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INTRODUCTION

Varicose

veins

(varicosities)

are

abnormally dilated, tortuous, superficial veins


caused by incompetent venous valves. 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 incidence correlated with increased age. The condition 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 development of varicosities, and it is not uncommon to
see this condition 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 development of varicose veins.

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.

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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 & 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 xray 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.
Changing position frequently, elevating the legs when they are tired, and getting up to walk for
several minutes of every hour promote circulation. 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
encouraged to begin a weight-reduction plan.

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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 fibrosis, 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 bandages 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 walking 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 minutes. Elastic compression stockings are used to maintain
compression of the leg. They are worn continuously for about 1 week after vein stripping. The

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nurse assists the patient to perform 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.
Dressings are inspected for bleeding, particularly at the groin, where the risk of bleeding is
greatest. The nurse is 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. 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 prescribed by a physician or nurse
practitioner and walking to provide relief.

PROMOTING HOME AND COMMUNITY-BASED CARE


Patients require long-term elastic support of the leg after discharge, and plans are made
to obtain adequate supplies of elastic 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.

REFERENCE
Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2006). Brunner & Suddarths Textbook
of Medical-Surgical Nursing (10th Ed.). Philadelphia: Lippincott Williams & Wilkins.

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