Varicose veins (varicosities) are abnormally dilated tortuous veins. They occur most often in the lower extremities but can appear anywhere in the body. Primary varicosities are caused by incompetent valves in the superficial saphenous veins, whereas secondary varicosities are the result of impaired blood flow in the deep veins. Primary varicosities tend to occur in both legs, whereas secondary varicosities usually occur in only one leg.
In a ladder-like fashion, perforator veins connect the deep vein and the superficial vein systems, promoting drainage of the lower extremities. Blood can be shunted from one system to the other in the event of either system’s being compressed. Incompetence in one system can lead to varicosities. Varicose veins are considered a chronic disease, and along with valvular incompetence can progress to chronic venous insufficiency (CVI).
Several factors cause increased venous pressure and venous stasis that result in dilation and stretching of the vessel wall. Increased venous pressure results from being erect, which shifts the full weight of the venous column of blood to the legs. Prolonged standing increases venous pressure because leg muscle use is less; therefore, blood return to the heart is decreased.
Heavy lifting, genetic factors, obesity, thrombophlebitis, pregnancy, trauma, abdominal tumors, congenital or acquired arteriovenous fistulae, and congenital venous malformations are among the causes of varicose veins. Chronic liver diseases such as cirrhosis can cause varicosities in the rectum, abdomen, and esophagus.
Nursing care plan assessment and physical examination
Elicit a history of symptoms, with particular attention to pain and discomfort, changes in appearance of vessels and skin, and complaints of a sensation of fullness of the lower extremities. Ask the patient to describe the amount of time each day spent standing. Take an occupational history with particular attention to those jobs that require long hours of walking or standing. Question the patient about lifetime weight changes, such as changes during pregnancy and sustained periods of being overweight. Ask the patient if there is a personal or family history of heart disease, obesity, or varicose veins.
The number, severity, and type of varicosities determine the symptoms experienced by the individual. With the patient standing, examine the legs from the groin to the foot in good lighting. Inspect the ankles, measure the calves for differences, and assess for edema. Time of examination is a factor because secondary varicosities are more symptomatic earlier in the day. Palpate both legs for dilated, bulbous, or corkscrew vessels. Patients may complain of heaviness, aching, edema, muscle cramps, increased fatigue of lower leg muscles, and itching. Severity of discomfort may be difficult to assess and is unrelated to the size of the varicosity.
The patient with varicose veins has usually been dealing with a progressively worsening condition. Assess the patient for any problems with body image because of the changed appearance of skin surface that is caused by varicose veins. Question the patient to determine possible lifestyle adjustments to decrease symptoms. The patient may need job counseling or occupational retraining.
Nursing care plan primary nursing diagnosis: Altered tissue perfusion (peripheral) related to increased venous pressure and obstruction.
Nursing care plan intervention and treatment plan
Treatment for varicose veins is aimed at improving blood flow, reducing injury, and reducing venous pressure. Pharmacologic treatment is not indicated for varicose veins. To give support and promote venous return, physicians recommend wearing elastic stockings. If the varicosities are moderately severe, the physician may recommend antiembolism stockings or elastic bandages or, in severe cases, custom-fitted heavy-weight stockings with graduated pressure. When obesity is a factor, the patient is placed on a weight loss regimen. Experts also recommend that the patient stop smoking to prevent vasoconstriction of the vessels.
A nonsurgical treatment is the use of sclerotherapy for varicose and spider veins. Sclerotherapy is palliative, not curative, and is often done for cosmetic reasons after surgical intervention. A sclerosing agent, such as sodium tetradecyl sulfate (Sotradecol), hypertonic saline, aethoxysclerol, or hyperosmolar salt-sugar solution, is injected into the vein, followed by a compression bandage for a period of time.
A surgical approach to varicose veins is vein ligation (tying off) or stripping (removal) of the incompetent veins. Removal of the vein is performed through multiple short incisions from the ankle to the groin. A compression dressing is applied after surgery and is maintained for 3 to 5 days. Patients are encouraged to walk immediately postoperatively. Elevate the foot of the bed 6 to 9 inches to keep the leg above the heart when the postoperative client is in bed.
Nursing interventions are aimed at educating the patient to decrease venous stasis, promote venous return, and prevent tissue injury. To prevent vein distension by compression of superficial veins, teach the patient to apply elastic support stockings before standing and to avoid long periods of standing. The patient should be encouraged to engage in an exercise program of walking to strengthen leg muscles. Teach the patient to avoid crossing the legs when sitting and to elevate the legs when sitting or lying down. The patient should be taught to observe the skin when removing stockings to check for signs of irritation, edema, decreased nerve sensation, and discoloration. Preventive measures are similar to those for a patient with thrombophlebitis.
For patients who have had sclerotherapy, teaching should focus on activity restrictions. The patient should learn to avoid heavy lifting. Teach the patient to wait 24 to 48 hours after the procedure before showering and to avoid tub baths. Teach the patient to wear supportive stockings as ordered. Prepare the patient by advising him or her to expect ecchymosis and some scarring, which will fade in several weeks. Caution the patient that some residual brown staining may remain at the injection sites. Inform the patient that the sclerotherapy may need to be repeated in other areas.
Nursing care plan discharge and home health care guidelines
To prevent worsening of varicosities, teach the patient to avoid prolonged standing in one place, to avoid sitting with the legs crossed, to elevate the legs frequently during the day, to wear support stockings as ordered, and to drink 2 to 3 L of fluid daily. The patient should wear shoes that fit comfortably and are not too tight. Teach the patient the purpose, dosage, route, and side effects of any medications ordered. Teach the patient to recognize, and observe daily for, signs of thrombophlebitis, which include redness, local swelling, warmth, discoloration (not related to
surgery area), and back pain on bending. Teach the patient which signs to report to the physician. Teach the patient to report any signs of infection, such as redness at incision sites or injection sites, severe pain, purulent drainage, fever, or swelling.
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