arterial pulse examination, and measurement of ankle-brachial index is recommended for all patients with suspected venous ulcers. Venous ulcers are believed to account for approximately 70% to 90% of chronic leg ulcers. Most venous ulcers occur on the leg, above the ankle. Patients typically experience no pain to mild pain in the extremity, which is relieved with elevation. To evaluate whether a treatment is effective. 2 Irrigate in the shower or bathe in buckets or bowls lined with a clean plastic bag to reduce the risk of cross-infection. Nursing Diagnosis: Ineffective Tissue Perfusion (multiple organs) related to hyperviscosity of blood. Choice of knee-high, thigh-high, toes-in, or toes-out compression stockings depends on patient preference. This is often used alongside compression therapy to reduce swelling. Pentoxifylline (Trental) is an inhibitor of platelet aggregation, which reduces blood viscosity and, in turn, improves microcirculation. Leg elevation minimizes edema in patients with venous insufficiency and is recommended as adjunctive therapy for venous ulcers. We and our partners use cookies to Store and/or access information on a device. 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. Debridement may be sharp (e.g., using curette or scissors), enzymatic, mechanical, biologic (i.e., using larvae), or autolytic. Normally, when you get a cut or scrape, your body's healing process starts working to close the wound. Nursing Diagnosis: Risk for Infection related to poor circulation and oxygen delivery and ischemia secondary to venous pressure ulcers. These ulcers are caused by poor circulation, diabetes and other conditions. Any of the lower leg veins can be affected. 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. This article has been double-blind peer reviewed August 9, 2022 Modified date: August 21, 2022. Provide analgesics or other painkillers as directed, at least 30 minutes before caring for a wound. The rationale for cleaning leg ulcers is the removal of any dry skin due to the wearing of bandages, it also removes any build-up of emollients that are being used. SAGE Knowledge. Specific written plans are necessary for long-term management to improve treatment adherence. Nursing care plans: Diagnoses, interventions, & outcomes. Symptoms of venous stasis ulcers include: Risk factors for venous stasis ulcers include the following: Diagnostic tests for venous stasis ulcers usually include: Compression therapy and direct wound management are the standard of care for VLUs. Chronic venous ulcers significantly impact quality of life. Abstract. The legs should be placed in an elevated position, ideally at 30 degrees to the heart, while lying down. In one small study, leg elevation increased the laser Doppler flux (i.e., flow within veins) by 45 percent.27 Although leg elevation is most effective if performed for 30 minutes, three or four times per day, this duration of treatment may be difficult for patients to follow in real-world settings. Associated findings include lower extremity varicosities, edema, venous dermatitis, and lipodermatosclerosis. such as venous ulcers and lymphoedema, concomitant bacterial and fungal colonisation or infection may be present. Venous Leg Ulcers are the most common type of lower extremity wound, afflicting approximately 1% of the western population during their lifetime. VLUs also represent a significant burden for patients and healthcare systems.. Two prospective randomized controlled trials reviewed the effect of sharp debridement on the healing of venous ulcers. 3M can help manage challenges related to VLUs and help improve patient outcomes so that people can fully engage and participate in normal everyday activities. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Venous thromboembolism occurs majorly in two ways like pulmonary embolism and deep vein thrombosis. Care Plan Provider: Jessie Nguyen Date: 10/05/2020 Treatment for venous stasis ulcer should usually include: The following lifestyle changes must be implemented to increase circulation and lower the risk of developing venous stasis ulcers: Nursing Diagnosis: Impaired Skin Integrity related to skin breakdown secondary to pressure ulcer as indicated by a pressure sore on the sacrum, a few days of sore discharge, pain, and soreness. To encourage ideal patient comfort and lessen agitation/anxiety. Encouraging the patient through physical therapy to get out of bed and sit down and carry out the necessary exercises. Timely specialized care is necessary to prevent complications, like infections that can become life-threatening. St. Louis, MO: Elsevier. They can affect any area of the skin. 1 The incidence of venous ulceration increases with age, and women are three times more likely than men to develop venous leg ulcers. B) Apply a clean occlusive dressing once daily and whenever soiled. 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. Early endovenous ablation to correct superficial venous reflux improves ulcer healing rates. The Unna boot improves healing rates compared with placebo or hydroactive dressings.22,26 However, a 2009 Cochrane review found that adding a component of elastic compression therapy is more effective than inelastic compression therapy alone.45 Also, because of its inelasticity, the Unna boot does not conform to changes in leg size and may be uncomfortable to wear. Venous stasis commonly presents as a dull ache or pain in the lower extremities, swelling that subsides with elevation, eczematous changes of the surrounding skin, and varicose veins.2 Venous ulcers often occur over bony prominences, particularly the gaiter area (over the medial malleolus). A systematic review of hyperbaric oxygen therapy in patients with chronic wounds found only one trial that addressed venous ulcers. Potential Nursing Interventions: (3 minimum) 1. Over time, as the veins become increasingly weak, they have more trouble sending blood to the heart. These actions are intended to improve overall muscle tone and strength, as well as boost venous return from the lower extremities and decrease venous stasis. Venous ulcers are believed to account for approximately 70% to 90% of chronic leg ulcers. As an Amazon Associate I earn from qualifying purchases. Sacral wounds are most susceptible to infection from urine or feces contamination due to their closeness to the perineum. There is no evidence that collagenase is superior to sharp debridement.23 Larval therapy using maggots is an effective method of debridement with added potential for disinfection, stimulation of healing, and biofilm inhibition and eradication.24,25 Potential barriers to larval debridement include patient acceptability and pain.26,27 Autolytic debridement uses moisture-retentive dressings and may be used in addition to other forms of debridement. Start providing wound care according to the decubitus ulcers development. Further evaluation with biopsy or referral to a subspecialist is warranted for venous ulcers if healing stalls or the ulcer has an atypical appearance. Color duplex ultrasonography is recommended to assess for deep and superficial venous reflux and obstruction. Venous ulcers typically have an irregular shape and well-defined borders.3 Reported symptoms often include limb heaviness, pruritus, pain, and edema that worsens throughout the day and improves with elevation.5 During physical examination, signs of venous disease, such as varicose veins, edema, or venous dermatitis, may be present. Inelastic compression therapy provides high working pressure during ambulation and muscle contraction, but no resting pressure. It can also occur if something, such as a deep vein thrombosis or other clot, damages the valves inside the veins. A yellow, fibrous tissue may cover the ulcer and have an irregular border. The patient will employ behaviors that will enhance tissue perfusion. In comparison to a single long walk, short, regular walks are healthier for the extremities and the prevention of pulmonary problems. To assess the size and extent of decubitus ulcers, as well as any affected areas that need specific care or wound treatment. Table 2 includes treatment options for venous ulcers.1622, Removal of necrotic tissue by debridement has been used to expedite wound healing. Buy on Amazon. Encourage deep breathing exercises and pursed lip breathing. Poor venous return is due to damage of the valves in leg veins that facilitate the return of the blood to the heart. Aspirin (300 mg per day) is effective when used with compression therapy for venous ulcers. Arterial pulse examination and measurement of ankle-brachial index are recommended for all patients with suspected venous ulcers. Human skin grafting may be used for patients with large or refractory venous ulcers. If not treated, increased pressure and excess fluid in the affected area can cause an open sore to form. To encourage numbing of the pain and patient comfort without the danger of an overdose. All Rights Reserved. Historically, trials comparing venous intervention plus compression with compression alone for venous ulcers showed that surgery reduced recurrence but did not improve healing.53 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.21 The most common complications of endovenous ablation were pain and deep venous thrombosis.21, The recurrence rate of venous ulcers has been reported as high as 70%.35 Venous intervention and long-term use of compression stockings are important for preventing recurrence, and leg elevation can be beneficial when used with compression stockings. 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. As the patient is experiencing pain, have him or her score it on a scale of 0 to 10 and describe it. Its essential to keep the impacted areas clean by washing them with the recommended cleanser. More analgesics should be given as needed or as directed. However, the dermatologic and vascular problems that lead to the development of venous stasis ulcers are brought on by chronic venous hypertension that results when retrograde flow, obstruction, or both exist. She has brown hyperpigmentation on both lower legs with +2 oedema. Peripheral vascular disease is the impediment of blood flow within the peripheral vascular system due to vessel damage, which mainly affects the lower extremities. Remind the client not to cross their legs or hyperextend their knees in positions where they are seated with their legs hanging or lying jackknife. Colonization refers to the presence of replicating bacteria without a host reaction or clinical signs of infection.45 Colonized venous ulcers generally should not be treated with antibiotics. No revisions are needed. 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. Even under perfect conditions, a pressure ulcer may take weeks or months to heal. Ackley, Nursing Diagnosis Handbook, Page 153 Nursing CLINICAL WORKSHEET Dat e: 10/2/2022 Student Name: Michele Tokar Assigned vSim: Vernon Russell Initia ls: VR Diagnosis: Right sided ischemic The specialists of the Vascular Ulcer and Wound Healing Clinic diagnose and treat people with persistent wounds (ulcers) at the Gonda Vascular Center on Mayo Clinic's campus in Minnesota. VLUs are the result of chronic venous insufficiency (CVI) in the legs. To diagnose chronic venous insufficiency, your NYU Langone doctor asks about your health history to determine the extent of your symptoms. Her Waterlow Scale is 16, and her skin is intact except for the venous stasis ulcer on the right medial malleolus. It allows time for the nursing team to evaluate the wound and the condition of the leg. Venous incompetence and associated venous hypertension are thought to be the primary mechanisms for ulcer formation. Any delay in care increases the risk of infection, sepsis, amputation, skin cancers, and death. A group of nurse judges experienced in the treatment of venous ulcer validated 84 nursing diagnoses and outcomes, and 306 interventions. Compression therapy Treatment focuses on preventing new ulcers, controlling edema, and reducing venous hypertension through compression therapy. This article reviews the incidence and pathophysiology of CVI, nursing assessment, diagnosis and interventions, and patient education needed to manage the disease and prevent . Eventually non-healing or slow-healing wounds may form, often on the . mostly non-infectious condition in association with venous insufficiency and atrophy of the skin of the lower leg during long . The recurrence of an ulcer in the same area is highly suggestive of venous ulcer. Referral to a wound subspecialist should be considered for ulcers that are large, of prolonged duration, or refractory to conservative measures. She received her RN license in 1997. This usually needs to be changed 1 to 3 times a week. Learn how your comment data is processed. There is inconsistent evidence concerning the benefits and harms of oral aspirin in the treatment of venous ulcers.40,41, Statins. Clean, persistent wounds that are not healing may benefit from palliative wound care. This provides the best conditions for the ulcer to heal. 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. The recommended regimen is 30 minutes, three or four times per day. A catheter is guided into the vein. 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. These measures facilitate venous return and help reduce edema. Compression stockings are removed at night and should be replaced every six months because of loss of compression with regular washing. In a small study, patients receiving simvastatin (Zocor), 40 mg once daily, had a higher rate of ulcer healing than matched patients given placebo.42, Phlebotonics. 11.0 Low level laser treatment 11.1 There is no evidence that low level laser therapy speeds the healing of venous leg ulcers. Risk factors for the development of 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, and venous reflux in deep veins. Dehydration makes blood more viscous and causes venous stasis, which makes thrombus development more likely. Copyright 2023 American Academy of Family Physicians. Possible causes of venous ulcers include inflammatory processes resulting in leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema. Professional Skills in Nursing: A Guide for the Common Foundation Programme. Caused by vein problems, these make up the majority of vascular ulcers. Compression therapy reduces edema, improves venous reflux, enhances healing of ulcers, and reduces pain.23 Success rates range from 30 to 60 percent at 24 weeks, and 70 to 85 percent after one year.22 After an ulcer has healed, lifelong maintenance of compression therapy may reduce the risk of recurrence.12,24,25 However, adherence to the therapy may be limited by pain; drainage; application difficulty; and physical limitations, including obesity and contact dermatitis.19 Contraindications to compression therapy include clinically significant arterial disease and uncompensated heart failure. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. Statins have vasoactive and anti-inflammatory effects. Granulation tissue and fibrin are often present in the ulcer base. She has worked in Medical-Surgical, Telemetry, ICU and the ER. In addition, the Unna boot may lead to a foul smell from the accumulation of exudate from the ulcer, requiring frequent reapplications.2, Elastic. 17 How to Cure Venous Leg Ulcers Mark Whiteley. 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. Topical negative pressure, also called vacuum-assisted closure, has been shown to help reduce wound depth and volume compared with a hydrocolloid gel and gauze regimen for wounds of any etiology.30 However, clinically meaningful outcomes, such as healing time, have not yet been adequately studied. Venous ulcers are usually recurrent, and an open ulcer can persist for weeks to many years. The pressure ulcer needs to be taken into consideration as a potential cause during the septic workup. Venous ulcers (open sores) can occur when the veins in your legs do not push blood back up to your heart as well as they should. It might be necessary to apply the prescription antibiotic cream or ointment directly to the affected area. The patient will verbalize an ability to adapt sufficiently to the existing condition. The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. Venous stasis ulcers are wounds that are slow to heal. Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). The patient will continue to be free of systemic or local infections as shown by the lack of profuse, foul-smelling wound exudate. Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. What is the most appropriate intervention for this diagnosis? Color duplex ultrasonography is recommended in patients with venous ulcers to assess for venous reflux and obstruction. Nursing Diagnosis: Impaired Peripheral Tissue Perfusion related to deficient knowledge of risk factors secondary to venous stasis ulcers as evidenced by edema, decreased peripheral pulses, capillary refill time > 3 seconds, and altered skin characteristics. Intermittent pneumatic compression may improve ulcer healing when added to layered compression.30,34, Although leg elevation can increase deep venous flow and reduce venous pressure, leg elevation added to compression may not improve ulcer healing.17 However, one prospective study found that leg elevation for at least one hour per day at least six days per week can reduce venous ulcer recurrence when used with compression.17,35, A systematic review evaluating progressive resistance exercise, resistance exercise plus prescribed physical activity, only walking, and only ankle exercises found that progressive resistance exercise with prescribed physical activity may result in an additional nine to 45 venous ulcers healed per 100 patients.36, Dressings are recommended to cover ulcers and promote moist wound healing.1,18 Dressings should be chosen based on wound location, size, depth, moisture balance, presence of infection, allergies, comfort, odor management, ease and frequency of dressing changes, cost, and availability.