Varicose Veins

VARICOSE VEINS

Varicose veins (varicosities) are abnormally dilated, tortuous, superficial veins caused by incompetent venous valves (see Fig. 31-16). Most commonly, this condition occurs in the lower extremities, the saphenous veins, or the lower trunk; however, it can occur elsewhere in the body, such as esophageal varices.

It is estimated that varicose veins occur in up to 60% of the adult population in the United States, with an increased inci-dence correlated with increased age ( Johnson, 1997). The condi-tion is most common in women and in people whose occupations require prolonged standing, such as salespeople, hair stylists, teachers, nurses, ancillary medical personnel, and construction workers. A hereditary weakness of the vein wall may contribute to the de-velopment of varicosities, and it is not uncommon to see this con-dition occur in several members of the same family. Varicose veins are rare before puberty. Pregnancy may cause varicosities. The 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 develop-ment of varicose veins ( Johnson, 1997).

Pathophysiology

Varicose veins may be considered primary (without involvement of deep veins) or secondary (resulting from obstruction of deep veins). A reflux of venous blood in the veins results in venous stasis. 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 Manifestations

Symptoms, if present, may take the form of dull aches, muscle cramps, and increased muscle fatigue in the lower legs. Ankle edema and a feeling of heaviness of the legs may occur. Nocturnal cramps are common. When deep venous obstruction results in varicose veins, patients may develop the signs and symptoms of chronic venous insufficiency: edema, pain, pigmentation, and ulcerations. Susceptibility to injury and infection is increased.

Assessment and Diagnostic Findings

Diagnostic tests for varicose veins include the duplex scan, which documents the anatomic site of reflux and provides a quantitative measure of the severity of valvular reflux. Air plethysmography measures the changes in venous blood volume. Venography is not routinely performed to evaluate for valvular reflux. When it is used, however, it involves injecting an x-ray contrast agent into the leg veins so that the vein anatomy can be visualized by x-ray studies during various leg movements.

Prevention

The patient should avoid activities that cause venous stasis, such as wearing tight socks or a constricting panty girdle, crossing the legs at the thighs, and sitting or standing for long periods. Chang-ing position frequently, elevating the legs when they are tired, and getting up to walk for several minutes of every hour promote cir-culation. The patient should be encouraged 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 is also good exercise for the legs.

Elastic compression stockings, especially knee-high stockings, are useful. Patients are more likely to use knee-high stockings than thigh-high stockings. The overweight patient should be encour-aged to begin a weight-reduction plan.

Medical Management

Surgery for varicose veins requires that the deep veins be patent and functional. The saphenous vein is ligated and divided. The vein is ligated high in the groin, where the saphenous vein meets the femoral vein. Additionally, the vein may be removed (stripped). After the vein is ligated, an incision is made in the ankle, and a metal or plastic wire is passed the full length of the vein to the point of ligation. The wire is then withdrawn, pulling (removing, “stripping”) the vein as it is removed (Fig. 31-18). Pressure and elevation keep bleeding at a minimum during surgery.

SCLEROTHERAPY

In sclerotherapy, a chemical is injected into the vein, irritating the venous endothelium and producing localized phlebitis and fibro-sis, thereby obliterating the lumen of the vein. This treatment may be performed alone for small varicosities or may follow vein ligation or stripping. Sclerosing is palliative rather than curative. After the sclerosing agent is injected, elastic compression ban-dages are applied to the leg and are worn for approximately 5 days. The health care provider who performed sclerotherapy removes the first bandages. Elastic compression stockings are then worn for an additional 5 weeks.

After sclerotherapy, patients are encouraged to perform walk-ing activities as prescribed to maintain blood flow in the leg. Walking enhances dilution of the sclerosing agent.

Nursing Management

Surgery can be performed in an outpatient setting, or patients can be admitted to the hospital on the day of surgery and discharged the next day, but nursing measures are the same as if the patient were hospitalized. Bed rest is maintained for 24 hours, after which the patient begins walking every 2 hours for 5 to 10 min-utes. Elastic compression stockings are used to maintain com-pression of the leg. They are worn continuously for about 1 week after vein stripping. The nurse assists the patient to perform ex-ercises 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 extremi-ties more comfortably. Dressings are inspected for bleeding, par-ticularly at the groin, where the risk of bleeding is greatest. The nurse is alert for reported sensations of “pins and needles.” Hyper sensitivity to touch in the involved extremity may indicate a tem-porary or permanent nerve injury resulting from surgery, because the saphenous vein and nerve are close to each other in the leg.

Usually, the patient may shower after the first 24 hours. The patient is instructed to dry the incisions well with a clean towel using a patting technique rather than rubbing. Application of skin lotion is to be avoided until the incisions are completely healed to decrease the chance of developing an infection.

If the patient underwent sclerotherapy, a burning sensation in the injected leg may be experienced for 1 or 2 days. The nurse may encourage the use of a mild analgesic (eg, propoxyphene napsylate and acetaminophen [Darvocet N], oxycodone and acetaminophen [Percocet], oxycodone and acetylsalicylic acid [Percodan]) as pre-scribed by a physician or nurse practitioner and walking to pro-vide relief.

PROMOTING HOME AND COMMUNITY-BASED CARE

Patients require long-term elastic support of the leg after dis-charge, and plans are made to obtain adequate supplies of elas-tic compression stockings or bandages as appropriate. Exercises of the legs are necessary; the development of an individualized plan requires consultation with the patient and the health care team.