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. Make a chart for wound care. If not treated, increased pressure and excess fluid in the affected area can cause an open sore to form. Compression therapy helps prevent reflux, decreases release of inflammatory cytokines, and reduces fluid leakage from capillaries, thereby controlling lower extremity edema and VSU recurrence. Venous ulcers are usually recurrent, and an open ulcer can persist for weeks to many years. 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. This content is owned by the AAFP. Nonhealing ulcers also raise your risk of amputation. Compression therapy reduces swelling and encourages healthy blood circulation. Granulation tissue and fibrin are typically present in the ulcer base. Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). The 10-point pain scale is a widely used, precise, and efficient pain rating measure. Venous ulcers are believed to account for approximately 70% to 90% of chronic leg ulcers. This quiz will test your knowledge on both peripheral arterial disease (PAD) and peripheral venous . Venous incompetence and associated venous hypertension are thought to be the primary mechanisms for ulcer formation. Continuous stress to the skins' integrity will eventually cause skin breakdowns. On initial assessment, it is crucial to cover the history of health: associated co-morbidities, habitual therapy, psycho-emotional state, influence of odour on social life, nutritional state, presence and intensity of pain and individual treatment preference. Copyright 2023 American Academy of Family Physicians. Leg elevation. To diagnose chronic venous insufficiency, your NYU Langone doctor asks about your health history to determine the extent of your symptoms. The most common method of inelastic compression therapy is the Unna boot, a zinc oxideimpregnated, moist bandage that hardens after application. We can define pressure ulcers as localized areas of necrosis that tend to occur when soft tissue is compressed between two planes, one bony prominences of the patient and other external surface. Even under perfect conditions, a pressure ulcer may take weeks or months to heal. Most patients have venous leg ulcer due to chronic venous insufficiency. 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. Compression therapy Treatment focuses on preventing new ulcers, controlling edema, and reducing venous hypertension through compression therapy. 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. Exercise should be encouraged to improve calf muscle pump function.35,54 Good social support and self-efficacy have also been shown to help prevent venous ulcer recurrence.35, This article updates a previous article on this topic by Collins and Seraj.55. A clinical severity score based on the CEAP (clinical, etiology, anatomy, and pathophysiology) classification system can guide the assessment of chronic venous disorders. Early venous ablation and surgical intervention to correct superficial venous reflux can improve healing and decrease recurrence rates. Intermittent Pneumatic Compression. 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 prevents overdistention and quickly empties the superficial and tibial veins, which reduces tissue swelling and boosts venous return. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. The ultimate aim is to promote evidence-based nursing care among patients with venous leg ulcer. The synthetic prostacyclin iloprost is a vasodilator that inhibits platelet aggregation. Severe complications include cellulitis, osteomyelitis, and malignant change. This causes blood to collect and pool in the vein, leading to swelling in the lower leg. Teach the caretaker how to properly care for the afflicted regions of the wounds if the patient is to be discharged. Intermittent pneumatic compression may be considered when there is generalized, refractory edema from venous insufficiency; lymphatic obstruction; and significant ulceration of the lower extremity. 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. Author: Leanne Atkin lecturer practitioner/vascular nurse consultant, School of Human and Health Sciences, University of Huddersfield and Mid Yorkshire Trust. Patients who are severely malnourished (serum albumin 2.5 mg/dl) are more likely to acquire an infection from a pressure ulcer. Further evaluation with biopsy or referral to a subspecialist is warranted if ulcer healing stalls or the ulcer has an atypical appearance. Venous stasis ulcers are wounds caused by the accumulation of fluid that commonly accompanies vein disorders. Oral antibiotics are preferred, and therapy should be limited to two weeks unless evidence of wound infection persists.1, Hyperbaric Oxygen Therapy. Conclusion 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. Pentoxifylline. 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. Nursing care plans: Diagnoses, interventions, & outcomes. Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. . Otherwise, scroll down to view this completed care plan. 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. Additionally, patients with pressure ulcers lose a lot of protein through their wound exudate and may need at least 4,000 calories per day to maintain their anabolic state. Although the main goal of treatment is ulcer healing, secondary goals include reduction of edema and prevention of recurrence. 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. Based on a clinical practice guideline on disease-oriented outcome, Based on a clinical practice guideline and clinical review on disease-oriented outcome, Based on a clinical practice guideline on disease-oriented outcome and systematic review of moderate-quality evidence, Based on a clinical practice guideline on disease-oriented outcome and review article, Based on a clinical practice guideline on disease-oriented outcome, commentary, and Cochrane review of randomized controlled trials, Based on one randomized controlled trial of more than 400 patients, Most common type of chronic lower extremity ulcer, Venous hypertension due to chronic venous insufficiency. Saunders comprehensive review for the NCLEX-RN examination. In comparison to a single long walk, short, regular walks are healthier for the extremities and the prevention of pulmonary problems. Make careful to perform range-of-motion exercises if the client is bedridden. 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. 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. Nursing Interventions 1. 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 ). It is performed with autograft (skin or cells taken from another site on the same patient), allograft (skin or cells taken from another person), or artificial skin (human skin equivalent).41,42,49 However, skin grafting generally is not effective if there is persistent edema, which is common with venous insufficiency, and the underlying venous disease is not addressed.40 A recent Cochrane review found few high-quality studies to support the use of human skin grafting for the treatment of venous ulcers.41, The role of surgery is to reduce venous reflux, hasten healing, and prevent ulcer recurrence. Risk Factors Trauma Thrombosis Inflammation Embolism They do not heal for weeks or months and sometimes longer. More analgesics should be given as needed or as directed. 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. To view the purposes they believe they have legitimate interest for, or to object to this data processing use the vendor list link below. Venous Ulcers. Venous thromboembolism occurs majorly in two ways like pulmonary embolism and deep vein thrombosis. Severe complications include infection and malignant change. Clean, persistent wounds that are not healing may benefit from palliative wound care. The student can make adjustments as soon as they receive feedback, as opposed to practicing the skill incorrectly. Buy on Amazon. When seated in a chair or bed, raise the patients legs as needed. 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.. The current plan of care is focused on promoting wound healing, improving venous return, and preventing skin breakdown. Wash the sores with the recommended cleanser to instruct the caregiver about good wound hygiene. 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. They typically occur in people with vein issues. In diabetic patients, distal symmetric neuropathy and peripheral . Compared with compression plus a simple dressing, one study showed that advanced therapies can shorten healing time and improve healing rates.52, Skin Grafting. Inelastic compression wraps, most commonly zinc oxideimpregnated Unna boots, provide high compression only during ambulation and muscle contraction. Removal of necrotic tissue and bacterial burden through debridement has long been used in wound care to enhance healing. Poor prognostic factors include large ulcer size and prolonged duration. The venous stasis ulcer is covered with a hydrocolloid dressing, . Buy on Amazon, Silvestri, L. A. Examine the patients skin all over his or her body. Chronic venous insufficiency (CVI) is a potentially debilitating disorder associated with serious complications such as lower extremity venous ulcers. 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. Slough with granulation tissue comprises the base of the wound, with moderate to heavy exudate. Shallow, exudative ulcer with granulating base and presence of fibrin; commonly located over bony prominences such as the gaiter area (over the medial malleolus; Associated findings include edema, telangiectasias, corona phlebectatica, atrophie blanche (atrophic, white scarring; Typically, a deep ulcer located on the anterior leg, distal dorsal foot, or toes; dry, fibrous base with poor granulation tissue and eschar; exposure of tendons, Associated findings include abnormal distal pulses, cold extremities, and prolonged venous filling time, Most commonly a result of diabetes mellitus or neurologic disorder, Peripheral neuropathy and concomitant peripheral arterial disease; associated foot deformities and abnormal gait with uneven distribution of foot pressure; repetitive mechanical trauma, Deep ulcer, usually on the plantar surface over a bony prominence and surrounded by callus, Usually occurs in people with limited mobility, Prolonged areas of high pressure and shear forces, Area of erythema, erosion, or ulceration; usually located over bony prominences such as the sacrum, coccyx, heels, and hips, Standard care; recommended for at least one hour per day at least six days per week to prevent recurrence, Recommended to cover ulcers and promote moist wound healing, Oral antibiotic treatment is warranted if infection is suspected, Improves healing with or without compression therapy, Early endovenous ablation to correct superficial venous reflux may increase healing rates and prevent recurrence, Primary therapy for large ulcers (larger than 25 cm, Calcium alginate with or without silver, hydrofiber with or without silver, super absorbent dressing, surgical pad, Releases free iodine when exposed to wound exudate, Hydrophilic fibers between low-adherent contact layers, Gel-forming agents in an adhesive compound laminated onto a flexible, water-resistant outer film or foam, Alginate to increase fluid absorption, with or without an adhesive border, multiple shapes and sizes, Starch polymer and water that can absorb or rehydrate, Variable absorption, silicone or nonsilicone coating, With or without an adhesive border, with or without a silicone contact layer, multiple shapes and sizes, Oil emulsion gauze, petrolatum gauze, petrolatum with bismuth gauze, Possible antimicrobial and anti-inflammatory properties; absorption based on associated dressing material or gel, Gel, paste, hydrocolloid, alginate, or adhesive foam, Chlorhexidine (Peridex), antimicrobial dyes, or hydrophobic layer, Antimicrobial dyes in a flexible or solid foam pad; hydrophobic layer available as a ribbon, pad, swab, or gel, Permeable to water vapor and oxygen but not to water or microorganisms, With or without an absorbent center or adhesive border, Collagen matrix dressing with or without silver, Silver ions (thought to be antimicrobial), Silver hydrocolloid, silver mesh, nonadhesive, calcium alginate, other forms, Silicone polymer in a nonadherent layer, moderately absorbent. 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. The patient will demonstrate increased tolerance to activity. 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. Caused by vein problems, these make up the majority of vascular 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. You will undertake clinical handover and complete a nursing care plan. Less often, patients have arterial leg ulcer resulting from peripheral arterial occlusive disease, the most common cause of which is arteriosclerosis. 17 Multicomponent compression systems comprised of various layers are more effective than single-component systems, and elastic systems are more effective than nonelastic systems.28, Important barriers to the use of compression therapy include wound drainage, pain, application or donning difficulty, physical impairment (weakness, obesity, decreased range of motion), and leg shape deformity (leading to compression material rolling down the leg or wrinkling). Nursing diagnoses handbook: An evidence-based guide to planning care. Ulcers heal from their edges toward their centers and their bases up. 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. The pressure ulcer needs to be taken into consideration as a potential cause during the septic workup. Her Waterlow Scale is 16, and her skin is intact except for the venous stasis ulcer on the right medial malleolus. The patient will verbalize an ability to adapt sufficiently to the existing condition. Other associated findings include telangiectasias, corona phlebectatica, atrophie blanche, lipodermatosclerosis, and inverted champagne-bottle deformity of the lower leg. Oral antibiotics are recommended to treat venous ulcers only in cases of suspected cellulitis. 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. Figure As the patient is experiencing pain, have him or her score it on a scale of 0 to 10 and describe it. Leg elevation when used in combination with compression therapy is also considered standard of care. On physical examination, venous ulcers are generally irregular and shallow with well-defined borders and are often located over bony prominences. Compression therapy is beneficial for venous ulcer treatment and is the standard of care. What is the most appropriate intervention for this diagnosis? SAGE Knowledge. 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). She has brown hyperpigmentation on both lower legs with +2 oedema. Patient who needs wound care for a chronic venous stasis ulcer on the lower leg. She found a passion in the ER and has stayed in this department for 30 years. Human skin grafting may be used for patients with large or refractory venous ulcers. 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. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. See permissionsforcopyrightquestions and/or permission requests. Unlike the Unna boot, elastic compression therapy methods conform to changes in leg size and sustain compression during both rest and activity. Isolating the wound from the perineal region can occasionally be challenging. Suspected osteomyelitis warrants an evaluation for arterial disease and consideration of intravenous antibiotics to treat the underlying infection. Gently remove dry skin scales from the legs, particularly around the ulcer edges to allow new growth of epithelium. Any of the lower leg veins can be affected. For patients who have difficulty donning the stockings, use of layered (additive) compression stockings; stockings with a Velcro or zippered closure; or donning aids, such as a donning butler (Figure 4), may be helpful.33, Intermittent Pneumatic Compression. Cellulitis or sepsis may develop in complicated wounds, necessitating antibiotic therapy. 34. Duplex Ultrasound Calf muscle contraction and intraluminal valves increase prograde flow while preventing blood reflux under normal circumstances. Color duplex ultrasonography is recommended in patients with venous ulcers to assess for venous reflux and obstruction. Start providing wound care according to the decubitus ulcers development. Interventions for Venous Insufficiency Encourage the patient to elevate the legs above the level of the heart several times per day. Print. Encourage deep breathing exercises and pursed lip breathing. Tiny valves in the veins can fail. Leg elevation minimizes edema in patients with venous insufficiency and is recommended as adjunctive therapy for venous ulcers. Choice of knee-high, thigh-high, toes-in, or toes-out compression stockings depends on patient preference. 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. How to Cure Venous Leg Ulcers Mark Whiteley. However, data to support its use for venous ulcers are limited.35, Overall, acute ulcers (duration of three months or less) have a 71 to 80 percent chance of healing, whereas chronic ulcers have only a 22 percent chance of healing after six months of treatment.7 Given the poor healing rates associated with chronic ulcers, surgical evaluation and management should be considered in patients with venous ulcers that are refractory to conservative therapies.48.
Lindsey Hunter Snooker, Articles N