AFAMS Master Lesson Plan (MLP)
Nursing Program
Venous Vascular Disease
Instructor
Serial/Semester
Location
Start/Finish Time
Date
LESSON OBJECTIVE
Performance: To gain an understanding of venous vascular disease.
Conditions:
The student will be presented a powerpoint presentation by the instructor and will have
all necessary references made available to him/her.
Standard:
1.
Adult Health Nursing, 4th Edition
Introductory Medical-Surgical Nursing, Timby and Smith, 8th Edition, Chpt 31, pp
416-420 and Chpt 33, pp 456-459.
TEACHING POINTS
1. Describe the etiology/pathophysiology,
clinical manifestations, assessment, diagnosis,
and medical management of thrombophlebitis.
2. Determine the nursing interventions and
patient teaching for a patient with
thrombophlebitis.
3. Describe the etiology/pathophysiology,
clinical manifestations, assessment, diagnosis,
and medical management of varicose veins.
4. Determine the nursing interventions and
patient teaching for a patient with varicose
veins.
5. Describe the etiology/pathophysiology,
clinical manifestations, assessment, diagnosis,
and medical and nursing management of a
venous stasis ulcer.
6.
7.
8
9.
10.
INSTRUCTIONAL STRATEGY
Interactive Lecture
Method:
Instructor
Media:
Classroom
Environment:
OTHER LESSON SPECIFICATIONS
Knowledge Lesson
Type of Lesson:
1/50
Ratio:
Resources:
.
End of Lesson Test: None
Instructional Time: 144
Reference(s):
Click here to enter reference(s).
Minutes
LESSON PLAN APPROVAL
Signature of Standards Officer
Date
AFAMS Master Lesson Plan (MLP)
Nursing Program
Venous Vascular Disease
INTRODUCTION
Allocated Time:
Review:
5 Minutes
You have had previous anatomy and physiology lectures in your combat medic
training, this lecture will build upon prior instruction.
Objective:
To discuss/describe topics related to the nursing process.
Importance:
Nurses work in various health care settings so it is important to gain an
understanding of this subject as it will apply to your clinical practice.
Fit:
Click here to enter a description of how and where this lesson fits in the course
or on the job.
Approach:
You will be presented the subject in lecture format and will be tested using a
written exam at a later date.
Control Statement:
If you have any questions during the lesson please feel free to ask.
BODY
1. Teaching Point: Describe the etiology/pathophysiology, clinical manifestations, assessment,
diagnosis, and medical management of thrombophlebitis.
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
1. Thrombophlebitis
a. Etiology/pathophysiology:
i. It occurs more frequently in women.
ii. Affects people of all races.
b. Definition - inflammation of a vein accompanied by the formation of a thrombus.
c. Contributing factors
i. Inactivity – prolonged sitting
ii. Trauma to the vessel wall
iii. Venous stasis
iv. Hypercoagability
v. Myocardial infarction or heart failure
vi. Elderly patients with heart disease, infections or dehydration
vii. Surgery that manipulates blood vessels such as total hip replacement or pelvic
surgery
viii. Immobilization after surgery
d. Clinical manifestations
i. Pain and edema occur when the vein is obstructed.
ii. The size of the calf or thigh may increase the circumference.
1
AFAMS Master Lesson Plan (MLP)
Nursing Program
Venous Vascular Disease
iii. Pain on dorsiflexion (Homan's Sign) is a classic sign but not specific for DVT.
iv. If the thrombophlebitis is superficial there may be signs of inflammation such as
erythema, warmth, and tenderness along the vein.
e. Assessment
i. Subjective data
1. Characteristics of pain, onset, and duration
ii. Objective data
1. Inspection of extremity includes:
2. Heat
3. Erythematous
4. Edema
5. Measure both legs circumference
6. Color
f. Diagnosis
i. Based on presenting symptoms
ii. Venography
iii. Doppler ultrasound
iv. Impedence Plethysmography (IPG) preferred test
g. Treatment
i. Superficial thrombophlebitis
1. Bedrest
2. Moist heat
3. Elevation of the affected extremity
ii. Anti-embolism stockings
iii. Medications
1. Medications:
2. NSAIDS
3. Anticoagulants
a. IV heparin
b. Warfarin
c. Low-molecular weight heparin (LWMH) administered SQ does
not require anticoagulant monitoring or dose adjustment
d. Enoxaparin (Lovenox)
e. Dalteparin (Fragmin)
iv. Surgical intervention only indicated when conservative measures have failed:
1. Thrombectomy
2. Transvenous placement of grid
3. Umbrella (Greenfield filter) placed in vena cava may prevent flow of
emboli to lungs
2
AFAMS Master Lesson Plan (MLP)
Nursing Program
Venous Vascular Disease
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
Click here to enter the question.
Click here to enter the answer.
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
2. Teaching Point: Determine the nursing interventions and patient teaching for a patient with
thrombophlebitis.
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
1. Nursing interventions
a. The emphasis is on prevention of complication, promoting comfort and teaching.
b. Nursing diagnosis and interventions pertinent to thrombophlebitis (See nursing diagnosis
box, page 343) for full details.
2. Nursing diagnosis
a. Tissue perfusion, ineffective peripheral, related to decrease venous blood flow
i. Interventions:
1. Strict bedrest during acute phase
2. Perform circulation checks frequently
3. Measure calf or thigh circumference daily
4. Assess site for signs of edema and infection
b. Knowledge, deficient, related to disease process and risk factors
i. Interventions
1. Develop a patient specific teaching plan to prevent venous stasis
2. Avoid prolonged sitting or standing
3. Lose weight if obese
4. Elevate legs when sitting
5. Avoid crossing legs
6. Take prescribed medications according to plan
7. Do flexion-extension exercises
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
Click here to enter the question.
Click here to enter the answer.
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
3
AFAMS Master Lesson Plan (MLP)
Nursing Program
Venous Vascular Disease
3. Teaching Point: Describe the etiology/pathophysiology, clinical manifestations, assessment,
diagnosis, and medical management of varicose veins.
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
1. Varicose veins
a. Etiology
i. Varicose vein is a tortuous, dilated vein with incompetent valves.
ii. Highest incidence is women 40 to 60 years of age.
iii. Fifteen percent of the population is affected.
iv. The great and small saphenous veins are most often affected.
b. Causes
i. Congenitally defective valves
ii. Incompetent valve
iii. Absent valve
iv. External pressure on leg from pregnancy
v. Poor posture
vi. Constrictive clothing
vii. Prolonged standing
c. Pathophysiology
i. The vessel wall weakens and dilates thereby stretching the valves and resulting in
pooling in the blood.
ii. This leads to varicosities in the veins.
d. Clinical manifestations
i. Varicosities can be primary or secondary.
ii. Primary have a gradual onset and affect superficial veins.
iii. Secondary affect the deep veins and result from venous insufficiency and
thrombosis.
e. Signs and Symptoms
i. Signs include darkened veins on the lower extremities.
ii. Symptoms include:
iii. Fatigue
iv. Dull ache
v. Cramping of the muscles
vi. Feeling of heaviness all arising from a decreased blood flow to the tissues.
f. Assessment
i. Signs include darkened veins on the lower extremities.
ii. Symptoms include:
1. Fatigue
4
AFAMS Master Lesson Plan (MLP)
Nursing Program
Venous Vascular Disease
2. Dull ache
3. Cramping of the muscles
4. Feeling of heaviness all arising from a decreased blood flow to the
tissues.
g. Diagnostic test
i. Trendelenburg's test is done to diagnose the ability of the valves to support a
column of blood by measuring venous filling time
1. Patient lies down with the affected leg elevated for venous emptying
2. A tourniquet is placed above the knee and the patient stands
3. The filling time for the veins are recorded before and after the tourniquet
is removed
4. When the veins fill rapidly from backward flow the veins are considered
to be incompetent
h. Surgical management
i. Surgery is comprised of vein ligation and stripping.
ii. The great saphenous vein is ligated close to femoral junction and the veins are
stripped.
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
Click here to enter the question.
Click here to enter the answer.
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
4. Teaching Point: Determine the nursing interventions and patient teaching for a patient with varicose
veins.
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
1. Patient teaching
a. Nursing interventions and patient focus on the post-op surgical care
b. Includes promoting comfort and maintaining peripheral circulation and venous return
c. Nursing diagnosis and interventions (see nursing diagnosis box, page 344 for complete
detail)
d. Tissue perfusion, ineffective peripheral, related to impaired venous return.
i. Interventions:
1. Monitor for post-op bleeding.
2. Keep elastic bandage snug and wrinkle-free. Do not remove daily for
dressing change.
5
AFAMS Master Lesson Plan (MLP)
Nursing Program
Venous Vascular Disease
3. Encourage deep breathing and early ambulation.
4. Encourage dorsiflexion exercises.
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
Click here to enter the question.
Click here to enter the answer.
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
5. Teaching Point: Describe the etiology/pathophysiology, clinical manifestations, assessment,
diagnosis, and medical and nursing management of a venous stasis ulcer.
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
1. Venous stasis ulcer
a. Etiology - Stasis ulcer or leg ulcer occur due to chronic deep vein insufficiency and statis
of the blood in the venous system.
i. Other causes include severe varicose veins, burns, trauma, sickle cell anemia,
diabetes, and neurogenic disorders.
ii. A leg ulcer is an open, necrotic lesion.
b. Pathophysiology
i. Necrotic lesions are formed when inadequate supply of oxygen rich blood and
nutrients reach the tissues. This results in cell death and tissue sloughing.
ii. Decreased circulation to the area leads to the development of infection and
increased healing time.
c. Assessment
i. Subjective
1. Onset and duration of pain and relief factors.
2. Interview patient about all predisposing factors.
ii. Objective
1. Check for size and depth of ulceration.
2. Presence of edema.
3. Palpate and compare pedal pulses.
iii. Diagnostic tests
1. Doppler ultrasonography.
2. Venography .
3. confirm venous insufficiency and stasis.
iv. Medical management
1. Focused on prevention of infection and promotion of wound healing.
6
AFAMS Master Lesson Plan (MLP)
Nursing Program
Venous Vascular Disease
2. Diet is crucial to ensure proper wound healing.
3. Large amounts of protein are lost in the form of albumin through the
ulcers. High intake of protein is essential.
4. Vitamins A, C and the mineral zinc are administered to ensure proper
healing.
5. Debridement to remove necrotic tissue is in three forms:
a. Mechanical - wet to dry dressing is used to remove debris when
the dry dressing is removed.
b. Chemical - enzymes are applied to break down necrotic tissue.
c. Surgical - is performed using a scalpel when all other measures
have failed.
6. Antibiotics
7. Protection of the ulcerated area using the Unna's boot.
8. See figure 8-23 on page 345 for illustration of the application of Unna's
boot.
9. The boot is left on for 1-2 weeks but may be changed more frequently
based on drainage.
v. Nursing interventions
1. Focus on promoting tissue healing .
2. Nursing Diagnosis:
a. Skin integrity, impaired, related to open ulceration.
i. Interventions:
1. Perform dressing changes.
2. Assess wound for sign of infection.
3. Provide prescribed antibiotic therapy.
4. Provide adequate nutritional support.
5. Collaborate with dietitians.
b. Tissue perfusion, ineffective, peripheral, related to insufficient
venous circulation.
i. Interventions:
1. Elevate extremities to promote venous return.
2. Protect extremity using bed cradle to pressure of
the linen.
3. Assess level of pain and provide pain relief
measures.
3. Clinical manifestations
a. Pain is present from mild to dull ache relieved by elevation.
b. Skin is visibly ulcerated most often on the medial aspect of the
ankle accompanied by dark pigmentation.
c. Edema may be present and pedal pulses may be present.
7
AFAMS Master Lesson Plan (MLP)
Nursing Program
Venous Vascular Disease
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
Click here to enter the question.
Click here to enter the answer.
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
END OF LESSON TEST
Allocated Time:
Instructions:
Test Questions or
Performance
Expected:
Test Key:
0 Minutes
You will be tested on this subject at a later date.
You will be expected to review and study the material taught in this session in
order to pass the associated written test. If you have difficulty with the material
please see me so we can review together.
None.
CONCLUSION
Allocated Time:
Summary:
5 Minutes
Review and re-emphasize the difficult Teaching Points below.
1.
2.
3.
4.
5.
Describe the etiology/pathophysiology, clinical manifestations,
assessment, diagnosis, and medical management of thrombophlebitis.
Determine the nursing interventions and patient teaching for a patient
with thrombophlebitis.
Describe the etiology/pathophysiology, clinical manifestations,
assessment, diagnosis, and medical management of varicose veins.
Determine the nursing interventions and patient teaching for a patient
with varicose veins.
Describe the etiology/pathophysiology, clinical manifestations,
assessment, diagnosis, and medical and nursing management of a
venous stasis ulcer.
6.
7.
8
9.
10.
Closing Statement:
Nurses work in various health care settings so it is important to gain an
understanding of this subject as it will apply to your clinical practice.
Re-motivating
Statement:
Click here to enter a statement to re-emphasize the importance of the lesson.
8