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Varicose Veins and

Varicose Veins and Support Stockings Varicose veins are large dilated blood vessels that have a red or bluish colour and protrude above the surface of the skin. Most people use the term varicose veins to describe veins in the legs but they can occur elsewhere on the body. When situated in the leg they can ache or throb, and cause cramp or leg swelling. Very small veins in the skin are called thread veins or spider veins and, although they cause fewer other symptoms, they may be more difficult to treat (see Bruises, Scars and Spider Veins). Varicose veins are usually caused by an incompetent valve system allowing blood to return into the superficial layers just beneath the skin. The resultant increase in pressure in these thin-walled skin veins can then cause vein enlargement and further valve failure. Varicose veins are usually hereditary and occur more often as people age. The risk is also higher in people who stand all day on hard surfaces, in pregnant women and in people who are obese. Initial assessment Varicose veins are best diagnosed by a doctor, as they may signal other circulatory problems or harbour blood clots. A doctor will conduct a physical exam and use other tests, such as an ultrasound, to determine valve functioning. For customers wanting flight socks, check they do not have any circulatory problems (such as diabetes), and that they have the physical capability to pull on the socks. Refer any customers with "yes" answers to the Refer to Pharmacist questions to a pharmacist. Treatment of varicose veins Support stockings (also called compression stockings) remain an important treatment for varicose veins. These stockings provide a graduated compression, which helps direct blood flow back from the lower leg to the heart. Compression is firmest at the ankle and gradually reduces as the distance from the ankle increases. Long-term use of support stockings is recommended, even after leg vein surgery, to prevent varicose veins from returning. Graduated compression stockings cannot cure varicose veins but can prevent further vein deterioration. Compression hosiery/stockings can be used: • after leg liposuction • after treatment of spider or varicose veins »» Treatments for varicose veins include Endovenous Laser Ablation (EVLA), Ultrasound Guided Sclerotherapy (UGS) and surgery. • as flight socks (grade 1 compression only) to help prevent deep vein thrombosis (DVT) on long-haul flights or prolonged car travel • to help symptoms of varicose veins. Advice for customers • Measurements may be required to fit the person with the correct size of stocking. Class 1 stockings do not require fitting, while classes 2 to 4 must have measurements taken for a correct fit, and can be sold only on the TREATMENT OPTIONS Category Examples Comments Graduated compression hosiery Other products Natural / herbal products / supplements eg, Encircle Merino, Jobst range, Mediven range, Scholl Flight Socks, TGX Socks, Venosan [GENERAL SALE] eg, mucopolysaccharide polysulfate (eg, Hirudoid) Butcher’s broom, horse chestnut (Venotrex), gotu kola, grape, nattokinase, pycnogenol, sweet clover Support hosiery is classified into four different grades of compression: Class 1 may be sold in pharmacies and without a doctor’s recommendation. Classes 2 to 4 may be sold only on the recommendation of a doctor. Grade/class 1 compression is recommended for people with tired, aching legs, mild varicose veins, mild ankle swelling and to prevent ankles and feet swelling during long flights, eg, Scholl Flight Socks. Grade/class 2 compression is used for people with moderate-to-severe varicose veins, pronounced ankle swelling after vein surgery, and to prevent recurrence of venous leg ulcers. Grade/classes 3 and 4 compression hosiery is used for people with severe varicose veins or ankle swelling, active leg ulcers and to prevent leg ulcers recurring. These would probably be recommended by a specialist. Full-length hosiery – stockings or pantyhose – are usually preferred for people with varicose veins in the thigh, and for pregnant women. Knee-high support stockings provide enough support for people with lower leg problems, eg, varicose veins, swollen ankles and ulcers. It is important to fit people with the correct size, according to the properly taken measurement. Contains enzymes that help disperse excess fluid in swollen areas. They reduce swelling and bruising. Can also be used as a treatment following sclerotherapy. There is some evidence for the benefits of horse chestnut, butcher’s broom, grape, pycnogenol, and sweet clover in chronic venous insufficiency and for the improvement in symptoms of varcose veins. Gotu kola, nattokinase or pycnogenol may decrease the risk of DVT related to long-distance travel. Page 162 HEALTHCARE HANDBOOK 2017-2018 Common Disorders

CONTINUING OTC EDUCATION Traveller ’s thrombosis Traveller’s thrombosis is the term used to describe the formation of a blood clot within a vein soon after travel. A deep vein thrombosis (DVT) is a blood clot that forms within major veins (ie, in the legs or pelvis). Life-threatening complications occur if these clots dislodge (embolise) or parts break off and lodge in other veins or arteries in the lungs, heart or brain. The risk of developing a blood clot after any form of travel (not just air travel) is generally low but is more likely to occur in people aged over 40 or who: •• are immobile for long periods of time •• are obese •• are taking the contraceptive pill or HRT •• are dehydrated (increases blood viscosity) •• have cancer or a chronic medical illness (eg, inflammatory bowel disease) •• have had previous venous disease or a stroke •• have had recent major surgery or trauma (particularly involving the lower limbs or hip) •• have thrombophilia or with a genetic predisposition to clotting •• who are pregnant or who have recently given birth •• with a central venous catheter or pacemaker •• with congestive heart failure, chronic obstructive pulmonary disease, pneumonia •• with a personal or family history of a DVT. Symptoms Symptoms vary depending on the area affected but the most common symptom of a blood clot or DVT is a cramping, aching pain that does not subside with rest. Other symptoms include swelling or tenderness and a localised redness or warmth. If a pulmonary embolism (PE) has occurred, the person may complain of chest pain and breathlessness. A DVT does not always cause symptoms. Recommendations: •• Maintain some activity during long-haul flights or long-distance car travel – wiggle ankles up and down, stretch, go for occasional cabin walk or stop the car and walk around for 20 minutes. •• Ask for an aisle seat on planes and avoid sedative medicines. •• Consider compression stockings for people identified as being at increased risk. Compression stockings are synergistic (work with) aspirin or heparin. •• Maintain fluid intake and limit alcohol to remain hydrated. •• People at high risk should see their doctor before travelling who may prescribe prophylactic treatment. Refer to PHARMACIST People with symptoms suggestive of a DVT or pulmonary embolism should seek urgent medical attention. Also refer all customers without a formal diagnosis of varicose veins to a pharmacist, who should refer them to a doctor. The following questions aim to identify customers who would benefit from further input from a pharmacist. Your initial assessment may have already provided some answers. Decide if any further questions still need to be asked and refer any “yes” answers to a pharmacist. • Does the person have any other health conditions (eg, heart or lung problems, diabetes, is pregnant or breastfeeding)? • Does the person take any medication or herbal remedy, either prescribed by a doctor or bought from a shop that may be causing fluid retention? • Does the leg look swollen or does the foot look pale or dark? • Are the varicose veins very large? • Are there leg ulcers or broken, weepy skin visible, or is there a deep raspberry stain colour over the lower calf area? • Is the person complaining of deep calf pain? • Does the person have eczema or dermatitis? and jewellery snagging the stockings. Rubber gloves also help the person to move the stocking up the leg. Trim rough nails on hands and feet. • When worn for treatment, compression hosiery is usually worn for 24 hours a day under medical advice, including while sleeping and showering for the first week. »» A hairdryer may be needed to dry stockings after showering or the hosiery may be covered with a large plastic bag. recommendation of a doctor. • Measurements are best taken as early as possible in the morning. If the person has walked to the pharmacy, rest the legs horizontally for as long as possible before taking measurements. • Graduated compression stockings are designed to be firm and supportive. Moving up or down a size is not recommended as the amount of compression applied to the lower leg will not be correct. • After washing, do not dry stockings in a clothes dryer – refer to manufacturer’s information for laundry details. • Wear rubber gloves when putting on support stockings to prevent fingernails Now you can complete your ENHANCE modules on your phone or tablet www.pharmacytoday.co.nz Page 163

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