Evaluation of  Conservative Nursing Measures among Patients with Lower Limbs Varicose Vein

 

Hanan Ramzy Ahmed Atalla^1*, Gehan. H. Soliman², Warda Mohamed Henedy³

^1,2Assistant prof. of Medical Surgical Nursing, Faculty of Nursing, Menoufia University, Egypt

³lecturer of Medical Surgical Nursing Faculty of Nursing, Menoufia University, Egypt

 

ABSTRACT:

Aim: the study was carried out to evaluate the effect of conservative management on varicose veins signs and symptoms among patients with lower limb varicose vein. Methods; Design: quasi experimental design. Setting: The study was carried out at cardiovascular surgery, outpatient clinic, menofia university hospitals, menofia governorate, Egypt. Study subject: A convenient sample of 100 varicose veins patients were included in the study Tools for data collection: Interviewing questionnaire comprised of the following sections: Socio- Demographic and medical data, Structured Knowledge sheet questionnaire regarding varicose veins, compliance to conservative treatment of varicose veins; and  visual analog pain scale.  Results; majority of studied sample were females and almost of them  were married,  there was a significant improvement of a mean total knowledge score post intervention than pre intervention about varicose veins with an obvious improvement of a mean total knowledge score of knowledge about using hydrotherapy. Conservative line of treatment of varicose veins is beneficial through it reducing presence of signs and symptoms reduce associated complications especially via continuous compliance. Conclusion: The study concluded that compliance with conservative measures of varicose veins was effectives for improving signs and symptoms as a protective measure for prevention of varicose veins and its complications. Recommendations: Enrichment of healthcare professionals regard to best conservative management of varicose veins is needed to decrease suffering of patients effectively and safely.

 

 

 

 

 

INTRODUCTION:

One of the most common progressive medical condition widely ranging estimates of prevalence that will steadily worsen was varicose veins. Varicose vein (VV) of the lower limbs is considered as the most common vascular disorder in humans, it can creating serious manifestation in patients leading to a dramatic effect ranging from surgical treatments to poor quality of patient life, and widespread morbidity ⁽¹⁾ . In clinical practice, clinical manifestations of varicose veins include; irregular pain in the lower limbs, tingling, fatigue, leg and foot burning sensation, nocturnal muscle spasms, restless legs, burning sensation and cold feeling, etc. also; spider veins, lower extremity edema, skin pigmentation, eczema, ulcers may be present as a common physical signs of varicose veins ⁽²⁾ .

 

Management of varicose veins can range from conservative treatment to surgical treatment; both of them have various advantages and disadvantages. Furthermore; the importance of non-pharmacological interventions have been highlighted as educational and exercise programs by international clinical practice guidelines ⁽³⁾. Moreover other conservative treatments include drugs, lifestyle changes, exercise, and massage and surgical treatment is reserved only for severe or medically refractory varicose veins⁽⁴⁾. The aim of management of varicose veins with these approaches is to; prevent development of complications that may occur as edema, bleeding, eczema, and leg ulcers, then decrease of patients’ complaints as heaviness, tired legs, and cramps, and finally improving cosmetic appearance”⁽⁵⁾ The various options of conservative treatment for varicose veins treatment involves  leg elevation when possible, avoiding prolonged sitting or standing, exercise, bandaging, prescribed compression stockings, wound care  and massage ^{(6 and7)} 

 

Maintaining appropriate body weight and regular exercise are the best strategy for prevention of varicose veins.  Regular exercise program leads to stimulation of circulation and improving muscle tone. Walking is the simplest exercise most suitable for lower leg varicose veins especially when associated with other interventions as leg elevation, water immersion and exercise ⁽⁸⁾. Also when encouraging exercise; the limited exercise ability of patients should be considered with more severe manifestations of chronic venous insufficiency (e.g., lower extremity ulceration). ^(9).

 

Compression stockings are an important noninvasive conservative treatment of varicose veins, venous edema, skin changes, and ulcerations ^(10). In addition to lifestyle modifications that include weight loss, exercise, and elevation of the legs when possible ⁽¹¹⁾. Also; Khetarpal and Sydnor ^(12), mentioned that; for many patients compliance to compression stockings provides the maximum benefit.

 

Other conservative treatment is hydrotherapy ^(13); which provide alternation between hot and cold baths aiming to stimulate circulation and relieving pain. The  immersion of body parts in warm or hot water elevating the body temperature, increasing blood flow so improved circulation that can heal injured tissues and improving muscles tone ⁽¹⁴⁾.

 

SIGNIFICANCE OF STUDY:

The prevalence of varicose veins affects nearly 30% of the world’s population and reaches up to one-third of the Western population. This condition is a social problem and needs interventions to improve quality of life and reduce risks. Recently, new and less invasive methods for varicose vein treatment have emerged. There is a need to define the best treatment options and to reduce the risks and costs as possible ⁽¹⁵⁾. Therefore this study was carried out to evaluate the effect of conservative management on varicose veins signs and symptoms among patients with lower limb varicose vein

 

AIM OF THE STUDY:

To evaluate the effect of conservative management on varicose veins signs and symptoms among patients with lower limb varicose vein

 

HYPOTHESIS:

·   There will be significant improvement in knowledge related to varicose veins’ conservative measures.

·   Signs and symptoms of varicose vein will be reduced among study group after application of conservative measures.

·   Compliance to conservative nursing measures will be obvious among study group

 

Design: quasi experimental design

 

Setting: The study was conducted at cardiovascular surgery, outpatient clinic, menoufia university hospitals, menoufia governorate, Egypt. 

 

Study subject: A Convenient sample was used. All patients who were admitted and treated for lower leg varicose veins were selected from cardiovascular surgery, outpatient clinic, menoufia university hospitals, menoufia governorate, Egypt.

 

Sample size was calculated dependent on the previous year census report of outpatient clinic, menoufia university hospitals, menoufia governorate, Egypt. Total numbers of varicose veins patients in lower leg was nearly 240 patients. Sample size was calculated using equation below:

N

n= ---------------------

1+ N(e)²

 

Where; n= sample size; N= total population number (150); e= margin error(0.05).

 

A total 110 of varicose vein patients with lower leg were included in the current study. 10 patients refused to follow the study so 100 patients were allocated randomly into two groups: control group (50 patients) they followed routine hospital care’ and study group (50 patients) followed the suggested conservative treatment. The data was implemented during period of 6 months (from August 2018 to January 2018).    

 

Tools: Structured interviewing questionnaire will be constructed as follow:

Part I – Socio- Demographic to assess patients’ characteristics as age, sex, marital status, education and occupation..

 

Part II- Medical Data: Medical data sheet include: smoking, positive family history, duration of varicose veins, and presence of chronic diseases

 

Part III: Knowledge sheet questionnaire:

Section I: Knowledge Regarding Varicose Veins: it was constructed by the researchers based on a review of the related literature ^(6,15) to assess patient’s knowledge. It involving 5 items covering the following areas: knowledge related to varicose veins definition, causes of varicose veins, management of varicose veins and measures taken to reduce signs and symptoms.

 

Section II: Knowledge Regarding Hydrotherapy: to assess patients' knowledge about hydrotherapy procedure. It involving 5 items covering the following areas: using, methods, frequency, duration, and benefits of it.

 

Scoring system: patient knowledge sheet questionnaire (Knowledge Regarding Varicose Veins and Knowledge Regarding Hydrotherapy) was assessed using the following: score 2 for correct and complete answer, 1 for correct incomplete answer and zero for wrong answer or don’t know answer. Then all score will be summed up and presented as following: poor knowledge (less than 50%score), fair knowledge (score 50% to less than 80%), and good knowledge (80%) and more.

 

Part IV- Questionnaire Sheet For patients' Compliance: it used developed by researchers after reviewing the related literature ^(1and44) to assess patients compliance to conservative nursing measures of varicose veins; it include the following components: questionnaire related to prescribed medication, exercise (walking), elastic stocking, leg elevation and using of hydrotherapy.

 

Part V- Lower Limb Varicose Vein Assessment Sheet: it was developed by the researchers to assess progress\ regress of signs and symptoms among patients' with lower limb varicose vein. It was consisted of eight items. As follow: pain, leg cramps, leg edema, skin itching, skin pigmentation, leg temperature, leg fatigue, and weight feeling. 

 

Tool III- visual analog pain scale: This scale was developed by Coll et al., (2004) ⁽¹⁶⁾ to assess pain level. It consisted of a horizontal 10 mm line on a piece of paper with ‘no pain’ at one end and severe at the other end. The scores were coded as none (0), mild (1-3), moderate (4-6) and severe (7-10).

 

Validity and reliability

Tools were tested for content validity by five experts (three experts in the field of Medical Surgical Nursing, Faculty of Nursing, Menoufia University, and two experts in the field of Medicine, Faculty of Medicine, and Menofia University) then modifications were done accordingly. All tools were tested for reliability using test retest method to ascertain consistency: patient’s knowledge questionnaire (r = 0.85) Visual analogue pain scale: ranged from 0.97 to 0.99).

 

Data collection:

·        The study was implemented during period of 6 months (from January 2018 to August 2018). The researcher will assess patients' through knowledge sheet questionnaire, questionnaire Sheet for patients' Compliance, Lower Limb Varicose Vein Assessment Sheet, and visual pain analog scale by the means of pre-test.

·        The educational protocol and colored Booklet was designed to provide educational information about the causes of varicose veins, signs and symptoms, prognosis, and conservative measures of it. This educational protocol consisted of a lecture given by the principal researcher for all participants, followed by a discussion for clarification of any obstacles. This session was provided in groups of five participants, face to face, in outpatient clinic. It takes about 30 minutes for every group. Educational intervention also followed weekly via telephone and to evaluate compliance to conservative treatment application after three weeks and after six weeks. The designed educational intervention remains without any changes during the course of the study.

·        The data were collected on first day as pretest and second post- test for the same data was collected after three week then after six weeks. For control group measurement was taken three times (on first day of meeting, after three week, and after six weeks) without any intervention

·        Conservative measures protocol including; taking medication, exercise (walking), elastic stocking, leg elevation, and hydrotherapy.

o    Taking medication as physician ordered and researcher’s advice patients to follow physician instructions.

o   Exercise after physician acceptance presented in walking at least 20 minutes per day at least for five days per week,

o   Leg elevation: patients instructed to elevate feet above the level of heart three or four times a day for about 15 minutes at a time.

o   Elastic stocking; It’s extremely important to put on compression stockings in the morning, before lower legs and get out of the bed. Putting on compression stockings in the morning in the right position to support healthy blood circulation in legs during the day. Wear compression stockings during the day and take them off before going to bed. Put them on again first thing in the morning.

o   Hydrotherapy: application of alternating cold and warm water to both lower extremities. It involves putting gentle pressure of water to help blood move through veins, as well as changing the water temperature from hot to cold (as patients can tolerate) quickly which also improves blood circulation and takes pressure off of swollen veins. Hot temperatures make veins dilate and it’s harder for vein valves to function properly. Cool temperatures, on the other hand, have a shrinking effect – it will be easier for vein valves to circulate blood properly and any kind of swelling will be reduced. It can be repeated from 2 to 3 times per day.

·        The data were collected using knowledge sheet questionnaire, questionnaire Sheet for patients' Compliance, Lower Limb Varicose Vein Assessment Sheet, and visual pain analog scale. The data was collected on first day of meeting and 2^nd post intervention for the same data was collected after three weeks, and after six weeks. For control group measurement was taken three times (on first day of meeting, after three weeks, and after six weeks) without any intervention.

 

Pilot study:

A pilot study was carried out on 10% of the total study sample to test the clarity, feasibility and practicability of the tools, in addition to subjects and settings. Pilot subjects were later excluded from the study.

 

Ethical consideration:

During planning for this study approval was granted from the managers of the cardiovascular surgery, outpatient clinic, menofia university hospitals. All patients were informed about the aim of the study and their rights that they were free to decide whether or not they would participate in the study. Then a written informed consent was obtained from each patient. Confidentiality was ensured by not sharing the information linked to the participants name with other individuals.

 

Statistical analysis:

Data was collected, tabulated and statistically analyzed with SPSS statistical package Descriptive statistics were first applied e.g number, percentage, mean and standard deviation Tests of significance were used to compare study group using chi square test, and for 2* 2 tables and one cell has expected number less than 5 fisher's exact test was applied, P- values, which were less than 0.05, were considered as statistically significant.

 

RESULTS:

Table (1): Illustrated the distribution of both study and control groups according to their socio demographic characteristics. It was evident that (64%) of the study group was ≥ 45 years with a mean age (47.38± 8.29) years as compared to (60%) of the control group with a mean age (47.00± 8.31) years. About (68%) of the study group as compared to (78%) of the control group were females. Also it was observed that equal percentage (94%) of the study group and control group were married. There is no statistical significant differences were seen between both groups in relation to above mentioned socio demographic characteristic

 

Table (2):  Illustrated the distribution of both study and control groups according to their Medical data..   There is no statistical significant differences were seen between both groups in relation to above mentioned Medical data.

 

Table (3): illustrated distribution of both study and control groups as regards to patient’s knowledge about Varicose veins at 3 times interval (pre intervention, 3 weeks post intervention 6 weeks post intervention).  There was a highly statistical significant improvement of a mean total knowledge score regarding varicose veins knowledge of the study group than control group at 3 and 6 weeks post intervention. P value (< 0.001).

 

Table (4):  this table show distribution of both study and control groups as regards to patient’s knowledge about using hydrotherapy procedure at 3 times interval (pre intervention, after 3 weeks of intervention and After 6 weeks of intervention). It was revealed an improvement of a mean total knowledge score of knowledge about using hydrotherapy procedure among study group (0.32 ± .81to become 9.42 ±1.61at 3 weeks post intervention and 9.74 ± 1.13 at 6 weeks post intervention) than control group at 3 weeks  and 6 weeks post intervention. There was a highly statistical significant improvement of a mean total knowledge score regarding knowledge about using hydrotherapy procedure of the study group than control group at 3 and 6 weeks post intervention, P value (< 0.001).

 

Table (5): shows distribution of both study and control groups as regards to patient’s symptoms at 3 times interval (pre intervention, after 3 weeks of intervention and After 6 weeks of intervention). A highly significant statistical difference were between study and control group in relation to the above mentioned variable as were found with X² P Values   = 15.78 P  < 0.000, 19.64 P< 0.000, 23.43 P  < 0.000, 9.89 P  < 0.002, 12.36 P  < 0.000, 15.76 P < 0.001 , 17.33 < 0.001

 

Table (6) shows Compliance of both study and control after 3 weeks post intervention and after 6 weeks post intervention.. There was a high significant difference between study and control group subjects as regards to the above mentioned variables with P < 0.001. 

 

Table (1): Distribution of both study and control groups according to their sociodemographic characteristics.

Sociodemographic characteristics	Study group (n=50)		Control group (n=50)		χ2 test	P value
	No	%	No	%
Age (years): 25 - 34 35 - 44  ≥ 45 Mean ±SD	3 15 32	6 30 64	5 15 30	10 30 60	.565	.754
	47.38± 8.29		47.00± 8.31		t.229	.819 NS
Sex :  Male  Female	16 34	32 68	14 36	28 72	.190	.663
Marital status:  Single  Married  divorced	1 47 2	2 94 4	2 47 1	4 94 2	.667	0.717
Levels of education : Illiterate Read and write Primary education Pre university University	5 8 20 9 8	10 16 40 18 16	4 8 22 10 6	8 16 44 20 12	.545	.969 NS
Occupation:  House wife  Officer  Worker  On pension	25 10 15 0	50 20 30 0	26 10 13 1	52 20 26 1	1.162	.762 NS

 

Table (2): Distribution of both study and control groups according to medical data

 

 

 

 

 

 

 

 

 

 

 

 

Table (3): Distribution of both study and control groups as regards to patient’s knowledge about varicose veins at 3 times interval (pre intervention, immediately post intervention and After 6 weeks of intervention

knowledge about varicose veins	Pre intervention				After 3 weeks of intervention					After 6 weeks of intervention
	Study     N= 5­0		Control  N= 50		Study   N= 50			control    N= 50		Study     N= 50		Control    N= 50
	3.52 ± 2.52		3.32 ± 2.41		8.26 ± 2.20			3.58± 2.29		8.90 ± 1.63		3.98 ± 2.55
Total score of knowledge (score=10):  Mean±SD   Independent t test  P value
	.404   .687				9.88 .000					11.48 .000
Total score categories:  Poor (< 50%) = < 5  Fair (50-< 80%) = 5-<8  Good (≥ 80 %) ≥ 8     χ2  P value	33 12 5	66 24 18	35 11 4	70 22 8	4 14 32	8 28 64	34 12 4		68 24 8	0 8 42	0 16 84	32 12 6	64 24 12
	.213 .899				45.61 .000					59.8 .000

P value: NS= non-significant         HS= highly significant

 

Table (4): Distribution of both study and control groups as regards to patient’s knowledge about using hydrotherapy procedure at 3 times interval (pre intervention, after 3 weeks of intervention and After 6 weeks of intervention

Group    Variables	Pre intervention				After 3 weeks of intervention						After 6 weeks of intervention
	Study     N= 50		Control  N= 50		Study N= 50			Control N= 50			Study N= 50		Control  N= 50
	No	%	No	%		%		No		%	No	%	No	%
Using hydrotherapy procedure:        Yes Sometimes No   χ2 P value	3 2 45	6 4 90	2 2 46	4 4 92	47 3 0	94 6 0		3 4 43		6 8 86	50 0 0	100 0 0	5 4 41	10 8 82
	.211 .900				81.863 0.000 HS						81.818 0.000 HS
Methods:        Didn’t use Incorrect Correct   χ2 P value	45 5 0	90 10 0	46 4 0	92 8 0	0 2 48		0 4 96	43 7 0		86 14 0	0 1 49	0 6 94	41 9 0	82 18 0
	.122 .727				91.600 0.000 HS						91.00 0.000 HS
Frequency:        Didn’t use Incorrect Correct   χ2 P value	45 5 0	90 10 0	46 4 0	92 8 0	0 2 48		0 6 94		43 7 0	86 14 0	0 3 47	0 2 98	41 9 0	82 18 0
	.122 .727				93.779 0.000 HS						96.09 0.000 HS
Duration of hydrotherapy:        Didn’t use Incorrect Correct   χ2 P value	45 5 0	90 10 0	46 4 0	92 8 0	0 3 47		0 6 94		43 7 0	86 14 0	0 1 49	0 2 98	41 9 0	82 18 0
	.122 .727				93.779 0.000 HS						96.09 0.000 HS
Benefits of hydrotherapy: Incorrect answer Correct and incomplete Correct and complete   χ2 P value	42 8 0	84 16 0	44 6 0	88 12 0	0 12 38		0 24 76		39 11 0	78 22 0	0 9 41	0 18 82	37 13 0	40 58 2
	.332 .564				77.043 0.000 HS						80.190 0.000 HS
Total score of knowledge (score=10): Mean±SD   Independent t test P value	0.32 ± .819				9.42 ±1.61						9.74 ± 1.13
	.520 .604				34.53 .000 HS						30.76 .000 HS

  P value: NS= non-significant         HS= highly significant

Table (5): Distribution of both study and control groups as regards to patient’s symptoms of varicose veins at 3 times interval (pre intervention, after 3 weeks of intervention and After 6 weeks of intervention)

Group                           Variables	Pre intervention																		After 3 weeks of intervention																	After 6 weeks of intervention
	Study N=50							Control N=50											Study N=50										Control N=50							Study N=50							Control N=50
	No						%	No						%					No	%									No					%		No		%					No	%
Pain No Mild  Moderate Sever   χ2  P value	0 18 27 5						0 36 54 10	0 20 26 4						0 40 52 8					20 18 10 2	34 36 26 4									8 18 20 4					20 40 32 8		35 13 2 0		66 24 10 0					17 20 13 0	34 40 26 0
	.235 .889																		9.143 .027																	15. 780 .000
Cramp No Sometimes Yes χ2 P value	14 27 9						28 54 18	12 30 8						24 60 16					30 15 5	46 40 14									13 30 7					30 60 10		39 11 0		78 22 0					17 33 0	34 66 0
	.371 .831																		12.054 .002																	19.643 .000
Edema No 0 - .5 inch +1 .5 – 1 inch +2 1 inch +3 χ2 P value	10 25 11 4	20 50 22 8						12 23 12 3					24 46 24 6						29 17 4 0	58 34 8 0					15 20 13 2					30 40 26 4						38 10 2 0	76 20 4 0				16 25 9 0			32 50 18 0
	.451 .929																		11.46 .009																	23.43 .000
Itching No Yes	38 12		76 24						35 15						70 30				45 5		90 10					41 9					82 18					50 0		100 0				42 8			84 16
χ2 P value	.457   .499																		1.329 .249																	9.89 .002
Pigmentation No Slight Sever	35 15 0		70 30 0						33 17 0						66 43 0				42 8 0			84 16 0					37 13 0					74 26 0				50 0 0		100 0 0					39 11 0			78 22 0
χ2 P value	.184 .668																		1.507 .220																	12.360 .000
Leg temperature Cold Warm (Normal) Hot     χ2 P value	0 47 3			0 94 6						0 46 4						0 92 8			0 49 1				0 98 2				0 48   2					0 96 4				0 50 0		0 100 0					0 49 1			0 98 2
	.102 .749																		.154 .695																	1.010 .315
Leg fatigue No Mild Moderate Sever        χ2  P value	8 17 21 4				16 34 42 8						7 15 23 5						14 30 46 10		28 11 10 1					56 22 20 2				11 19 18 2					22 38 36 4			33 15 2 0			42 48 8 2				15 23 10 2			28 42 26 4
	.394  .942																	13.51 .004																		15.76 .001
Weight feeling No Slight Disturbing Sever	8 22 16 4					16 44 32 8			7 23 15 5			22 48 24 6						28 13 7 2					32 50 14 4		13 20 15 2										26 52 20 2	34 13 3 0		42 52 6 0		14 21 13 2							28 50 20 2
χ2 P value	.178                            .981																		9.880                    .020																	17.33                             .001

 

 

 

 

 

 

Table (6) Compliance of both study and control groups after 3 weeks and 6 weeks post intervention.

Group     Complied	After3 weeks post intervention				Test of significant X2	after 6 weeks post intervention				Test of significant X2
	Study		Control			Study		Control
	No	%	No	%		No	%	No	%
Taking Medication ·        Never ·        Rarely ·        Usually ·        Always	0 0 5 45	0 0 10 90	0 0 20 30	0 0 40 60	12.92 0.001	0 0 2 48	0 0 4 96	0 0 19 31	0 0 38 62	17.42
Exercise (walking) ·        Never ·        Rarely ·        Usually ·        Always	0 4 3 43	0 8 6 86	0 15 26 9	0 30 52 18	46.61	0 0 2 48	0 0 4 96	0 14 24 12	0 28 48 24	54.21
Elastic stocking ·        Never ·        Rarely ·        Usually ·        Always	2 3 7 38	4 5 14 76	12 10 20 8	24 20 40 16	36.51	1 1 2 46	2 2 4 92	11 13 16 10	22 26 32 20	52.65
Leg elevation ·        Never ·        Rarely ·        Usually ·        Always	0 0 4 46	0 0 8 92	13 20 9 8	26 40 18 16	61.66	0 0 3 47	0 0 6 94	13 16 10 11	26 32 20 22	68.25

 

 

DISCUSSION:

Regarding to Socio-Demographic Characteristics; in the present study; it was evident that two thirds of both groups of the study and control groups aged ≥ 45 years Matching this result a study of Das, Ahmed, Abro, Arain, ⁽¹⁷⁾; showed majority of studied group with varicose veins aged 41-60 years. And Abd El-Mabood and Salama, ⁽¹⁸⁾ showed that the varicose veins patients  aged 24 - 59 years. While Kakani and Nayak⁽¹⁹⁾, presented that the age of more than two thirds of the studied sample suffering from varicose vein were from 18 to 29 years. 

 

In the present study, majority of both groups were females and almost of them were married. Concerning this result; Yun et al., ⁽²⁰⁾ who studied prevalence and risk factors of varicose vein  found that 407 women and 7 men from total study sample have varicose veins. On the same line Barandiaran, Hall, El-Barghouti, and Perry ⁽²¹⁾ found that a female represent a greater number among studied group with varicose veins. Furthermore; The reported dominance rate of varicose veins ranging from 2 % to 56% in men and 1% to 73% in women Mishra, Solankim, and Mishra,  ⁽²²⁾.  While  Kakani et al.,  ⁽¹⁹⁾, reported that more than three quarters of studied group were males, and around two thirds of them were unmarried. And majority of studied group were males, as observed in Mirji, Emmi, Joshi ⁽²³⁾. 

 

Regarding to patient’s knowledge about varicose veins; in the present study there was a significant improvement of a mean total knowledge score post intervention than pre intervention. Concerning this result; the study conducted by Swank and Ellis, et. al⁽²⁴⁾ aimed to assess the effectiveness of Information, Education and Communication programme on prevention of Varicose Vein found that three thirds  of studied sample had inadequate knowledge. A similar study on prevention of Varicose Vein done by Santopietro  et. al, ⁽²⁵⁾ revealed an improving in post- intervention knowledge score  of studied group with statistical significant difference. Also; Hospital, Ravindra, College, Vidyapeeth,(26) revealed that almost of the studied sample had moderate knowledge regarding preventive measures of varicose vein.

 

Regarding to patient’s knowledge about using hydrotherapy; there was an obvious improvement of a mean total knowledge score of knowledge about using hydrotherapy procedure among study group than control group post intervention. Ozkaptan and Kapucu., ⁽²⁷⁾reported that majority of sample had knowledge about hydrotherapy.. On the other hand;  Momeni et al; ⁽²⁸⁾   showed positive effect of hydrotherapy on reducing pain and improving quality of life of women with varicose veins  further more;  Sharma, Yadav, and Kumar ⁽²⁹⁾  revealed ” good use of hydrotherapy impact on pain and quality of life with cost effective.

 

Concerning presence of patient’s symptoms of varicose vein; in the present study more than half of both groups had moderate pain and had sometimes cramp in their lower limbs pre intervention which improved post intervention. On the same line; Mirji, Emmi, and Joshi ⁽³⁰⁾ showed that pain with prominent veins was the most common symptom in combination with edema, eczema, pigmentation or ulceration. And it was the second most frequent complaint in Joseph et al., ⁽³¹⁾ study as 56.5% of studied sample reported pain.” From the researcher point of view; this difference between different studies results due to individual difference related to pain threshold and tolerance.

 

Concerning compliance to conservative treatment of varicose veins; as regard the compliance with medication majority of study group comparing to half of control group always comply or take medications. However, 6 weeks post intervention the majority of study group reported that they always take medication compared to the same percentage pre intervention of control group. Opposite to the present study; one third of studied sample comply to treatment Memon, Shaikh, Soomro, Shaikh, and Khwaja ⁽³²⁾. This discrepancy of result from researcher point of view was due to cultural attitude of studied subjects.

 

Concerning compliance to exercise; Walking is great exercise for lower leg, the majority of studied group always complied with walking as compared to control group After 6 weeks post intervention slightly increased percentage of both groups who reported they always done exercise. ⁽³³⁾_. Moreover; Regular exercise related to varicose veins of lower limbs; even it cannot cure varicose veins, but can promote venous blood return against its further development.

 

 Regarding to the compliance to wearing elastic stocking (compression), after 3 weeks post intervention it is apparent that majority of study group comparing to one third of control group subjects always comply with wearing elastic stocking which increased after 6 weeks post intervention for both groups. In accordance with this result; compression has appositive effect on varicose veins and its complications, this effects including reduce leg symptoms, edema, pain, and improve quality of life while non-compliance with elastic compression stockings have negative effect as it decreased ulcer healing and increases recurrence ⁽³⁴⁾. For many patients, compression stockings needed for varicose veins to relieve pain and swelling, prevent complications and it can effectively help to avoid surgery ⁽³⁵⁾

 

On the other hand; Ayala, Guerra, Ulloa, and Kabnick ⁽³⁶⁾ study’s that “aimed to represent the principal causes of lack of compliance with compression therapy.. For instance, clothing varies considerably according to weather. Using a skirt or shorts for example. Education remains the best approach for increasing the use of compression therapy, as it helps the patient to understand the utility of it”.

 

Regarding to compliance with elevating leg in the present study, after 3 weeks post intervention, reported that they always comply with elevating leg while setting. While after 6 weeks post intervention with a high significant difference.. Furthermore; Limb elevation helped to reduce the pressure of blood in the vein by reversing the effect of gravity, prevent them from worsening and relieves associated symptoms ⁽³⁷⁾. Also; Lei XFand Chen SX  ⁽³⁸⁾ ; study about nurses’ awareness in preventing varicose veins of lower extremity reported that 50% of them raise their legs to prevent varicose veins.

 

Conservative line of management has a definitive role to play in management of varicose veins like limb elevation, compression bandage ⁽³⁹⁾. The findings from Mallick et al.,⁽⁴⁰⁾ study revealed that the majority of patients received conservative management (eg, compression therapy and lifestyle modifications) was expected trial of compression stockings before treatment with interventional modalities.

 

CONCLUSION:

The study concluded that signs and symptoms among patients with lower limb varicose vein after application of conservative management on varicose veins were decreased which is indicator of effectiveness of conservative management. In case of presence of varicose veins patients should be educated the benefits of conservative management as a protective measures for prevention of varicose veins and its complications.

 

RECOMMENDATIONS:

·        Enrichment of healthcare professionals of knowledge, skills and competencies with regard to best conservative management of varicose veins which is needed to decrease suffering of patients effectively and safely.

 

·        Raising awareness should be incorporated in existing research relating to conservative therapy, and highlighting effectiveness that may have on health outcomes for varicose veins’ patients using conservative measures for protection and prevention of varicose vein complications.

 

LIMITATIONS:

This study was conducted only in a selected area which imposed limitations in generalization of findings.

 

ACKNOWLEDGEMENT:  

The researchers would like to thank all patients who participated in the current study

 

 

 

REFERENCES:

1.         Sharif Nia, H., Chan, Y. H., Haghdoost, A. A., Soleimani, M. A., Beheshti, Z., and Bahrami, N. Varicose Veins of The Legs Among Nurses: Occupational and Demographic Characteristics. International Journal of Nursing Practice, (2015). 21(3), 313–320. Https://Doi.Org/10.1111/Ijn.12268

2.         Nuo P. Clinical Diagnosis and Treatment of Varicose Veins. Shanghai: The Second Military University Press; 2012.Google Scholar

3.         Dias, J. M., Cisneros, L., Dias, R., Fritsch, C., Gomes, W., Pereira, L., … Ferreira, P. H. Hydrotherapy Improves Pain and Function In Older Women With Knee Osteoarthritis: A Randomized Controlled Trial. Brazilian Journal of Physical Therapy. (2017).  21(6), 449–456. Https://Doi.Org/10.1016/J.Bjpt.2017.06.012

4.         Yamany, A., and Hamdy, B. Effect of Sequential Pneumatic Compression Therapy on Venous Blood Velocity, Refilling Time, Pain and Quality of Life In Women With Varicose Veins: A Randomized Control Study. Journal of Physical Therapy Science, (2016). 28(7), 1981–1987. Https://Doi.Org/10.1589/Jpts.28.1981

5.         Atik, D., Atik, C., and Karatepe, C. The Effect of External Apple Vinegar Application on Varicosity Symptoms, Pain, and Social Appearance Anxiety: A Randomized Controlled Trial. Evidence-Based Complementary And Alternative Medicine, 2016. Https://Doi.Org/10.1155/2016/6473678

6.         Nwafor IA, Eze JC, Ezemba N, Chinawa JM, Idoko LF, Et Al. Management of Varicose Veins of The Lower Extremities: A 10-Year Institutional Experience. (2017),  J Vasc Med Surg 5: 309. Doi: 10.4172/2329-6925.1000309

7.         Abu-Own A, Scurr JH, Coleridge Smith PD. Effect of Leg Elevation on the Skin Microcirculation in Chronic Venous Insufficiency. J Vasc Surg. 1994; 20(5):705–10.Crossrefpubmedgoogle Scholar).

8.         Rabea, M. M. Effect of Walking Intervention Program on Varicose Veins among Pregnant Women, (2010).  3, 942–946.

9.         Araki CT, Back TL, Padberg FT, Thompson PN, Jamil Z, Lee BC, Et Al. The Significance of Calf Muscle Pump Function in Venous Ulceration. J Vasc Surg. 1994; 20(6):872–7. Discussion 878-9crossrefpubmedpubmedcentralgoogle Scholar

10.       O'Meara S, Cullum N, Nelson EA, Dumville JC. Compression for Venous Leg Ulcers. Cochrane Database Syst Rev. 2012; 11: CD000265.Pubmedgoogle Scholar

11.       Gloviczki, P., Comerota, A. J., Dalsing, M. C., Eklof, B. G., Gillespie, D. L., Gloviczki, M. L., … Wakefield, T. W. (2011). The Care Of Patients With Varicose Veins And Associated Chronic Venous Diseases: Clinical Practice Guidelines Of The Society For Vascular Surgery And The American Venous Forum. Journal Of Vascular Surgery. Https://Doi.Org/10.1016/J.Jvs.2011.01.079

12.       Khetarpal A., Sydnor M.K. (2018) Varicose Veins. In: Keefe N., Haskal Z., Park A., Angle J. (Eds) IR Playbook. Springer, Cham.)

13.       Akoijam, S. D., and Aathi, M. K. Prevention Of Varicose Veins. International Journal Of Advances In Nursing Management (2014).  2(1). Retrieved From Https://Www.Researchgate.Net/Profile/Malar_Kodi6/Publication/294764354_Prevention_Of_Varicose_Veins/Links/56c3e70108aeeaf199f9010d.Pdf

14.       Mathew, C. S., Babu, B., Shaji, C., Pothan, N., Kutoor, D. S., and Abraham, E. Hydrotherapy: A Review. International Journal Of Pharmaceutical And Chemical Science, (2016).  5(4), 196–200. Retrieved From Www.Ijpcsonline.Com

15.       Oliveira, R. De Á., Mazzucca, A. C. P., Pachito, D. V., Riera, R., and Baptista-Silva, J. C. Da C. Evidence For Varicose Vein Treatment: An Overview Of Systematic Reviews. Sao Paulo Medical Journal, (2018).  136(4), 324–332. Https://Doi.Org/10.1590/1516-3180.2018.0003240418

16.       Coll A., Ameen J. and Mead D. Postoperative Pain Assessment Tools in Day Surgery: Literature Review. J Adv Nurs (2004) 46(2), 124–33.

17.       K. Das, S. Ahmed, S. Abro, M.S. Arain, Vericose Veins; Outcome of Surgical Management and Recurrences, Prof. Med. J. 21 (2014) 509e513

18.       Abd El-Mabood, E.-S., and Salama, R. (2017). Efficacy of Endovenous Laser Ablation (Endovenous Laser Ablation) Versus Conventional Stripping In The Treatment Of Great Saphenous Vein Reflux. The Egyptian Journal of Surgery. Https://Doi.Org/10.4103/Ejs.Ejs_7_17

19.       Kakani, R., Y N, S., and Nayak, M. G. Signs and Symptoms of Varicose Veins among Security Guards. International Journal of Scientific Research, (2015). 4(6), 187–190.

20.       Yun, M. J., Kim, Y. K., Kang, D. M., Kim, J. E., Ha, W. C., Jung, K. Yeol, and Choi, H. W. (2018). A Study on Prevalence and Risk Factors for Varicose Veins in Nurses At A University Hospital. Safety and Health At Work. Https://Doi.Org/10.1016/J.Shaw.2017.08.005

21.       Barandiaran. J., Hall. T., El-Barghouti. N., Perry. E., Day Case Management of Varicose Veins, Vasc. Surg. Princ. Pract. (2012). Available From: Http://Www. Intechopen.Com/Books/Vascular-Surgery-Principles-And-Practice/Day-Case- Management-Of-Varicose-Veins Http://Dx.Doi.Org/10.5772/51935

22.       Mishra, N., Solankim, S. L., and Mishra, S. Lower Limb Varicose Veins Among Nurses : A Cross Sectional Study In. International Journal of Current Research And Review, (2015). 7(24), 51–55.

23.       P. Mirji, S. Emmi, C.J. Joshi, Study of Clinical Features and Management of Varicose Veins of Lower Limb, J. Clin. Diagn. Res. 5 (2011) 1416e1420

24.       Swank C Ellis .Et. Al. To Assess The Effectiveness of Information, Education and Communication Programme on Prevention of Varicose Vein. Journal of Epidemiology and Community Health. (2012), 35(4). P: 301-06.

25.       Santopietro .FA. Et.Al. Knowledge Regarding Prevention of Varicose Vein. Journal of Clinical Epidemiology. (2009), 331(47). P:34-36

26.       Hospital, G., Ravindra, H. N., College, A. T., Vidyapeeth, S., and Author, V. C. (2018). Original Research Paper Nursing Knowledge Regarding Risk Factors And Preventive Measures of Varicose Vein Among Staff Nurses At Dhiraj Assistant Professor , Dept . Of Medical Surgical Nursing , Sumandeep Nursing College , (6), 2017–2019.

27.       Ozkaptan BB, Kapucu S. Views of Turkish Nurses and Physicians about Complementary and Alternative Therapies. International Journal of Caring Sciences 2014; 7(3):914-24.)

28.       Momeni Mehrjerdi, Maryam And Ravari, Hassan And Attarzadeh Hoseini, Reza And Khoshraftar Yazdi, Nahid  The Effects of Aquatic Exercise on Pain Severity And Quality of Life In Women With Varicose Veins. Medical Journal of Mashhad University of Medical Sciences, (2015) 58 (7). Pp. 403-410.

29.       Sharma, B., Yadav, D. K., and Kumar, B. A Review on Naturopaty and Its Noteworthiness, (2018). 7(4), 665–683. Https://Doi.Org/10.20959/Wjpps20184-11375

30.       Mirji, P., Emmi, S., and Joshi, C. Study of Clinical Features And Management of Varicose Veins of Lower Limb. Journal of Clinical and Diagnostic Research, (2012). 5(7), 1416–1420.

31.       Joseph, N., B, A., Faizan Thouseef, M., Devi M, U., Abna, A., and Juneja, I. A Multicenter Review of Epidemiology And Management Of Varicose Veins For National Guidance. Annals of Medicine and Surgery, (2016). 8, 21–27. Https://Doi.Org/10.1016/J.Amsu.2016.04.024

32.       Memon, K. N., Shaikh, N. Z., Soomro, R. A., Shaikh, S. R., and Khwaja, A. M. (2017). Non-Compliance To Doctors’ Advices Among Patients Suffering From Various Diseases: Patients’ Perspectives:A Neglected Issue. Journal Of Medicine (Bangladesh), 18(1), 10–14. Https://Doi.Org/10.3329/Jom.V18i1.31170

33.       Klonizakis M, Tew G, Michaels J, Saxton J. Impaired microvascular endothelial function is restored by acute lower-limb exercise in post-surgical varicose vein patients. Microvascular Research 2009; 77: 158–162

34.       Perrin, M., and Cutting, K. (2006). Varicose Veins . Conservative Treatments : Medical / Drug Therapies Firstproof, (January). Https://Doi.Org/10.13140/2.1.3074.5927

35.       Akoijam, S. D., and Aathi, M. K. (2014). Prevention of Varicose Veins. International Journal of Advances In Nursing Management, 2(1). Retrieved From Https://Www.Researchgate.Net/Profile/Malar_Kodi6/Publication/294764354_Prevention_Of_Varicose_Veins/Links/56c3e70108aeeaf199f9010d.Pdf

36.       Ayala, A., Guerra, J. D., Ulloa, J. H., and Kabnick, L. (2018). Compliance With Compression Therapy In Primary Chronic Venous Disease: Results From A Tropical Country, (116). Https://Doi.Org/10.1177/0268355518798153

37.       L. Allen, Assessment and Management of Patients with Varicose Veins, Nurs. Stand. 23 (2009) 49e57.

38.       Lei XF, Chen SX. Investigation on Nurses' Protective Consciousness of Varicose Veins of Lower Extremities. Jilin Med J. 2014; 35: 1068-1069.

39.       Jaykar, R. D., Kasabe, P., and Kumar, V. (2016). A Study of Clinical Profile of Varicose Veins In Our Tertiary Care Center : A Randomized Prospective Observational Study, 3(3), 1517–1523.

40.       Mallick, R., Raju, A., Campbell, C., Carlton, R., Wright, D., Boswell, K., and Eaddy, M. (2016). Treatment Patterns And Outcomes In Patients With Varicose Veins. American Health And Drug Benefits. Https://Doi.Org/10.5773/Rai.V10i1.1078

 

 

Received on 25.01.2019        Modified on 22.06.2019

Accepted on 12.08.2019      ©A&V Publications All right reserved