Med-Surg - Cardiovascular System, part 15: Venous Thromboembolism, Venous Insufficiency, Varicose Veins
by Cathy Parkes October 14, 2021 Updated: August 09, 2023 6 min read
Hi, I'm Cathy, with Level Up RN In this video, we are going to discuss venous disorders such as venous thromboembolism, venous insufficiency, and varicose veins. At the end of the video, I'm going to give you guys a little knowledge check to test your understanding of some of the key facts I'll be covering in this video. So definitely stay tuned for that. And if you have our Level Up RN medical-surgical nursing flashcards, definitely pull those out so you can follow along with me.
First up, we have venous thromboembolism or VTE. This is where we have a blood clot that starts in the vein. And there are two types of VTEs.
We have a deep vein thrombosis, which is a DVT, and a pulmonary embolism, which is a PE. So the thrombus, or blood clot, will form in a deep vein, usually in the lower leg, thigh, or pelvis. And it forms because of something called Virchow's Triad.
So for Virchow's Triad consists of three things. So triad, three things. These three characteristics include endothelial injury, which means we have damage to the vein. Impaired blood flow. So we have venous stasis. The blood is not moving along like it should. And then hypercoagulability, which means that the patient's blood is clotting too easily. So if these three factors are in place, it places the patient at high risk for forming a thrombus or blood clot. So that blood clot, that thrombus, can break off and travel through the body into the lungs.
And it becomes an embolus when it breaks off and it can block circulation in the lungs, which is called a pulmonary embolism.
In terms of risk factors associated with a VTE, risk factors include hip and knee replacement surgery, heart failure, immobility, pregnancy, combined oral contraceptives, as well as a family history.
Signs and symptoms will depend on whether we're talking about a DVT or a PE.
So with a DVT, the patient may complain of calf or thigh pain. You may also see swelling and redness on the affected side.
If that thrombus has become an embolus and has caused a PE, then the patient may have symptoms such as shortness of breath, dyspnea, chest pain with inspiration, tachycardia, tachypnea, hypotension, as well as petechiae, which are the red dots that form on their skin. So you may notice those if your patient is having a PE.
In terms of diagnosis of a VTE, if we run labs and the patient's D-dimer level is elevated, then that is indicative of the presence of a clot. Other diagnostic tools can include a venous duplex ultrasound, as well as a CAT scan.
In terms of treatment, we're going to put the patient on an anticoagulant such as heparin or warfarin. These anticoagulants will help the blood clot from getting any bigger and will prevent the formation of new clots, but it will not break down that existing clot. In order to do that, we need a thrombolytic agent such as Alteplase.
Procedures can be done as well, which includes a thrombectomy, which is removal of the clot, or placement of a vena cava filter, which helps to prevent the embolism from reaching the lungs and causing a PE.
In terms of nursing care, for a patient who has a DVT, you want to elevate their extremity. However, you should not place a knee gatch or pillow under their knee. You want to apply warm, moist compresses. You should not massage the limb. And you want to apply compression stockings as ordered. And then you always want to monitor your patient for signs and symptoms of a PE in case that blood clot breaks off and travels up into the lungs. So if your patient suddenly has shortness of breath, difficulty breathing, etc., then those would be warning signs.
Treatment of a PE includes sitting the patient upright into a high Fowler's position so they can breathe more effectively, and administering oxygen as ordered.
Now let's talk about venous insufficiency, which is where the veins in the lower extremities do not transport blood back up to the heart effectively. So blood is getting down into the legs just fine, but it's not able to get back up very well due to an issue with the valves in the veins.
In terms of risk factors for venous insufficiency, risk factors include obesity, immobility, pregnancy, and a history of DVTs.
Signs and symptoms include edema, as well as brown discoloration of the skin over the lower extremities, which is called stasis dermatitis. In addition, with venous insufficiency, patients often have heavily draining wounds that occur around the ankles.
In terms of nursing care, we're going to want to elevate the patient's legs to help promote blood return to the heart. We're going to apply compression stockings or wraps per orders, and those are best applied in the morning when swelling is reduced. And then we want to monitor the patient for complications such as cellulitis. So if we don't address the issue with venous insufficiency by elevation and compression, those venous stasis ulcers can become infected and lead to cellulitis. This is a very common complication with venous insufficiency.
In terms of patient teaching, you want to advise your patient to avoid sitting or standing still for too long. So they should change their positions often and make sure they are walking around. We also want to advise them to avoid crossing their legs or wearing restrictive clothing. And again, we're going to need to reinforce the importance of wearing compression stockings. So, you know, patients are very noncompliant with this typically. So we want to make sure those compression stockings are fitted properly, that they're not too tight, or else patients won't wear them. And we need to advise the patient to apply them in the morning before getting out of bed.
Finally, we have varicose veins which are dilated tortuous veins. And by tortuous, I mean full of twists and turns that occur in the lower extremities.
The pathophysiology behind varicose veins is that we have pooling of blood in the legs, which causes the veins to become enlarged and weakened, and impairs valve function such that blood flows backwards.
Risk factors associated with varicose veins include being female, prolonged standing, like what we do as nurses, as well as pregnancy, obesity, and family history.
Signs and symptoms include distended rope-like veins. So I actually have varicose veins, and I don't like them. I thought about showing you guys what they look like, but you guys can google it because that would be a little awkward. Also, varicose veins can cause a feeling of kind of heaviness. It can cause a little itching and aching feeling.
In terms of treatment, elevation and compression are going to be two important things to do. So I wear compression socks every time I go to the hospital. I would definitely recommend that you do that as well.
We can also do a number of procedures to either remove or decrease or shrink those veins. So sclerotherapy is an option, as well as vein stripping, radiofrequency, and laser treatment.
All right, time for a quiz. I have three questions for you. First question might be a little challenging, but I know you guys can do it. What three conditions make up for Virchow's Triad? The answer is endothelial injury, impaired blood flow, and hypercoagulability. Question number two. For a DVT, you should elevate your patient's leg with a pillow under the knee. True or false? The answer is false. So we do want to elevate the patient's leg, but no pillow under the knee, and no knee gatch under the knee as well. Question number three. Edema, heavily draining wounds around the ankles and brown discoloration of the lower legs are indicative of what disorder? The answer is venous insufficiency.
All right. I hope this video has been helpful. If so, be sure to like this video. Leave me a comment and subscribe if you haven't already done so. Thank you so much for watching.
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