : good exercise for the legs.

� Elastic compression stocking or antiembolic stockings, especially knee-high stocking.

� weight-reduction plan for overweight

� Avoid constrictive clothing

Management� Ligation and stripping

� Endovenous Laser Treatment

� Radiofrequency Ablation

� Sclerotherapy

Ligation and strippingLigation and strippingLigation and strippingLigation and stripping� Ligation and stripping of the great and the small

saphenous veins.

� Veins are removed if they are larger than 4 mm in diameter or if they are in clusters

� requires that the deep veins be patent and functional. � requires that the deep veins be patent and functional.

� saphenous vein - ligated and divided.

Ligation and strippingLigation and strippingLigation and strippingLigation and stripping� Vein stripping: Postop care

� Evaluate pulses� Elastic bandages� Elevate legs� Monitor extremities for edema, warmth , color , bleeding

Analgesics � Analgesics

EndovenousEndovenousEndovenousEndovenous Laser Laser Laser Laser TreatmentTreatmentTreatmentTreatment� thin fiber is inserted into

damaged vein via a very small skin nick.

� Laser light energy is delivered to the targeted delivered to the targeted tissue, which reacts with the light, causing the vein to close and seal shut.

Radiofrequency Radiofrequency Radiofrequency Radiofrequency AblationAblationAblationAblation� Endovenous

radiofrequency (RF) ablation

� insertion of a catheter with electrodes into the target electrodes into the target vein and passage of RF energy (electricity) through the vein tissue.

SCLEROTHERAPYSCLEROTHERAPYSCLEROTHERAPYSCLEROTHERAPY� Sclerotherapy ( Sodium murrhuate)

� chemical is injected into vein, irritating venous endothelium and producing localized phlebitis and fibrosis, thereby obliterating the lumen of vein.

� may be performed alone for small varicosities or may follow � may be performed alone for small varicosities or may follow vein ligation or stripping.

� Sclerosing is palliative rather than curative.

SCLEROTHERAPY� After the sclerosing agent is injected

� elastic compression bandages are applied to the leg; worn approx 5 days

� The health care provider who performed sclerotherapy removes the first bandages.

� Elastic compression stockings are then worn for an additional 5 � Elastic compression stockings are then worn for an additional 5 weeks.

� After sclerotherapy, patients are encouraged to perform walking activities as prescribed to maintain blood flow in the leg.

� Walking enhances dilution of the sclerosing agent.� Incision and drainage of trapped blood are performed after 14-21

days

SCLEROTHERAPY

Nursing ManagementNursing ManagementNursing ManagementNursing Management� Surgery

� outpatient setting, or admitted to the hospital on the day of surgery and discharged the next day

� Bed rest 24 hours� Then walking q 2 hrs for 5 to 10 minutes� Elastic compression stockings� Elastic compression stockings

� used to maintain compression of the leg� worn continuously for about 1 week after vein stripping.

� exercises and move the legs� The foot of the bed should be elevated� Standing still and sitting are discouraged

PROMOTING COMFORT AND

UNDERSTANDING

� Analgesics are prescribed to help patients move affected extremities more comfortably.

� inspect dressings for bleeding, particularly at the groin, where the risk of bleeding is greatest.

� alert for reported sensations of “pins and needles.”� alert for reported sensations of “pins and needles.”

� hypersensitivity to touch in the involved extremity may indicate a temporary or permanent nerve injury resulting from surgery, because the saphenous vein and nerve are close to each other in the leg

� may shower after the first 24 hours.

� use patting technique rather than rubbing to dry incisions with a clean towel

� Avoid skin lotion until incisions are completely healed� to decrease chance developing infection.� to decrease chance developing infection.

� Post sclerotherapy� burning sensation in the injected leg for 1 or 2 days. � mild analgesic (eg, propoxyphene napsylate and acetaminophen

[Darvocet N], oxycodone and acetaminophen [Percocet], oxycodone and acetylsalicylic acid [Percodanoxycodone and acetylsalicylic acid [Percodan

� walking to provide relief.

CellulitisCellulitisCellulitisCellulitis

Cellulitis� an infection of the deep layer of skin (dermis) and the layer of

fat and tissues just under the skin (the subcutaneous tissues).� most common infectious cause of limb swelling� can occur as a single isolated event or a series of recurrent

events. events. � often misdiagnosed, usually as recurrent thrombophlebitis or

chronic venous insufficiency.

� occurs when an entry point through normal skin barriers allows bacteria to enter and release their toxins in the subcutaneous tissues.

http://www.patient.co.uk/health/Cellulitis.htm

Clinical ManifestationsClinical ManifestationsClinical ManifestationsClinical Manifestations� acute onset of swelling� localized redness� pain � systemic signs of fever,

chills, and sweating. chills, and sweating. � redness may not be

uniform and often skips areas.

� Regional lymph nodes may also be tender and enlarged.

Medical ManagementMedical ManagementMedical ManagementMedical Management� Mild cases: oral antibiotic therapy.

� Severe: intravenous antibiotics for at least 7 to 14 days.

� key to preventing recurrent episodes 1. adequate antibiotic therapy for initial event 2. identify site of bacterial entry. 2. identify site of bacterial entry. � The most commonly overlooked areas are cracks and fissures

that occur in the skin between the toes. � Other possible locations are drug use injection sites, contusions,

abrasions, ulcerations, ingrown toenails, and hangnails.

Nursing ManagementNursing ManagementNursing ManagementNursing Management� elevate the affected area above heart level and apply warm,

moist packs to the site every 2 to 4 hours.� Individuals with sensory and circulatory deficits, such as

diabetes and paralysis, should use caution when applying warm packs because burns may occur; it is advisable to use a thermometer or have a caregiver ensure that the temperature thermometer or have a caregiver ensure that the temperature is not more than lukewarm.

� Education should focus on preventing a recurrent episode. � The patient with peripheral vascular disease or diabetes

mellitus should receive education or re-education about skin and foot care.

PreventionPreventionPreventionPrevention

Protect skin by:Protect skin by:Protect skin by:Protect skin by:

Whenever you have a break Whenever you have a break Whenever you have a break Whenever you have a break

in the skin:in the skin:in the skin:in the skin:

� Keeping skin moist with lotions or ointments to prevent cracking

� Wearing shoes that fit well and

� Clean the break carefully with soap and water. Apply an antibiotic cream or ointment every day.� Wearing shoes that fit well and

provide enough room for feet� Learning how to trim nails to

avoid harming the skin around them

� Wearing appropriate protective equipment when participating in work or sports

every day.� Cover with a bandage and

change it every day until a scab forms.

� Watch for redness, pain, drainage, or other signs of infection.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001858/

� To prevent DVT, heparin may be given in low doses subcutaneously for high-risk clients, especially after orthopedic surgery.

� Other pharmacologic agents that may be used for prophylaxis are as follows:

� Ø Low-molecular weight heparin (e.g., enoxaparin [Lovenox]) � Ø Dextran, an IV plasma expander � Ø Dihydroergotamine (DHE) � Ø Dihydroergotamine (DHE) � Ø Warfarin (Coumadin, Warfilone) � Ø Aspirin (ASA) � Prevention of DVT also includes early ambulation and mobilization,

thigh-high graduated compression elastic stockings (such as TED stockings), and external intermittent or sequential compression devices (SCDs) (Church, 2000). The nurse ensures that the compression devices fit properly and do not restrict blood flow.

LYMPHATIC DISORDERSLYMPHATIC DISORDERSLYMPHATIC DISORDERSLYMPHATIC DISORDERS

LYMPHATIC DISORDERS� Lymphangitis and Lymphadenitis

� Lymphedema and Elephantiasis

lymphatic system � consists of a set of vessels that spread throughout most of the

body.

� lymph capillaries � drain unabsorbed plasma from the interstitial spaces� unite to form the lymph vessels� unite to form the lymph vessels

� pass through lymph nodes� empty into large thoracic duct that joins jugular vein

lymphatic system � Lymph

� fluid drained from interstitial space by lymphatic system� Flow depends on intrinsic contractions of lymph vessels, contraction

of muscles, respiratory movements, and gravity.

� lymphatic system of abdominal cavity maintains a steady flow of digested fatty food (chyle) from the intestinal mucosa to flow of digested fatty food (chyle) from the intestinal mucosa to the thoracic duct.

� other parts of body, the lymphatic system’s function is regional� lymphatic vessels of head empty into clusters of lymph nodes located

in neck� lymphatic vessels of extremities empty into nodes of the axillae and

the groin

LymphangitisLymphangitisLymphangitisLymphangitis and Lymphadenitisand Lymphadenitisand Lymphadenitisand Lymphadenitis

Lymphangitis� an acute inflammation of the lymphatic channels.

� arises most commonly from a focus of infection in an extremity.

� Cause: hemolytic Streptococcus

� groin, axilla, or cervical region: Nodes most often involved� groin, axilla, or cervical region: Nodes most often involved

Clinical manifestations� red streaks - extend up arm or leg from an infected wound

� acute lymphadenitis� enlarged, red, and tender lymph nodes along course of

lymphatic channels

� suppurative lymphadenitis� suppurative lymphadenitis� necrotic and form an abscess

Management � Antibiotics � After acute attacks, an

elastic compression stocking or sleeve -worn on affected extremity for several months to for several months to prevent long-term edema.

� Recurrent episodes of lymphangitis� often associated with

progressive lymphedema

Lymphangitis

Lymphangitis� is an acute inflammation of the lymphatic channels.

� Cause: infection in an extremity.� hemolytic Streptococcus.

Clinical manifestation � red streaks that extend up the arm or the leg from an

infected wound

� lymph nodes located along the course of the lymphatic channels also become enlarged, red, and tender (acute lymphadenitis).lymphadenitis).

� can also become necrotic and form an abscess (suppurativelymphadenitis).

� nodes involved most often are groin, axilla, or cervical region.

Management� Antibiotic

� Post infection: wear elastic compression stocking or sleeve on affected extremity for several months to prevent long-term edema.

LymphedemaLymphedemaLymphedemaLymphedema

Lymphedemas� classified

� primary (congenital malformations)� secondary (acquired obstructions).

� Tissue swelling occurs in extremities because of an increased quantity of lymph that results from obstruction of lymphatic quantity of lymph that results from obstruction of lymphatic vessels.

Types of lymphedema� Primary lymphedema

� 3 forms � congenital lymphedema� lymphedema praecox� lymphedema tarda� lymphedema tarda

Types of lymphedema� Secondary lymphedema

� has an identifiable cause that destroys or renders inadequate the otherwise normal lymphatics.

� results from damage or removal of regional lymph nodes through surgery, radiation, infection, or tumor invasion or compression.

� Filariasis� Filariasis� vein stripping� peripheral vascular surgery� Lipectomy� Burns� burn scar excision� insect bites.

Clinical Manifestations� Tissue swelling extremities

� Especially when in a dependent position.

� (1) edema is soft, pitting, and relieved by treatment.

� (2) edema becomes firm, nonpitting, and unresponsive to treatment. treatment.

congenital lymphedema (lymphedema congenital lymphedema (lymphedema congenital lymphedema (lymphedema congenital lymphedema (lymphedema

praecoxpraecoxpraecoxpraecox))))

� most common primary type

� caused by hypoplasia of the lymphatic system of the lower extremity. lower extremity.

� usually seen in women and first appears between ages 15 and 25.

Filariasis� most common cause

worldwide the direct infestation of lymph nodes by the parasite Wuchereriabancrofti.bancrofti.

http://emedicine.medscape.com/article/191350-treatment

Medical Medical Medical Medical ManagementManagementManagementManagement� goal :reduce and control edema & prevent infection

� Active and passive exercises � assist in moving lymphatic fluid into the bloodstream.

� External compression devices� milk the fluid proximally from the foot to the hip or from the � milk the fluid proximally from the foot to the hip or from the

hand to the axilla. � When ambulatory, custom-fitted elastic compression stockings

or sleeves are worn; those with the highest compression strength (exceeding 40 mm Hg) are required.

� strict bed rest with the leg elevated

PHARMACOLOGIC THERAPY� diuretic furosemide (Lasix)

� Prevent fluid overload that can result from mobilization of extracellular fluid.

� antibiotic therapy� For lymphangitis or cellulitis� For lymphangitis or cellulitis

SURGICAL MANAGEMENT1. excision of affected subcutaneous tissue and fascia, with

skin grafting to cover defect.

2. surgical relocation of superficial lymphatic vessels into the deep lymphatic system by means of a buried dermal flap to provide a conduit for lymphatic drainage.provide a conduit for lymphatic drainage.

Nursing Nursing Nursing Nursing Management: Management: Management: Management: Postop care� Prophylactic antibiotics may be prescribed for 5 to 7 days. � Constant elevation of affected extremity � Observe for complications

� flap necrosis� Hematoma� abscess under flap� abscess under flap� cellulitis

� inspect the dressing daily � Inform patient loss of sensation in skin graft area. � Avoid application of heating pads or exposure to sun to prevent

burns or trauma to the area.

Three worms externalized