Diagnostic and Clinical Reasoning for Geriatric Varicose Vein

Subjective Data

Chief complaint: “I feel warmth in the legs.”

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History of present illness

Onset – She reports that the problem began two weeks ago.
Location – She reports that the condition affects her legs.
Duration – She reports feeling better in the morning, and the problem worsens as the day progresses.
Characteristics – The disorder presents with twisted and bulging dark purple veins in the legs.
Associated factors – She reports that the problem is aggravated by prolonged standing or sitting.
Relieving factors – She reports a relieve when and after walking around.
Treatment – She notes taking acetaminophen.
Summary – The client is a 67-year-old woman who presents at the facility complaining of warmth feeling in her legs. She notes cord-like bulging veins in her legs and reports that the feeling begun about two weeks ago. She also notes taking OTC acetaminophen for the last three days before seeking medical advice. According to the patient, the problem feels better in the morning and worsens as the day progresses, aggravates with prolonged sitting or standing, and relieves with activity.

Past medical and Obstetric history: The woman reports no recent medical history related to the current condition. However, she says she suffered hypertension in her last pregnancy, but the situation was successfully managed to lead to a healthy childbirth. She also reports being diagnosed with hyperlipidemia ten years ago and successfully recovered from the disorder. She reports getting shingles and pneumococcal vaccine immunization, as recommended by the “Centers for Disease Control and Prevention” (2016).

Allergies: The patient reports no known drug-related allergies and keeps house pets without any far allergic reaction.

Medications: The client is currently under no prescribed medication but reports taking over-the-counter acetaminophen.

Social history: The client is a wife and a mother of two daughters. She is a retired teacher and currently helps her husband in running a textiles outlet. Ethnically, she is an African American married to a Hispanic white. She does not smoke cigarette or drinks alcohol, and neither does her husband do.

Family history: The client’s late mother was in good health and expired from old age. Her late father suffered hypertension and succumbed to heart failure in his old age. Her maternal grandmother suffered dementia while the grandfather had diabetes. Her paternal grandmother suffered hypertension and aneurysm while the grandfather suffered a stroke.

Health maintenance: The patient reports taking geriatric immunizations in the past two years, but since then has not undergone any preventive health checkup. She reports maintaining a healthy diet low in sugar and fats to keep her body lipids low. She also reports not engaging in physical exercise due to work demands.

Review of system

General – she denies dizziness denies weight loss
Skin – reports dark purple coloration, warmth, and itching around the affected areas.
HEENT – denies head trauma, denies nasal drainage, and denies hearing loss, denies vision loss.
Neck – denies stiffness and swelling of neck glands
Cardiovascular – denies chest pain
Lungs – denies breathlessness
Gastrointestinal –denies nausea and vomiting denies stomach upset, denies flatulence, and denies diarrhea
Genito-urinary – denies incontinence, denies dysuria, denies hematuria, denies pelvic pain,
Periphery vascular – reports edema and discoloration in the lower limb
Musculoskeletal – reports muscle fatigue and cramping in the lower limbs
Neurological – denies confusion and memory loss
Endocrine – denies fatigue
Psychological – denies anxiety

Objective Data

Vital signs: The vital signs were recorded as follows.

T– 98.6 F, HR– 92, RR– 16, BP – 130/86 mmHg, report pain 4/10

BMI – 28 mmHg, ABG – 95%

General appearance: The patient is well looking.
HEENT: Assessment of the head revealed absence of head trauma, assessment of the mouth indicated bright red gums and lips, assessment of the throat indicated non-inflamed uvula, assessment of the eyes indicated normal vision and normal eye movement. Evaluation of the ear showed typical sound reception, reasonable flexibility of tympanic membrane, and absence of ear stuffiness and effusion.
Neck: Assessment of the neck indicated reasonable flexibility and head movement, non-inflamed lymph nodes, and no jugular vein distention.
CV: Assessment of the heart indicated normal cardiac sounds, normal heart rhythm, a regular capillary refill, absence of rub, and normal hearth expansion.
Lungs: Assessment of the lungs revealed the absence of respiratory distress, normal respiratory rate, absence of crackles and rhonchi
Abdomen: Upon palpation, the abdomen is soft and non-tender and absence of guarding, rebound, distention, organomegaly, and mass. Upon auscultation, bowel sounds present in all four quadrants, no bruits over the aorta and renal arteries.
Genito-Urinary: Assessment genital-urinary system revealed normal shiny external genitalia, no ulcer or papule, no discharge, no abnormal odor, and absence of pelvic pain
PV: Assessment of the peripheral vascular system through auscultation, palpation, inspection, and special maneuvers indicated warmth, edema, skin discoloration, normal popliteal, and femoral regions. Special maneuvers, including Buerger’s test and ankle-brachial pressure index and indicated venous insufficiency and artery sufficiency.
MSK: Palpation revealed discomfort in the affected areas, inspection revealed cord-like visible swelling, cramping, normal muscle tone, active and passive ROM within normal ranges, normal range of motion, and Gait.
Integumentary: assessment of the skin revealed absence of petechiae, ulcers, and jaundice, no lesions
Neuro: Examination of the cranial nerves, sensory and motor examination, reflexes, coordination, and Gait indicated normal neurological function including normal olfactory, optic, extraocular movements, normal reflexes (2+), and absence of palsy.
Psych: psychological assessment indicated normal mental status.

Diagnostic tests: plethysmography

The rationale for utilizing this test is to assess possible muscle pump dysfunction, obstruction, and reflux.

Assessment

Given the presenting symptoms of swelling, warmth, and discoloration, the differential diagnosis in the order of possibility is as follows.

Differential diagnosis:

Varicose vein
Chronic venous insufficiency (CVI)
Deep vein thrombosis (DVT)

Plan

Diagnostics: Ultrasound (transducer) and D-dimer blood test

Therapeutic: Endothermal ablation

Compression stockings
Aspirin 300mg PO q 6 hr for 5 days

Educational Plan – The patient is educated on the need of undertaking physical exercises to increase venous sufficiency and prevent new varicose veins from occurring, wearing of nonrestrictive clothing, and lifestyle changes to avoid standing or sitting (Raetz, Wilson, & Collins, 2019).

Collaboration – I collaborated with a vascular doctor during patient care.

Referrals – No referrals required at this time.

Clinical Decision Making

Pathophysiology

One-way valves control the circulation of gore inward ad upward in healthy veins. Blood gathers in the superficial venous capillaries moves into more prominent superficial veins, and finally passes through valves into the deep vein. Deep veins are within the fascia of the muscles, while superficial veins are suprafascial. Contraction of muscles compresses the deep veins causing pump activity that generates transient pressure in the deep venous. Because of their anatomy, deep veins can withstand high pressure than the superficial veins. A normal pressure produces venous insufficiency and varicose changes in persons with hereditary vein wall weakness. Increased pressure in the veins frequently results from venous deficiency due to valve incompetence in the superficial and deep veins (Jacobs, Andraska, Obi, & Wakefield, 2017). Varicose veins are the unpleasant pathways gore refluxes back into the congested extremity (Youn & Lee, 2019). As more valves fail under strain, high pressure is communicated into the broadening network of dilated superficial veins in a recruitment occurrence.

Therapy Information

The procedure considered to treat this patient “endovenous thermal ablation,” which entails the use of energy either from a laser or from radiofrequency to seal the affected veins (Youn & Lee, 2019). Due to its higher safety, the technique selected is radiofrequency ablation, which involves heating the wall of the affected vein. One can safely undertake the procedure under general or local anesthesia. A small cut is made just below or above the knee to access the vein, and a narrow catheter is guided into the vessel using an ultrasound scan. The vessel walls are heated to collapse, thereby closing and sealing the vein. After shutting the vein, blood naturally redirects to one of the healthy vessels, and the technique may cause short-term paresthesia. Compression stockings are needed for up to seven days post technique.

Clinical Diagnostic Reasoning

The patient presents with swelling, discoloration, and warmth in the legs, manifestations that can present in various venous conditions, including varicose vein, CVI, and deep vein thrombosis in the order of ruling. The presence of visible twisted veins distinguishes varicose vein as a possible cause. The ruling factor for CVI is the absence of leg ulcer. The lack of cramps radiating to the calves rules out DVT.

Rationale for Plan of Care

Since the patient is symptomatic, collaboration with a vascular specialist is imperative to guarantee vascular services, according to NICE Clinical Guidance CG168 recommendation (Carradice et al., 2018). Endothermal ablation is one of the baseline technique for managing varicose veins (National Institute for Health and Care Excellence, 2013). The method focuses on lowering venous pressure back to “normal physiological levels.” Undertaking physical exercise would stimulate the circulation of blood in the legs. Besides, exercise, combined with proper diet, would help the patient to reduce weight to a healthy BMI, thereby lowering unnecessary pressure off the veins. Avoiding tight clothing around the groin or waist and high heels is imperative because they can reduce blood flow. Changing positions to avoid prolonged sitting or standing would stimulate blood flow.

Ethical and or Cultural Concerns

Ethnically, the client is an African American, a group considered to be disproportionately at higher risk of cardiovascular disorders (Carnethon et al., 2017). African Americans are also at increased risk of health inequalities due to social and cultural influences, which limits their access to healthcare services. Nursing ethical considerations are imperative to care provision, and the ethical considerations viewed in the encounter are as follows.

“Practicing with respect and compassion for the distinctive attributes, worth, and inherent dignity of all persons” (Haddad & Geiger, 2018). – Human dignity is one of the most critical professional value in nursing practice. This entailed bracing the patient’s “right to dignity” by applauding her needs. Analyzing and doing away with potential sources of prejudice or bias developed an excellent nurse-patient relationship founded on trust, including supporting her choices and welcoming decisions. The nursing objective of enabling patients to live with the highest sense of well-being was achieved by guaranteeing that the client received adequate care, irrespective of financial ability. Understanding the moral and legal rights of the client and observing the right to self-determination was guaranteed information provision to support informed medical resolution.
“The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth” (Haddad & Geiger, 2018). – Health promotion, including diet and exercise to ameliorates blood and maintain healthy BMI, was imperative to maintaining good health and wellbeing.
“Collaborating with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities” (Haddad & Geiger, 2018). – Collaborating with vascular specialist and other medical professionals guaranteed a high standard of care and good patient encounter. Besides, collaborations established a compassionate, ethical, and medical effective environment free from possible errors. Cross-cultural nursing, incorporating openness and empathy braced patient-centered care, sense of security, and competent nursing care.

Barriers to Care

Arnett, Thorpe, Gaskin, Bowie, and LaVeist, (2016) presume that African Americans are less likely to utilize primary care compared to White Americans. The barriers to care addressed in this encounter were medical mistrust, race discordance, and perceived discrimination. According to Abramson, Hashemi, and Sánchez-Jankowski (2015), perceived discrimination influences self-esteem, willingness to adhere to medical devices, whether to engage in health-protective conducts and when and how to seek medical care. Perceived discrimination also donates to medical mistrust and links to poor health and persistent adverse health outcomes (Benjamins & Middleton, 2019). Advancing age links to the onset of numerous chronic conditions and poor health associated with the process of aging. According to Arnett et al., the preferential utilization of non-primary care sites as a usual source of healthcare limits the African American’s exposure to the possible preventive health gains of primary care encounter (2016). These barriers were addressed through the employment of cross-cultural nursing. Recommending the regular primary care geriatric services was imperative to not only addressing perceived discrimination but also improving health-seeking habit and engagement in health-protective conducts.

Evidence-Based Practice

Question: How does transcultural cultural nursing affect healthcare outcomes and quality of life when dealing with the ethnic minority?

The logic for this PICO question is that transcultural cultural nursing enables patients and care providers from disparate ethnic and cultural background to bring those values, perceptions, and belief together to ameliorate health. Having excellent transcultural nursing skills can enable caring for and supporting persons of various cultures and overcoming hurdles. The clinical queries and terminologies utilized to guide the exploration include transcultural nursing and cultural competency in nursing. The materials obtained include “transcultural Nursing” by Değer (2018) and “nurses’ perceptions of their cultural competence in caring for diverse patient populations” by Hart and Mareno (2016). Cultural competency forms the basis for transcultural nursing practice that meets the needs of all persons in a diverse society like the US. Hart and Mareno (2016) posit that ethnic minority populations face an increased risk of long-term disorders, are less likely to get vital preventive healthcare services, and have shorter life expectancies. Transcultural nursing guarantees patient-centered care that focuses on patients as individuals at the personal level, thereby ensuring better service provision and improved healthcare outcomes.

Self-Reflection

Reflecting on the decision-making on patient diagnosis, I have realized that the patient’s religion was not considered. Religious beliefs can influence healthy behaviors, adoption of health interventions, and the health-seeking habits of an individual, thereby affecting an individual’s health either positively or negatively. The issue of social environment could have been advantageous in this diagnosis because violence or blunt trauma to the neck is a predisposing factor to epiglottitis. With the advanced experience and skills in providing care to patients and families, I drove the development of the plan of care for the woman, including medical evaluation, diagnostics, therapeutic, and advocacy, leading positive outcomes.

Diagnostic and Clinical Reasoning for Geriatric Varicose Vein

Reference List

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Arnett, M. J., Thorpe, R. J., Gaskin, D. J., Bowie, J. V., & LaVeist, T. A. (2016). Race, medical mistrust, and segregation in primary care as usual source of care: findings from the exploring health disparities in integrated communities study. Journal of Urban Health, 93(3), 456-467. doi: 10.1007/s11524-016-0054-9

Benjamins, M. R., & Middleton, M. (2019). Perceived discrimination in medical settings and perceived quality of care: A population-based study in Chicago. PloS one, 14(4), e0215976.
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Carnethon, M. R., Pu, J., Howard, G., Albert, M. A., Anderson, C. A., Bertoni, A. G., … & Yancy, C. W. (2017). Cardiovascular health in African Americans: a scientific statement from the American Heart Association. Circulation, 136(21), e393-e423. https://doi.org/10.1161/CIR.0000000000000534

Carradice, D., Forsyth, J., Mohammed, A., Leung, C., Hitchman, L., Harwood, A. E., … & Chetter, I. (2018). Compliance with NICE guidelines when commissioning varicose vein procedures. BJS open, 2(6), 419-425. https://doi.org/10.1002/bjs5.95

Centers for Disease Control and Prevention. (2016). Vaccine information for adults. Retrieved from https://www.cdc.gov/vaccines/adults/rec-vac/index.html

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Haddad, L. M., & Geiger, R. A. (2018). Nursing Ethical Considerations. In StatPearls [Internet]. StatPearls Publishing.

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Jacobs, B. N., Andraska, E. A., Obi, A. T., & Wakefield, T. W. (2017). Pathophysiology of varicose veins. Journal of Vascular Surgery: Venous and Lymphatic Disorders, 5(3), 460-467. DOI: https://doi.org/10.1016/j.jvsv.2016.12.014

Raetz, J., Wilson, M., & Collins, K. (2019). Varicose Veins: Diagnosis and Treatment. American family physician, 99(11).

Youn, Y. J., & Lee, J. (2019). Chronic venous insufficiency and varicose veins of the lower extremities. The Korean journal of internal medicine, 34(2), 269. DOI: https://doi.org/10.3904/kjim.2018.230

Diagnostic and Clinical Reasoning for Geriatric Varicose Vein