NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Cardiac Procedures

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Angioplasty

Focus topic: Medical–Surgical Nursing

A. Percutaneous transluminal coronary angioplasty procedure that can be balloon stent or laser to open narrowed or blocked arteries.
B. Preparation of client.

  • NPO after midnight.
  • In cath lab, catheter is inserted through groin or arm and contrast dye is injected.
  • Procedure takes 30–60 minutes.
  • Vital signs checked frequently following procedure.

Medical–Surgical Nursing

Medical–Surgical Nursing: Atherectomy

Focus topic: Medical–Surgical Nursing

A. Procedure used to cut away blockage (plaque responsible for narrowing of the artery).
B. There are several atherectomy techniques.

  • Rotational extraction, using a high-speed rotational burr, a cutting device that removes plaque through a vacuum suction system.
  • Rheolytic thrombectomy, a system designed for clot removal via a special pump to deliver a saline “jet” to break away the clot, transform it into fragments, and vacuum it out.

Medical–Surgical Nursing: Coronary Stents

Focus topic: Medical–Surgical Nursing

A. A stainless steel structure placed in a coronary vessel to expand and help keep the artery open.
B. Stents are metabolic wires implanted at the site of a narrowed coronary artery.
C. Treatment of choice for lesions in diseased bypass grafts.

Medical–Surgical Nursing: Pacemaker Insertion

Focus topic: Medical–Surgical Nursing

Definition: A temporary or permanent device to initiate and maintain heart rate when client’s intrinsic pacemaker is unreliable.

Assessment
A. Assess client for conditions requiring pacemaker insertion.

  • Conduction defect following heart surgery.
  • Heart block (usually third-degree [complete] heart block) due to anterior MI.
  • Tachyarrhythmias (overdrive pacing).
  • Bradyarrhythmias (“sick sinus syndrome”).

B. Assess vital signs for baseline data.
C. Obtain and assess monitor rhythm strips for baseline.
D. Determine type of pacemaker inserted.

  • Temporary pacemaker—external generator used in emergency situations.
    a. Pacing lead wire threaded transvenously to right ventricle and attached to external power source.
    b. Right atrial and ventricular epicardial wires placed during heart surgery, exist transthoracically and connected to external pulse generator.
    c. Transcutaneous—gelled electrode patches placed anteriorly and posteriorly.
    d. Used for heart block, bradycardia, or tachyarrhythmias.
    e. Client at risk for microshock if transvenous or transthoracic.
  • Permanent pacemaker.
    a. Pacing lead wire with electrodes inserted through central vein and advanced into apex of right ventricle.
    b. Pulse generator implanted into subcutaneous tissue below clavicle.
    c. Demand—mode functions only if client’s own heart rate is inadequate (most common type).
    (1) Pacemaker is set at a specific rate and is inhibited if client’s heart rate is adequate.
    (2) May be dual-chamber or AV synchronous.
    (3) Used mainly in bradyarrhythmias or heart block.
    (4) Programmable pacemaker allows noninvasive adjustment of pacemaker.

Implementation
A. Observe for hematoma at site of insertion.
B. Immobilize extremity on side of pacemaker generator.

C. Do not lift client under arm on side of pacemaker.
D. Evaluate pacemaker function/malfunction.

  • Absence of pacemaker artifact when client’s rate is inadequate (failure to sense or discharge).
  • Failure of pacemaker inhibition (failure to sense)—leads to inappropriate pacing.
  • Pacing without depolarization response ( failure to capture).
  • Assess for cardiac tamponade (decreased BP).
  • Monitor for hiccoughs—indicates dislodged pacing wire.

E. Monitor vital signs.
F. Provide client teaching.

  • Purpose of pacemaker.
  • Medication dose and side effects.
  • Monitoring pulse.
  • Signs and symptoms of infection.
  • No range of motion (ROM) on affected side for 2 days.
  • Wear medical alert bracelet and carry pacemaker ID card.
  • Follow up with pacemaker evaluation (e.g., clinic).
  • Avoid large electromagnetic fields.

G. Counsel client to observe for pacemaker malfunction.

  • Dizziness or fatigue.
  • Shortness of breath.
  • Slowed pulse rate (five beats less than pacemaker rate).
  • Chest pain.
  • Edema or weight gain.

Surgical Procedures

Focus topic: Medical–Surgical Nursing

Definition: Surgical procedures on the cardiac vessels, valves, or myocardium.

Assessment
A. Assess type of heart surgery to be done.

  • Percutaneous transluminal coronary angioplasty (PTCA)—less invasive than bypass surgery and preferred as initial procedure.
    a. A catheter with a deflated balloon is threaded into artery at site of blockage.
    b. Balloon is inflated and opens artery by breaking up and compressing plaque against artery wall.
    c. Stent often placed to maintain patency.
  • Coronary bypass surgery—healthy sections of a leg or chest blood vessel are grafted distal to blocked area of coronary artery.
  • Commissurotomy of stenosed valve.
    a. Closed commissurotomy—finger inserted to dilate valvular opening.
    b. Open commissurotomy—dissection of scarred area by means of a scalpel.
  • Valve replacement—artificial, or prosthetic, valves; heterografts (porcine or bovine).
  • Transplantation—therapeutic option for severe heart disease.
    a. Immunosuppressant drugs decrease body’s rejection of foreign protein (another’s human heart).
    b. Clients must balance risk of rejection with risk of infection.

B. Evaluate client’s knowledge of operative procedure to prepare for preoperative teaching.

C. Assess vital signs, heart and lung sounds, other vital parameters for baseline data.

Implementation
A. Observe for fluid and electrolyte imbalance.

  • Obtain lab specimens for hypokalemia and hyperkalemia.
  • Measure CVP for hypovolemia and volume overload.
  • Measure blood gases for acidosis and alkalosis.
  • Monitor hematocrit and hemoglobin.
  • Weigh daily after voiding and before breakfast.

B. Observe respiratory function.

  • Client receives mechanical ventilation for varying length of time postoperatively.
    a. Endotracheal intubation with cuffed tube.
    b. Suction airway prn.
    c. Auscultate for bilateral breath sounds.
    d. Monitor pulmonary volumes; pulse oximetry.
  • Auscultate for abnormal lung sounds.

C. Observe for circulatory complications.

  • Decreased blood pressure.
  • Tachycardia, thready pulse.
  • Weak peripheral pulses.
  • Decreased urine output.
  • Skin—cool, clammy, cyanotic.
  • Restlessness.
  • Elevated cardiac and central venous pressures.
  • Electrolyte imbalance.

D. Observe for signs of cardiac tamponade (mediastinal/chest tubes output over 100 mL/hr).
E. Place in semi-Fowler’s position to facilitate cardiac and respiratory function.
F. Administer pain medication such as morphine sulfate IV.
G. Monitor IV fluid and blood requirements by use of intracardiac pressures, blood pressure, urine output, hemoglobin and hematocrit.

  • Keep CVP between 5 and 12 cm water pressure (or 0–6 mm Hg) or as directed by physician.
  • Keep urine above 30 mL/hr.
  • Hematocrit maintained at 30–35.

H. Maintain circulation.

  • Inotropic medications.
  • Vasoactive medications.
  • IV fluids.
  • Antibiotics.

I. Maintain kidney function.

  • Keep urine output above 30 mL/hr with IV fluids or plasma expanders.
  • Maintain blood pressure above 90 mm Hg systolic.
  • Diuresis is common.
  • Report cloudy or pink urine.

J. Maintain patent chest tubes.

  • Used to remove fluid and air from mediastinum/ pleural space.
  • Maintain 20 cm H2O suction.

K. Maintain body temperature. (Clients are usually hypothermic following cardiac surgery.)

  • Raise body temperature gradually.
    a. Blankets used cautiously following hypothermic surgical procedure.
    b. Monitor core temperature with pulmonary artery (PA) catheter.
  • Client at risk for developing fever caused by infection or postpericardiotomy syndrome.
    a. Bed rest and anti-inflammatory agents are primary treatment.
    b. Keeping temperature below 100°F – 37.7°C prevents increased metabolic rate, which increases cardiac workload.

L. Assess level of consciousness (LOC), pupil response, motor response.

  • Neurologic complications may result from extracorporeal perfusion or aorta clamping.
  • Orient client frequently.

M. Administer anticoagulant therapy for valve replacements.
N. Monitor laboratory values for anticoagulation.

  • Partial thromboplastin time for heparin administration based on weight and sliding scale protocol.
  • Prothrombin time/international normalized ratio (INR) for Coumadin (warfarin sodium) therapy.

O. Monitor for complications associated with valve replacement.

  • Conduction defects (may require temporary pacing).
  • Cardiac tamponade.
  • Supraventricular tachyarrhythmias (may use pacemaker overdrive).
  • Malfunction of prosthetic valve (murmur).

P. Monitor for complications associated with use of cardiopulmonary bypass.

  • Fluid and electrolyte imbalance.
  • Decreased cardiac output.
  • Coagulation defects.
  • Atelectasis (hypoventilation).
  • Thromboembolic disorders.
  • Alterations of BP.
  • Cardiac tamponade.
  • Arrhythmias.
  • Renal failure.
  • Neurologic dysfunction.
  • Pain.

Q. Progressive care.

  • Progressive ambulation.
  • Lifestyle modification teaching (smoking cessation, AHA diet, exercise).
  • Medications (antithrombotics/anticoagulants, inotropic agents, beta blockers, antihypertensives, antiarrhythmics).
  • Sternal incision protection/wound care.

Medical–Surgical Nursing: Inflammatory Heart Disease

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Infective (Bacterial) Endocarditis

Focus topic: Medical–Surgical Nursing

Definition: An infection of the lining of the heart and valves caused by pathogenic microorganisms.

Characteristics
A. Acute—fulminating disease due to organisms engrafted on a preexisting heart lesion.

  • Occurs following open heart surgery or with IV drug use.
  • Causative agents—gram-positive, gram-negative bacilli, yeasts; more rapid serious infection with Staphylococcus aureus.

B. Subacute—slowly progressive disease of rheumatic or congenital lesions or prosthetic valve.

  • Occurs following dental, genitourinary, gynecological procedures, bacteremia, or surgery.
  • Streptococcus most common organism.

Assessment
A. Observe for chills, diaphoresis, lassitude, anorexia, weight loss, arthralgia.
B. Check for fever and night sweats that recur for several weeks.
C. Assess for regurgitant heart murmur.
D. Identify history of recent infection, dental work, cystoscopy, IV drug use.
E. Evaluate for systemic emboli.

  • Assess for petechiae on skin or mucous membranes: tender, red nodules on fingers, palms, or toes (arterial emboli).
  • Splenic infarction—pain, upper left quadrant, radiating to left shoulder.
  • Renal infarction—hematuria, pyuria, flank pain.
  • Cerebral infarction—hemiparesis or neurological deficits.
  • Pulmonary infarction—cough, pleuritic pain, dyspnea, hemoptysis.

F. Evaluate lab tests—increased WBC, erythrocyte sedimentation rate (ESR), blood culture, echocardiogram.

Implementation
A. Maintain intensive chemotherapy with antibiotic drugs for several weeks.
B. Follow general nursing measures.

  • Decrease cardiac workload—bed rest.
  • Ensure physical and emotional rest.

C. Encourage fluids.
D. Anticoagulant therapy contraindicated because of danger of cerebral hemorrhage.
E. Monitor for signs of congestive heart failure (CHF).
F. Prophylactic antibiotics for high-risk client with existing cardiac lesion or prosthetic valve.

Medical–Surgical Nursing: Pericarditis

Focus topic: Medical–Surgical Nursing

Definition: Inflammation of the pericardium.

Assessment
A. Assess for possible cause of inflammation.

  • Transmural infarction—frequent cause.
  • Inflammation of heart or lungs.
  • Radiation.
  • Trauma/cardiac surgery.
  • Neoplasms.

B. Evaluate type of pain—stabbing and knifelike; starts at sternum and radiates to neck and shoulder or back; aggravated by deep inspiration, supine position, and turning from side to side; relieved by sitting.
C. Identify if pericardial friction rub is present.
D. Assess vital signs for indication of infection.
E. Evaluate lab tests—increased WBC, ESR, slightly elevated cardiac enzymes, and ECG changes (elevated ST segment, inverted T waves).

Implementation
A. Maintain client on bed rest in semi-Fowler’s position.
B. Administer and observe for side effects of salicylates and Indocin (indomethacin).
C. Monitor vital signs.
D. Monitor for pericardial friction rub on forced expiration with client in forward leaning position.
E. Relieve pain with analgesics.
F. Prepare client for pericardiocentesis if required.
G. Observe for complications following pericardiocentesis.

  • Monitor vital signs and CVP for possible cardiac tamponade recurrence.
  • Auscultate heart sounds to determine if decrease in intensity of heart sound is present.

H. Monitor for pericarditis complications.

  • Pericardial effusion leading to tamponade.
  • Constrictive pericarditis—prevents adequate diastolic filling of ventricles, leading to decreased cardiac output.

Medical–Surgical Nursing: Peripheral Va scular Disorders

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Hypertension

Focus topic: Medical–Surgical Nursing

Definition: Blood pressure that is greater than either 140 mm Hg systolic or 90 mm Hg diastolic.

Characteristics
A. Approximately 50 million people have hypertension in United States—only 25% are controlled to normotensive.
B. More frequent in African Americans. Higher incidence in white men than women before age 50; after age 50, this is reversed.
C. Risk factors.

  • Obesity.
  • Family history.
  • Age > 60 years.
  • Race.
  • Diabetes.
  • Smoking.
  • Dyslipidemia.
  • Gender—male.

D. Types of hypertension.

  • Primary or essential—no known etiology (accounts for 90% of clients).
  • Secondary—directly related to another condition.
    a. Renal disease.
    b. Endocrine disorders.
    (1) Pheochromocytoma.
    (2) Adrenal cortex lesions—hyperaldosteronism, Cushing’s syndrome.
    c. High-dose estrogen use.
    d. Pregnancy.
    e. Acute autonomic dysreflexia.
    f. Increased intracranial pressure.

Assessment
A. Assess for risk factors by evaluating history.

B. Assess for common manifestations.

  • Headache in early am.
  • Loud S2 heart sound.
  • Epistaxis.

C. Identify if target organ complications are present.

  • Brain—mental and neurologic abnormalities.
  • Kidneys—renal insufficiency (especially if diabetic).
  • Cardiovascular system—left ventricular hypertrophy, heart failure, atherosclerosis, peripheral vascular disease (PVD).
  • Eyes—narrowing of arteries, papilledema, visual disturbances.

Implementation
A. Lifestyle modifications.

  • Weight loss.
  • Reduce sodium intake.
  • Maintain adequate intake of dietary potassium and magnesium.
  • Decrease stress.
  • Engage in regular aerobic exercise.
  • Limit alcohol intake.
  • Stop smoking.

B. Drug therapy (combination frequently used).

  • Diuretics.
    a. Act on kidneys to increase urine output.
    b. Thiazides: Diuril (chlorothiazide).
    c. Loop (potent) diuretics: Lasix, Bumex (bumetanide).
    d. Potassium-sparing (Aldactone)—weak diuretic effect, often used in combination with other diuretic.
  • Beta blockers (Inderal).
    a. Decrease response to sympathetic stimulation; decrease contractility and myocardial workload.
    b. Can cause bradycardia, conduction blocks.
  • ACE inhibitors: Capoten (captopril)—inhibit the conversion of angiotensin I to angiotensin II.
    a. Allow blood vessels to dilate.
    b. Help prevent target organ damage.
    c. May cause dry cough, due to increased bradykinin levels.
    d. Used cautiously with renal insufficiency.
    e. May cause hyperkalemia if potassium supplements also used.
  • Angiotensin II receptor blockers: Cozaar (losartan).
    a. Dilate vessels without increasing bradykinin levels.
    b. Used for those who cannot tolerate ACE inhibitor.
    c. May cause hyperkalemia if potassium supplements also used.
  • Calcium-channel blockers: Procardia (nifedipine).
    a. Relax smooth muscles.
    b. Block calcium flow into the cell.
  • Central alpha agonists: Catapres (clonidine)—centrally acting agents that cause vasodilation.
    a. Available in transdermal patch changed weekly.
    b. May cause sedation, dry mouth.
  • Alpha1 blockers: Minipress (prazosin)— peripherally acting antiadrenergic.
    a. Risk for postural hypotension.
    b. Also used for prostatic urinary obstruction.
  • Arterial vasodilators: Apresoline (hydralazine)—direct acting.
    a. May cause tachycardia—often used with beta blocker.
    b. May cause fluid retention—monitor weight.

C. Client education.

  • Importance of regimen compliance.
  • Not to discontinue medication abruptly.
  • Avoid concurrent use of alcohol.
  • Check with physician before taking over-the-counter (OTC) medications (e.g., NSAIDs counteract the effect of many antihypertensive agents).

Medical–Surgical Nursing: Hypertensive Crisis

Focus topic: Medical–Surgical Nursing

Definition: Critical (“accelerated/malignant”) elevation of blood pressure that becomes acute and life-threatening.

Assessment
A. Assess for signs/symptoms.

  • Diastolic blood pressure usually over 120 mm Hg.
  • Known history of hypertensive disease or diseases that cause hypertension (e.g., renal vascular disease, head injury).
  • Medical therapy (medications and compliance) or use of sympathomimetic drug.

B. Monitor for potential end-organ complications.

  • Depressed level of consciousness.
  • Focal neurologic signs.
  • Chest pain.
  • Pulmonary edema.
  • Signs of renal failure (azotemia—increased BUN and creatinine).

Implementation
A. Monitor vital signs, ECG, and neurological signs closely.

  • Assess blood pressure every 5 minutes with antihypertensive drug therapy.
  • Avoid too-rapid reduction in blood pressure.
  • Note for end-organ signs/symptoms worsening with rapid pressure reduction.
  • Note for side effects of antihypertensive agents (tachycardia).

B. Administer antihypertensive medications (and particular agents relative to cause of crisis) as prescribed.

  • Drug most frequently used is Nipride (nitroprusside) because of its rapid onset of action (increased intracranial pressure). Possible cyanide poisoning with high doses.
  • Drugs such as Apresoline (hydralazine hydrochloride), Cardene (nicardipine hydrochloride), or Brevibloc (esmolol hydrochloride) take longer to act than Nipride.

C. Monitor urinary output closely.

  • Indwelling urinary catheter may be indicated.
  • Oliguria or anuria should be reported immediately.

D. Maintain client on strict bed rest.

  • Elevate head of bed 45 degrees.
  • Keep room quiet.

E. Support client and assist to remain calm.

  • Do not leave the client unattended.
  • Use anxiety-reducing measures; client may sense impending doom and be frightened.

F. Provide safety interventions.

  • Keep side rails up if client is not fully alert.
  • Employ seizure precautions if indicated.
  • Place client on side if level of consciousness is diminished to prevent aspiration.
  • Keep suction equipment readily available.

Medical–Surgical Nursing: Thromboangiitis Obliterans (Buerger’s Disease)

Focus topic: Medical–Surgical Nursing

Definition: Inflammatory occlusions of distal arteries and veins. Most often affects males under 40 years of age who smoke.

Assessment
A. Observe for signs of arterial insufficiency: impaired pulse, intermittent claudication, pain, postural color changes in foot.
B. Disease may involve upper and lower extremities.
C. Observe for signs of neuropathy; decreased sensation, paresthesia.

Implementation
A. Urge client to stop smoking.
B. Administer vasodilator drugs to increase blood supply to lower extremities: Trental (pentoxifylline).
C. Administer low-dose aspirin.
D. Instruct client in foot care.
E. Instruct client to prevent chemical, mechanical, and thermal trauma to feet.
F. Monitor peripheral pulses frequently.
G. May require arterial bypass surgery or amputation.

Medical–Surgical Nursing: Raynaud’s Disease and Phenomenon

Focus topic: Medical–Surgical Nursing

Definition: Episodic vasospasms of the small cutaneous arteries, usually involving the fingers and toes. Primarily seen in young women.

Assessment
A. Raynaud’s disease.

  • Primary idiopathic paroxysmal arteriolar vasospasm due to abnormality of the sympathetic nervous system.
  • Precipitated by cold or emotional stimuli; relieved by warmth.
  • Bilateral or symmetric pallor and cyanosis followed by redness of the digits (usually fingers).
  • May have throbbing and paresthesia during recovery.
  • Ulcers near fingertips.

B. Raynaud’s phenomenon.

  • Often related to underlying collagen or connective tissue disease (rheumatoid arthritis, lupus).
  • May be unilateral and involve few digits, but usually symmetric.
  • Pallor, cyanosis, redness, and changes in skin temperature in response to cold or strong emotion.

Implementation
A. Encourage client to stop smoking.
B. Encourage client to avoid precipitating factors such as cold temperature and emotional stress—keep warm.
C. Wear warm clothing when in cold weather: boots, gloves, etc.
D. Protect hands from injury—wounds heal slowly.
E. Keep skin soft with emollients—avoid dry skin.
F. Administer vasodilator drugs.

  • Calcium-channel blocker—Procardia (nifedipine).
  • Nitrates (transdermal or oral).

G. May require sympathectomy.

Medical–Surgical Nursing: Deep Vein Thrombophlebitis

Focus topic: Medical–Surgical Nursing

Definition: Formation of clot in a vein with inflammatory changes in the vein wall. Most prevalent sites: deep veins of lower extremities and pelvis. Usually begins in calf and propagates proximally.

Characteristics
A. Persons most vulnerable are from 45 to 65 years of age.
B. Causes of deep vein thrombophlebitis (DVT; Virchow’s triad).

  • Impaired venous flow—stasis. Associated with periods of inactivity (bed rest, surgery, long plane trips, or car rides).
  • Endothelial injury exposes platelets in bloodstream to collagen, promoting thrombosis.
  • Hypercoagulopathy (increased tendency to clot).
    a. Dehydration.
    b. Malignancy (breast, prostate, ovary, pancreas).
    c. Polycythemia and sickle-cell disease.
    d. Use of oral contraceptive agents and smoking.
    e. Inherited disorders (antithrombin III deficiency).

Assessment
A. Symptoms closely related to size and location of clot—may have no signs or symptoms.
B. Assess leg.

  • Unilateral edema.
  • Calf pain—dull ache.
  • Changes in color and temperature; may be warm with red color, but may also be pale “milk leg.”
  • Affected area may also feel firm and hard.
  • Distended superficial veins.
  • Homan’s sign (not recommended or reliable and may mobilize clot).

C. Doppler flow studies, phlebography, and impedance plethysmography confirm diagnosis.

Implementation
A. Administer anticoagulant therapy.

  • Heparin therapy for 7–10 days.
  • Coumadin (warfarin) prescribed for 3 months; dose adjusted to keep INR between 2.0 and 3.0.
  • Observe for signs of bleeding (urine, stool occult blood, ecchymosis).

B. Maintain strict bed rest for minimum 3–4 days.

  • Do not use knee gatch or pillows under knees.
  • Elevate foot of bed 20 degrees.
  • Handle affected limb with care to prevent compression of tissue.

C. Monitor for pulmonary embolism (PE).

  • Assess subtle changes; report immediately (confusion, anxiety, restlessness).
  • Cough; rapid, shallow respirations; dyspnea.
  • Chest pain that is worse with deep breath.
  • Tachycardia.

D. Position client to avoid venous stasis and turn every 2 hours.

E. Take vital signs at least every 4 hours.
F. Promote venous return.

1. Use ROM exercises on unaffected limbs only.
2. Do not massage or exercise affected leg.
3. Apply antiembolic stocking to unaffected leg
or use pneumatic compression device.

G. Provide client education.

  • Avoid standing in one position or sitting for long periods (either walk or lie flat; avoid crossing legs at knees; elevate legs while sitting).
  • Avoid wearing constrictive clothing.
  • Wear support hose.
  • Understand correct use of anticoagulants and the necessity for follow-up lab tests.
    a. Include measures to reduce risk of bleeding (soft toothbrush, electric razor).
    b. Avoid contact sports; notify physician if injury occurs.
  • Teach prevention.
    a. Elevate foot of bed.
    b. Avoid sitting in chair for long periods.
    c. Leg and ankle exercises.
    d. Pneumatic compression devices/thromboembolic devices (TEDs).
    e. Low-dose heparin or low-molecular-weight heparin.
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Medical–Surgical Nursing: Varicose Veins

Focus topic: Medical–Surgical Nursing

Definition: A condition in which the veins are dilated and tortuous caused by incompetent venous valves.

Characteristics
A. Causes.

  • Pregnancy.
  • Standing for long periods of time.
  • History of DVT.
  • Prolonged and heavy lifting.

B. Pathology.

  • Most commonly affects superficial saphenous veins.
  • Possible inherited defect of valves or vein wall.

Assessment
A. Visible dilated, tortuous veins.
B. Assess for dull aching, heaviness in legs after standing.
C. Observe for edematous ankles with itching.
D. Skin brown above ankles from blood that has escaped due to increased venous pressure.
E. Secondary ulceration (medial ankle).

Implementation
A. Encourage client to use antiembolic stockings, support hose.

B. Elevate legs when possible.
C. Educate client to see need for cessation of smoking (makes blood hypercoagulable).
D. Prevent constrictive clothing and positions; protect legs from pressure/trauma.
E. Prepare client for vein stripping or sclerosing injections.

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