Copyright 2019 by the American Academy of Family Physicians. 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). Common drugs in this class include saponins (e.g., horse chestnut seed extract), flavonoids (e.g., rutosides, diosmin, hesperidin), and micronized purified flavonoid fraction.43 Although phlebotonics may improve edema and other signs and symptoms of chronic venous insufficiency (e.g., trophic disorders, cramps, restless legs, swelling, paresthesia), there was no difference in venous ulcer healing when compared with placebo.44, Antibiotics. The Peristomal Skin Assessment Guide for Clinicians is a mobile tool that provides basic guidance to clinicians on identifying and treating peristomal skin complications, including instructions for patient care and conditions that warrant referral to a WOC/NSWOC (Nurse Specialized in Wound, Ostomy and Continence). A simple non-sticky dressing will be used to dress your ulcer. Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. B) Apply a clean occlusive dressing once daily and whenever soiled. Table 2 includes treatment options for venous ulcers.1622, Removal of necrotic tissue by debridement has been used to expedite wound healing. 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. 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. This article reviews the incidence and pathophysiology of CVI, nursing assessment, diagnosis and interventions, and patient education needed to manage the disease and prevent . Please follow your facilities guidelines, policies, and procedures. 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. Skin grafting should be considered as primary therapy only for large venous ulcers (larger than 25 cm2 [3.9 in2]), in which healing is unlikely without grafting. Nursing Diagnosis: Risk for Infection related to poor circulation and oxygen delivery and ischemia secondary to venous pressure ulcers. To assess the size and extent of decubitus ulcers, as well as any affected areas that need specific care or wound treatment. However, a recent Cochrane review of 22 RCTs of systemic and topical antibiotics and antiseptics for venous ulcer treatment found no evidence that routine use of oral antibiotics improves healing rates.1 Studies comparing topical antibiotics and antiseptics, such as povidone-iodine solution (Betadine), peroxide-based preparations, ethacridine lactate (not available in the United States), and mupirocin (Bactroban), have found some evidence to support the use of the topical antiseptic agent cadexomer iodine (not available in the United States; a pooled estimate from two trials suggests an increased healing rate at four to six weeks compared with placebo).1 More high-quality data are needed to better evaluate the effectiveness of topical preparations, however.1. Chronic venous insufficiency can pose a more serious result if not given proper medical attention. More analgesics should be given as needed or as directed. Date of admission: 11/07/ Current orders: . Continue with Recommended Cookies, Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions. Your care team may include doctors who specialize in blood vessel (vascular . Venous ulcers are believed to account for approximately 70% to 90% of chronic leg ulcers. The treatment goal for venous ulcers is to reduce the edema, promote ulcer healing, and prevent a recurrence of the ulcer. As the patient is experiencing pain, have him or her score it on a scale of 0 to 10 and describe it. 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. Venous ulcers (also known as venous stasis ulcers or nonhealing wounds) are open wounds around the ankle or lower leg. Human skin grafting may be used for patients with large or refractory venous ulcers. Anna Curran. It also is expensive and requires immobilization of the patient; therefore, intermittent pneumatic compression is generally reserved for bedridden patients who cannot tolerate continuous compression therapy.24,40. Patient who needs wound care for a chronic venous stasis ulcer on the lower leg. This is often used alongside compression therapy to reduce swelling. Copyright 2010 by the American Academy of Family Physicians. Start providing wound care according to the decubitus ulcers development. They typically occur around the medial malleolus, tend to be shallow and moist, and may be malodorous (especially when poorly cared for) or painful. Start performing active or passive exercises while in bed, including occasionally rotating, flexing, and extending the feet. Impaired Skin Integrity ADVERTISEMENTS Impaired Skin Integrity Nursing Diagnosis Impaired Skin Integrity May be related to Chronic disease state. What intervention should the nurse implement to promote healing and prevent infection? The patient will demonstrate improved tissue perfusion as evidenced by adequate peripheral pulses, absence of edema, and normal skin color and temperature. Some of our partners may process your data as a part of their legitimate business interest without asking for consent. Examine for fecal and urinary incontinence. Oral antibiotics are recommended to treat venous ulcers only in cases of suspected cellulitis. A) Provide a high-calorie, high-protein diet. Caused by vein problems, these make up the majority of vascular ulcers. Associated findings include lower extremity varicosities, edema, venous dermatitis, and lipodermatosclerosis. On physical examination, venous ulcers are generally irregular and shallow (Figure 1). Further evaluation with biopsy or referral to a subspecialist is warranted for venous ulcers if healing stalls or the ulcer has an atypical appearance. Desired Outcome: The patients skin integrity will be at its best by adhering to the decubitus ulcer treatment plan, Nursing Diagnosis: Risk for Ineffective Health Maintenance related to impaired functional status, need for long-term pressure management, and the possible need for special equipment secondary to venous stasis ulcers. Elderly people are more frequently affected. Self-care such as exercise, raising the legs when sitting or lying down, or wearing compression stockings can help ease the pain of varicose veins and might prevent them from getting worse. Venous ulcers commonly occur in the gaiter area of the lower leg. She has brown hyperpigmentation on both lower legs with +2 oedema. Monitor for complications a. Thromboembolic complications due to hyperviscosity, including DVT; MI & CVA b. Hemorrhage tendency is caused by venous and capillary distention and abnormal platelet function. 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. Despite a number of studies to support its effectiveness as adjunctive therapy, and possibly as monotherapy, the cost-effectiveness of pentoxifylline has not been established. The nurse is caring for a patient with a large venous leg ulcer. He or she also performs a physical exam to look for swelling, skin changes, varicose veins, or ulcers on the leg. All Rights Reserved. Poor prognostic signs for healing include ulcer duration longer than three months, initial ulcer length of 10 cm or more, presence of lower limb arterial disease, advanced age, and elevated body mass index. Color duplex ultrasonography is recommended in patients with venous ulcers to assess for venous reflux and obstruction. 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. 11.0 Low level laser treatment 11.1 There is no evidence that low level laser therapy speeds the healing of venous leg ulcers. 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. Encourage performing simple exercises and getting out of bed to sit on a chair. Detailed Description: The study takes place in home-care in two Finnish municipality, which are similar size and staff structure and working ideology are basically the same. Compression therapy is the standard of care for venous ulcers and chronic venous insufficiency.23,45 A recent Cochrane review found that venous ulcers heal more quickly with compression therapy than without.45 Methods include inelastic, elastic, and intermittent pneumatic compression. Author disclosure: No relevant financial affiliations. 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. The patient will continue to be free of systemic or local infections as shown by the lack of profuse, foul-smelling wound exudate. Provide information about local wound care to the patient and the caregiver, and then let them watch a demonstration. Guidelines suggest cleansing of the affected leg should be kept simple, using warm tap water or saline. All Rights Reserved. August 9, 2022 Modified date: August 21, 2022. 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. Clean, persistent wounds that are not healing may benefit from palliative wound care. The pressure ulcer needs to be taken into consideration as a potential cause during the septic workup. Determine whether the client has unexplained sepsis. 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). 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. 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. . Leg elevation minimizes edema in patients with venous insufficiency and is recommended as adjunctive therapy for venous ulcers. Without clear evidence to support the use of one dressing over another, the choice of dressings for venous ulcers can be guided by cost, ease of application, and patient and physician preference.29. Characteristic differences in clinical presentation and physical examination findings can help differentiate venous ulcers from other lower extremity ulcers (Table 1).2 The diagnosis of venous ulcers is generally clinical; however, tests such as ankle-brachial index, color duplex ultrasonography, plethysmography, and venography may be helpful if the diagnosis is unclear.1518. Nursing care plans: Diagnoses, interventions, & outcomes. A wide range of dressings are available, including hydrocolloids (e.g., Duoderm), foams, hydrogels, pastes, and simple nonadherent dressings.14,28 A meta-analysis of 42 randomized controlled trials (RCTs) with a total of more than 1,000 patients showed no significant difference among dressing types.29 Furthermore, the more expensive hydrocolloid dressings were not shown to have a healing benefit over the lower-cost simple nonadherent dressings. This prevents overdistention and quickly empties the superficial and tibial veins, which reduces tissue swelling and boosts venous return. Here are three (3) nursing care plans (NCP) and nursing diagnosis for pressure ulcers (bedsores): ADVERTISEMENTS Impaired Skin Integrity Risk For Infection Risk For Ineffective Health Maintenance 1. 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. 1, 28 Goals of compression therapy. The current plan of care is focused on promoting wound healing, improving venous return, and preventing skin breakdown. Potential Nursing Interventions: (3 minimum) 1. o LPN education and scope of practice includes wound care. It can eventually lead to ulcerations or skin breakage on the skin making the person prone infections. Preamble. Examine the clients and the caregivers wound-care knowledge and skills in the area. The oldest term for pressure ulcers is decubitus, which evolved into decubitus ulcers or ischemic ulcer s in the 1950s. Severe complications include infection and malignant change. On physical examination, venous ulcers are generally irregular, shallow, and located over bony prominences. Blood flow from the legs to the heart is propelled by the pumping action of the calf muscle during flexion of the ankle (during walking, for example). Compared with compression plus a simple dressing, one study showed that advanced therapies can shorten healing time and improve healing rates.52, Skin Grafting. Two prospective randomized controlled trials reviewed the effect of sharp debridement on the healing of venous ulcers. 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. Compression stockings Wearing compression stockings all day is often the first approach to try. Buy on Amazon. The nursing management of patients with venous leg ulcers Recommendations 30 10.0 Drug treatments 10.4 There is no evidence that aspirin increases the healing of venous leg ulcers. As long as the heart can handle it, up the patients daily fluid intake to at least 1500 to 2000 mL. A 25-year-population research found that it typically takes 5 years from the diagnosis of chronic venous insufficiency to the development of an ulcer. They usually develop on the inside of the leg, between the and the ankle. 2 In some studies, 50% of patients had venous ulcers that persisted for more than 9 months, and 20% had ulcers that did not Once the ulcer has healed, continued use of compression stockings is recommended indefinitely. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Traditional conservative management of venous ulcers usually entails compression therapy, leg elevation to reduce edema, and dressings on the wound. 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. To diagnose chronic venous insufficiency, your NYU Langone doctor asks about your health history to determine the extent of your symptoms. Compression therapy. 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. Compression therapy is a standard treatment modality for initial and long-term treatment of venous ulcers in patients without concomitant arterial disease. Early venous ablation and surgical intervention to correct superficial venous reflux can improve healing and decrease recurrence rates. 2010. Leg elevation. Conclusion Enzymatic debridement using collagenase has been shown to effectively remove nonviable tissue. . They also support healthy organ function and raise well-being in general. Normally, when you get a cut or scrape, your body's healing process starts working to close the wound. Oral antibiotics are preferred, and therapy should be limited to two weeks unless evidence of wound infection persists.1, Hyperbaric Oxygen Therapy. Nursing Care of the Patient with Venous Disease - Fort HealthCare 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. We and our partners use cookies to Store and/or access information on a device. Saunders comprehensive review for the NCLEX-RN examination. Teach the patient and the caretaker to report any of the following symptoms of wound infection: fever, malaise, chills, an unpleasant odor, and purulent drainage. Inelastic. Venous ulcers are believed to account for approximately 70% to 90% of chronic leg ulcers. BACKGROUND Primary DX: venous stasis ulcer on right medial malleolus and chronic venous insufficiency. Venous incompetence and associated venous hypertension are thought to be the primary mechanisms for ulcer formation. Affect 9% of patients admitted to hospital and 23% of those admitted to nursing homes. 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. The term bedsores indicate the association of wounds with a stay in bed, which ignores the potential occurrence . Make a chart for wound care. We and our partners use data for Personalised ads and content, ad and content measurement, audience insights and product development. A more recent article on venous ulcers is available. Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). 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. In one study, patients with venous ulcers used more medical resources than those without, and their annual per-patient health expenditures were increased by $6,391 for those with Medicare and $7,030 for those with private health insurance. St. Louis, MO: Elsevier. Compression therapy is a standard treatment modality for initial and long-term treatment of venous ulcers in patients without concomitant arterial disease.1,28 Goals of compression therapy include reduced edema and pain, improved venous reflux, and enhanced healing.16 Compression therapy is useful for ulcer healing and prevention of recurrence. If not treated, increased pressure and excess fluid in the affected area can cause an open sore to form. Along with the materials given, provide written instructions. As an Amazon Associate I earn from qualifying purchases. Teach the caretaker how to properly care for the afflicted regions of the wounds if the patient is to be discharged. Granulation tissue and fibrin are often present in the ulcer base. Although intermittent pneumatic compression is more effective than no compression, its effectiveness compared with other forms of compression is unclear. Venous ulcers are large and irregularly shaped with well-defined borders and a shallow, sloping edge. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. 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. The synthetic prostacyclin iloprost is a vasodilator that inhibits platelet aggregation. 2 Irrigate in the shower or bathe in buckets or bowls lined with a clean plastic bag to reduce the risk of cross-infection. 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. 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. Ulcers are open skin sores. To prevent the infection from getting worse, it is best to discourage the youngster from scratching the sores, even if they are just mildly itchy. 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. . ANTICIPATED NURSING INTERVENTIONS Venous Stasis Ulcer = malfunctioning venous valves causing pressure in the veins to increase o Pathophysiology: Venous (or stasis) ulceration is initiated by venous hypertension that develops because of inadequate calf muscle pump action o Risk factors: Diabetes mellitus Congestive heart failure Peripheral . If necessary, recommend the physical therapy team. Poor venous return is due to damage of the valves in leg veins that facilitate the return of the blood to the heart. A deep vein thrombosis nursing care plan includes assessment of the body parts, appropriate intervention, prevention, and patient education to prevent thromboembolism. 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. Peripheral vascular disease (PVD) NCLEX review questions for nursing students! 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). mostly non-infectious condition in association with venous insufficiency and atrophy of the skin of the lower leg during long . 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. Wash the sores with the recommended cleanser to instruct the caregiver about good wound hygiene. Severe complications include cellulitis, osteomyelitis, and malignant change. Venous thromboembolism occurs majorly in two ways like pulmonary embolism and deep vein thrombosis. Ulcers heal from their edges toward their centers and their bases up. 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. By. Patient information: See related handout on venous ulcers. Any delay in care increases the risk of infection, sepsis, amputation, skin cancers, and death. 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 ).