St. Louis, MO: Elsevier. Hyperbaric oxygen therapy has also been proposed as an adjunctive therapy for chronic wound healing because of potential anti-inflammatory and antibacterial effects, and its benefits in healing diabetic foot ulcers. Start performing active or passive exercises while in bed, including occasionally rotating, flexing, and extending the feet. This article reviews the incidence and pathophysiology of CVI, nursing assessment, diagnosis and interventions, and patient education needed to manage the disease and prevent complications. Signs of chronic venous insufficiency, such as: The patient will verbalize an understanding of the aspects of home care for venous stasis ulcers such as pressure relief and wound management. On physical examination, venous ulcers are generally irregular and shallow (Figure 1). Its healing can take between four and six weeks, after their initial onset (1). They do not heal for weeks or months and sometimes longer. These ulcers are caused by poor circulation, diabetes and other conditions. August 9, 2022 Modified date: August 21, 2022. Venous ulcers are open skin lesions that occur in an area affected by venous hypertension.1 The prevalence of venous ulcers in the United States ranges from 1% to 3%.2,3 In the United States, 10% to 35% of adults have chronic venous insufficiency, and 4% of adults 65 years or older have venous ulcers.4 Risk factors for venous ulcers include age 55 years or older, family history of chronic venous insufficiency, higher body mass index, history of pulmonary embolism or superficial/deep venous thrombosis, lower extremity skeletal or joint disease, higher number of pregnancies, parental history of ankle ulcers, physical inactivity, history of ulcers, severe lipodermatosclerosis (panniculitis that leads to skin induration or hardening, increased pigmentation, swelling, and redness), and venous reflux in deep veins.5 Poor prognostic signs for healing include ulcer duration longer than three months, ulcer length of 10 cm (3.9 in) or more, presence of lower limb arterial disease, advanced age, and elevated body mass index.6, Complications of venous ulcers include infections and skin cancers such as squamous cell carcinoma.7,8 Venous ulcers are a major cause of morbidity and can lead to high medical costs.3 Economic and personal impacts include frequent visits to health care facilities, loss of productivity, increased disability, discomfort, need for dressing changes, and recurrent hospitalizations. Calf muscle contraction and intraluminal valves increase prograde flow while preventing blood reflux under normal circumstances. Patients who are severely malnourished (serum albumin 2.5 mg/dl) are more likely to acquire an infection from a pressure ulcer. Factors that may lead to venous incompetence include immobility; ineffective pumping of the calf muscle; and venous valve dysfunction from trauma, congenital absence, venous thrombosis, or phlebitis.14 Subsequently, chronic venous stasis causes pooling of blood in the venous circulatory system triggering further capillary damage and activation of inflammatory process. Calf muscle contraction and intraluminal valves increase prograde flow while preventing blood reflux under normal circumstances. These are most common in your legs and feet as you age and happen because the valves in your leg veins can't do their job properly. Situation: Mrs. Morrow is an obese, 80-year-old white female who developed a venous stasis ulcer on her right medial malleolus while still living at home. Leg elevation requires raising lower extremities above the level of the heart, with the aim of reducing edema, improving microcirculation and oxygen delivery, and hastening ulcer healing. Provide analgesics or other painkillers as directed, at least 30 minutes before caring for a wound. If necessary, recommend the physical therapy team. Unless the client is immunocompromised or diabetic, a fever is defined as a temperature above 100.4 degrees F (38 degrees C), which indicates the presence of an illness. In comparison to a single long walk, short, regular walks are healthier for the extremities and the prevention of pulmonary problems. Surgical options for treatment of venous insufficiency include ablation of the saphenous vein; interruption of the perforating veins with subfascial endoscopic surgery; treatment of iliac vein obstruction with stenting; and removal of incompetent superficial veins with phlebectomy, stripping, sclerotherapy, or laser therapy.19,35,40, In one study, ablative superficial venous surgery reduced the rate of venous ulcer recurrence at 12 months by more than one half, compared with compression therapy alone.42 In another study, surgical management led to an ulcer healing rate of 88 percent, with only a 13 percent recurrence rate over 10 months.43 There is no evidence demonstrating the superiority of surgery over medical management; however, evaluation for possible surgical intervention should occur early.44. Elastic compression bandages conform to the size and shape of the leg, accommodate to changes in leg circumference, provide sustained compression during rest and walking, have absorptive capacity, and require infrequent changes (about once a week).5 There is strong evidence for the use of multiple elastic layers vs. single layers to increase ulcer healing.30, Inelastic. However, there are few high-quality studies that directly evaluate the effect of debridement versus no debridement or the superiority of one type of debridement on the rate of venous ulcer healing.3640 In addition, most wounds with significant necrotic tissue should be evaluated for arterial insufficiency because purely venous ulcers rarely need much debridement. Sacral wounds are most susceptible to infection from urine or feces contamination due to their closeness to the perineum. There is inconsistent evidence concerning the benefits and harms of oral aspirin in the treatment of venous ulcers.40,41, Statins. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Date of admission: 11/07/ Current orders: . This process is thought to be the primary underlying mechanism for ulcer formation.10 Valve dysfunction, outflow obstruction, arteriovenous malformation, and calf muscle pump failure contribute to the pathogenesis of venous hypertension.8 Factors associated with venous incompetence are age, sex, family history of varicose veins, obesity, phlebitis, previous leg injury, and prolonged standing or sitting posture.11 Venous ulcers result from a complex process secondary to increased pressure (venous hypertension) and inflammation within the venous circulation, vein wall, and valve leaflet with extravasation of inflammatory cells and molecules into the interstitium.12, Clinical history, presentation, and physical examination findings help differentiate venous ulcers from other lower extremity ulcers (Table 15 ). Provide information about local wound care to the patient and the caregiver, and then let them watch a demonstration. -. Associated findings include lower extremity varicosities, edema, venous dermatitis, and lipodermatosclerosis. It has been estimated that active VU have She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. You will undertake clinical handover and complete a nursing care plan. To encourage numbing of the pain and patient comfort without the danger of an overdose. Some of our partners may process your data as a part of their legitimate business interest without asking for consent. Assist client with position changes to reduce risk of orthostatic BP changes. Peripheral vascular disease (PVD) NCLEX review questions for nursing students! Surgical management may be considered for ulcers. At-home wound healing can be accelerated by providing proper wound care and bandaging the damaged regions to stop pressure injury from getting worse. The patient verbalized 2 exercise regimens to improve venous return to help promote wound healing within 12-hour shift by elevated her legs and had antiembolism stockings on all day, continue to reevaluate or educate patient. Dressings are beneficial for venous ulcer healing, but no dressing has been shown to be superior. For wound closure to be effective, leg edema must be reduced. Examine the patients skin all over his or her body. It can eventually lead to ulcerations or skin breakage on the skin making the person prone infections. Negative pressure wound therapy is not recommended as a primary treatment of venous ulcers.48 There may be a future role for newer, ultraportable, single-use systems that can be used underneath compression devices.49,50, Venous ulcers that do not improve within four weeks of standard wound care should prompt consideration of adjunctive treatment options.51, Cellular and Tissue-Based Products. Inelastic compression therapy provides high working pressure during ambulation and muscle contraction, but no resting pressure. Conclusion Venous stasis ulcers often present as shallow, irregular, well-defined ulcers with fibrinous material at the base at the distal end of the legs across the medial surface. Recent trials show faster healing of venous ulcers when early endovenous ablation to correct superficial venous reflux is performed in conjunction with compression therapy, compared with compression alone or with delayed intervention if the ulcer did not heal after six months. Compression stockings are removed at night, and should be replaced every six months because they lose pressure with regular washing.2. This causes blood to collect and pool in the vein, leading to swelling in the lower leg. This means they can't stop blood which should be headed upward to your heart from being pulled down by gravity. This prevents overdistention and quickly empties the superficial and tibial veins, which reduces tissue swelling and boosts venous return. The disease has shown a worldwide rising incidence as the worlds population ages. The patient will continue to be free of systemic or local infections as shown by the lack of profuse, foul-smelling wound exudate. Leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema contribute to venous ulcer development and impaired wound healing.2,14, Determining etiology is a critical step in the management of venous ulcers. Patient who needs wound care for a chronic venous stasis ulcer on the lower leg. Venous ulcers (also known as venous stasis ulcers or nonhealing wounds) are open wounds around the ankle or lower leg. But they most often occur on the legs. Care Plan/Nursing Diagnosis Template Potential Nursing Diagnosis (Priority) At risk for ineffective peripheral tissue perfusion related to DVT and evidenced by venous stasis ulcer on right medial malleolus (Wayne, 2022). The essential requirements of management are to debride the ulcer with appropriate precautions, choose dressings that maintain adequate moisture balance, apply graduated compression bandage after evaluation of the arterial circulation and address the patient's concerns, such as pain and offensive wound discharge. Other findings include lower extremity varicosities; edema; venous dermatitis associated with hyperpigmentation and hemosiderosis or hemoglobin deposition in the skin; and lipodermatosclerosis associated with thickening and fibrosis of normal adipose tissue under skin. See permissionsforcopyrightquestions and/or permission requests. She has worked in Medical-Surgical, Telemetry, ICU and the ER. The patient will demonstrate improved tissue perfusion as evidenced by adequate peripheral pulses, absence of edema, and normal skin color and temperature. Her Waterlow Scale is 16, and her skin is intact except for the venous stasis ulcer on the right medial malleolus. In one study, intravenous iloprost (not available in the United States) used with elastic compression therapy significantly reduced healing time of venous ulcers compared with placebo.33 However, the medication is very costly and there are insufficient data to recommend its use.40, Zinc is a trace metal with potential anti-inflammatory effects. Make careful to perform range-of-motion exercises if the client is bedridden. To assess the size and extent of decubitus ulcers, as well as any affected areas that need specific care or wound treatment. Continuous stress to the skins' integrity will eventually cause skin breakdowns. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process and help nursing students pass the NCLEX exams. Compression therapy. Although the main goal of treatment is ulcer healing, secondary goals include reduction of edema and prevention of recurrence. Pentoxifylline. Four trials showed that pentoxifylline alone improved healing compared with placebo alone.19 Common adverse effects of pentoxifylline include nausea, gastrointestinal discomfort, headaches, dizziness, and prolonged bleeding time. They should not be used in nonambulatory patients or in those with arterial compromise. As soon as the client is allowed to leave the bed, assist with a progressive return to ambulation. Examine for fecal and urinary incontinence. Continue with Recommended Cookies, Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions. 17 1 The incidence of venous ulceration increases with age, and women are three times more likely than men to develop venous leg ulcers. . To encourage ideal patient comfort and lessen agitation/anxiety. Of the diagnoses developed, 62 are included in ICNP and 23 are new diagnoses, not included. What is the most appropriate intervention for this diagnosis? Encouraging the patient through physical therapy to get out of bed and sit down and carry out the necessary exercises. The patient will verbalize an ability to adapt sufficiently to the existing condition. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). Stasis ulcers. Examine the clients and the caregivers comprehension of pressure ulcer development prevention. No one dressing type has been shown to be superior when used with appropriate compression therapy. Severe complications include infection and malignant change. Early venous ablation and surgical intervention to correct superficial venous reflux can improve healing and decrease recurrence rates. Data Sources: We conducted searches in PubMed, Essential Evidence Plus, the Cochrane database, and Google Scholar using the key terms venous ulcers and venous stasis ulcers. Surgical management may be considered for ulcers that are large in size, of prolonged duration, or refractory to conservative measures. Although intermittent pneumatic compression is more effective than no compression, its effectiveness compared with other forms of compression is unclear. Males experience a lower overall incidence than females do. Venous incompetence and associated venous hypertension are thought to be the primary mechanisms for ulcer formation. By. dull pain (improves with the elevation of the affected extremity), oozing pus or another fluid from the lesion, swelling (edema) that worsens throughout the day. Most common type; women affected more than men; often occurs in older persons, Shallow, painful ulcer located over bony prominences, particularly the gaiter area (over medial malleolus); granulation tissue and fibrin present, Leg elevation, compression therapy, aspirin, pentoxifylline (Trental), surgical management, Associated findings include edema, venous dermatitis, varicosities, and lipodermatosclerosis, Associated with cardiac or cerebrovascular disease; patients may present with claudication, impotence, pain in distal foot; concomitant with venous disease in up to 25 percent of cases, Ulcers are commonly deep, located over bony prominences, round or punched out with sharply demarcated borders; yellow base or necrosis; exposure of tendons, Revascularization, antiplatelet medications, management of risk factors, Most common cause of foot ulcers, usually from diabetes mellitus, Usually occurs on plantar aspect of feet in patients with diabetes, neurologic disorders, or Hansen disease, Off-loading of pressure, topical growth factors; tissue-engineered skin, Usually occurs in patients with limited mobility, Tissue ischemia and necrosis secondary to prolonged pressure, Located over bony prominences; risk factors include excessive moisture and altered mental status, Off-loading of pressure; reduction of excessive moisture, sheer, and friction; adequate nutrition, Compression therapy (inelastic, elastic, intermittent pneumatic), Standard of care; proven benefit (benefit of intermittent pneumatic therapy is less clear); associated with decreased rate of ulcer recurrence, Standard of care when used with compression therapy; minimizes edema; recommended for 30 minutes, three or four times a day, Topical negative pressure (vacuum-assisted closure), No robust evidence regarding its use for venous ulcers, Effective when used with compression therapy; may be useful as monotherapy, Effective when used with compression therapy; dosage of 300 mg once per day, Intravenous administration (not available in the United States) may be beneficial, but data are insufficient to recommend its use; high cost limits use, Oral antibiotic treatment is warranted in cases of suspected cellulitis; routine use of systemic antibiotics provides no healing benefit; benefit of adding the topical antiseptic cadexomer iodine (not available in the United States) is unclear, May be beneficial when used with compression therapy; concern about infection transmission, May be beneficial for severe or refractory cases; associated with decreased rate of ulcer recurrence. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). As an Amazon Associate I earn from qualifying purchases. Removal of necrotic tissue and bacterial burden through debridement has long been used in wound care to enhance healing. Over time, as the veins become increasingly weak, they have more trouble sending blood to the heart. Teach the caretaker how to properly care for the afflicted regions of the wounds if the patient is to be discharged. She received her RN license in 1997. The legs should be placed in an elevated position, ideally at 30 degrees to the heart, while lying down. Compression stockings can be used for ulcer healing and prevention of recurrence (recommended strength is at least 20 to 30 mm Hg, but 30 to 40 mm Hg is preferred).31,32 Donning stockings over dressings can be challenging. Patients treated with debridement at each physician's office visit had significant reduction in wound size compared with those not treated with debridement.20. Tell the healthcare provider if you have ever had an allergic reaction to contrast liquid. o LPN education and scope of practice includes wound care. We and our partners use cookies to Store and/or access information on a device. Unna boots have limited capacity for fluid absorption in patients with highly exudative ulcers and are best used for early, small, dry ulcers and for venous dermatitis because of the skin soothing effects of zinc oxide.30, Stockings. Eventually non-healing or slow-healing wounds may form, often on the . St. Louis, MO: Elsevier. Patient information: See related handout on venous ulcers, written by the authors of this article. Pentoxifylline (400 mg three times per day) has been shown to be an effective adjunctive treatment for venous ulcers when added to compression therapy.31,40 Pentoxifylline may also be useful as monotherapy in patients who are unable to tolerate compression bandaging.31 The most common adverse effects are gastrointestinal (e.g., nausea, vomiting, diarrhea, heartburn, loss of appetite). RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. She found a passion in the ER and has stayed in this department for 30 years. Treat venous stasis ulcers per order. If you would like to change your settings or withdraw consent at any time, the link to do so is in our privacy policy accessible from our home page.. Figure Intermittent pneumatic compression therapy comprises a pump that delivers air to inflatable and deflatable sleeves that embrace extremities, providing intermittent compression.7,23 The benefits of intermittent pneumatic compression are less clear than that of standard continuous compression. St. Louis, MO: Elsevier. Venous ulcers are believed to account for approximately 70% to 90% of chronic leg ulcers. A more recent article on venous ulcers is available. Clean, persistent wounds that are not healing may benefit from palliative wound care. This hemorheologic agent affects microcirculation and oxygenation, and can be used effectively as monotherapy or with compression therapy for venous ulcers.1,39 In seven randomized controlled trials, pentoxifylline plus compression improved healing of venous ulcers compared with placebo plus compression. B) Apply a clean occlusive dressing once daily and whenever soiled. SUSAN BONKEMEYER MILLAN, MD, RUN GAN, MD, AND PETRA E. TOWNSEND, MD. Current evidence supports treatment of venous ulcers with compression therapy, exercise, dressings, pentoxifylline, and tissue products. Intermittent pneumatic compression may be considered when there is generalized, refractory edema from venous insufficiency; lymphatic obstruction; and significant ulceration of the lower extremity. When seated in a chair or bed, raise the patients legs as needed. Less often, patients have arterial leg ulcer resulting from peripheral arterial occlusive disease, the most common cause of which is arteriosclerosis. Evidence has not shown that any one dressing is superior when used with appropriate compression therapy.18 Types of dressings are summarized in Table 3.37, Topical antiseptics, including cadexomer iodine (Iodosorb), povidone-iodine (Betadine), peroxide-based preparations, honey-based preparations, and silver, have been used to treat venous ulcers. Citation: Atkin L (2019) Venous leg ulcer prevention 1: identifying patients who are at risk. Buy on Amazon, Silvestri, L. A. Causes of Venous Leg Ulcers The speci c cause of venous ulcers is poor venous return. However, in a recent meta-analysis of six small studies, oral zinc had no beneficial effect in the treatment of venous ulcers.34, Bacterial colonization and superimposed bacterial infections are common in venous ulcers and contribute to poor wound healing. Aspirin (300 mg per day) is effective when used with compression therapy for venous ulcers. Evidence has not shown that any one dressing is superior when used with appropriate compression therapy. Nursing Diagnosis: Risk for Infection related to poor circulation and oxygen delivery and ischemia secondary to venous pressure ulcers. Professional Skills in Nursing: A Guide for the Common Foundation Programme. Employed individuals with venous ulcers missed four more days of work per year than those without venous ulcers (29% increase in work-loss costs).9, Venous hypertension is defined as increased venous pressure resulting from venous reflux or obstruction. Specific written plans are necessary for long-term management to improve treatment adherence. Further evaluation with biopsy or referral to a subspecialist is warranted for venous ulcers if healing stalls or the ulcer has an atypical appearance. Make a chart for wound care. Slough with granulation tissue comprises the base of the wound, with moderate to heavy exudate. What intervention should the nurse implement to promote healing and prevent infection? Granulation tissue and fibrin are typically present in the ulcer base. Manage Settings She has brown hyperpigmentation on both lower legs with +2 oedema. Chronic venous insufficiency (CVI) is a potentially debilitating disorder associated with serious complications such as lower extremity venous ulcers. Infection occurs when microorganisms invade tissues, leading to systemic and/or local responses such as changes in exudate, increased pain, delayed healing, leukocytosis, increased erythema, or fevers and chills.46 Venous ulcers with obvious signs of infection should be treated with antibiotics.
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