Women aging from 40 to 49 years old may present symptoms of venous insufficiency. Venous ulcer, also known as stasis ulcer, is the most common etiology of lower extremity ulceration, affecting approximately 1 percent of the U.S. population. The first step is to remove any debris or dead tissue from the ulcer, wash and dry it, and apply an appropriate dressing. The synthetic prostacyclin iloprost is a vasodilator that inhibits platelet aggregation. She moved into our skilled nursing home care facility 3 days ago. 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. Patients are no longer held in hospitals until their pressure ulcers have healed; they may still require home wound care for several weeks or months. Chronic venous insufficiency (CVI) is a potentially debilitating disorder associated with serious complications such as lower extremity venous ulcers. The 10-point pain scale is a widely used, precise, and efficient pain rating measure. mostly non-infectious condition in association with venous insufficiency and atrophy of the skin of the lower leg during long . It can also occur if something, such as a deep vein thrombosis or other clot, damages the valves inside the veins. . A deep vein thrombosis nursing care plan includes assessment of the body parts, appropriate intervention, prevention, and patient education to prevent thromboembolism. 1, 28 Goals of compression therapy. PVD can be related to an arterial or venous issue. Treat venous stasis ulcers per order. If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. This usually needs to be changed 1 to 3 times a week. This prevents overdistention and quickly empties the superficial and tibial veins, which reduces tissue swelling and boosts venous return. The current plan of care is focused on promoting wound healing, improving venous return, and preventing skin breakdown. Chronic venous insufficiency can develop from common conditions such as varicose veins. This means they can't stop blood which should be headed upward to your heart from being pulled down by gravity. Saunders comprehensive review for the NCLEX-RN examination. What is the most appropriate intervention for this diagnosis? Nursing diagnoses handbook: An evidence-based guide to planning care. More analgesics should be given as needed or as directed. 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. This, again, helps in the movement of venous blood to the heart.This also prevents the build-up of liquid in the legs that leads to swelling. 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. Copyright 2010 by the American Academy of Family Physicians. Calf muscle contraction and intraluminal valves increase prograde flow while preventing blood reflux under normal circumstances. 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. Poor prognostic factors include large ulcer size and prolonged duration. Nursing Care of the Patient with Venous Disease - Fort HealthCare She has brown hyperpigmentation on both lower legs with +2 oedema. 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. Leg elevation when used in combination with compression therapy is also considered standard of care. 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. Elastic bandages (e.g., Profore) are alternatives to compression stockings. Compression therapy helps prevent reflux, decreases release of inflammatory cytokines, and reduces fluid leakage from capillaries, thereby controlling lower extremity edema and VSU recurrence. No revisions are needed. Nursing Care Plan Description Peripheral artery disease ( PAD ), also known as peripheral vascular disease ( PVD ), peripheral artery occlusive disease, and peripheral obliterative arteriopathy, is a form of arteriosclerosis involving occlusion of arteries, most commonly in the lower extremities. Venous stasis ulcers are often on the ankle or calf and are painful and red. 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. Timely specialized care is necessary to prevent complications, like infections that can become life-threatening. Inelastic compression therapy provides high working pressure during ambulation and muscle contraction, but no resting pressure. Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. To view the purposes they believe they have legitimate interest for, or to object to this data processing use the vendor list link below. A) Provide a high-calorie, high-protein diet. Sacral wounds are most susceptible to infection from urine or feces contamination due to their closeness to the perineum. 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. They typically occur in people with vein issues. Copyright 2023 American Academy of Family Physicians. 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). Choice of knee-high, thigh-high, toes-in, or toes-out compression stockings depends on patient preference. 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. 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. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. Patients who are severely malnourished (serum albumin 2.5 mg/dl) are more likely to acquire an infection from a pressure ulcer. See permissionsforcopyrightquestions and/or permission requests. 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. What intervention should the nurse implement to promote healing and prevent infection? An example of data being processed may be a unique identifier stored in a cookie. Medical-surgical nursing: Concepts for interprofessional collaborative care. Valves in the veins prevent backflow, but failure of the valves results in increased pressure in the veins. The patient will maintain their normal body temperature. Continue with Recommended Cookies, Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions. Aspirin (300 mg per day) is effective when used with compression therapy for 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. Preamble. Severe complications include infection and malignant change. On physical examination, venous ulcers are generally irregular, shallow, and located over bony prominences. Venous ulcers are large and irregularly shaped with well-defined borders and a shallow, sloping edge. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. 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. Dressings are often used under compression bandages to promote faster healing and prevent adherence of the bandage to the ulcer. VLUs are the result of chronic venous insufficiency (CVI) in the legs. Pressure Ulcer/Pressure Injury Nursing Care Plan. The disease has shown a worldwide rising incidence as the worlds population ages. Immobile clients will need to be repositioned frequently to reduce the chance of breakdown in the intact parts. 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. RNspeak. 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. Intermittent Pneumatic Compression. Start performing active or passive exercises while in bed, including occasionally rotating, flexing, and extending the feet. 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. 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 student can make adjustments as soon as they receive feedback, as opposed to practicing the skill incorrectly. 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. They do not penetrate the deep fascia. 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. Along with the materials given, provide written instructions. Oral antibiotics are preferred, and therapy should be limited to two weeks unless evidence of wound infection persists.1, Hyperbaric Oxygen Therapy. She received her RN license in 1997. Other findings suggestive of venous ulcers include location over bony prominences such as the gaiter area (over the medial malleolus; Figure 1), telangiectasias, corona phlebectatica (abnormally dilated veins around the ankle and foot), atrophie blanche (atrophic, white scarring; Figure 2), lipodermatosclerosis (Figure 3), and inverted champagne-bottle deformity of the lower leg.1,5, Although venous ulcers are the most common type of chronic lower extremity ulcers, the differential diagnosis should include arterial occlusive disease (or a combination of arterial and venous disease), ulceration caused by diabetic neuropathy, malignancy, pyoderma gangrenosum, and other inflammatory ulcers.13 Among chronic ulcers refractory to vascular intervention, 20% to 23% may be caused by vasculitis, sickle cell disease, pyoderma gangrenosum, calciphylaxis, or autoimmune disease.14, Initial noninvasive imaging with comprehensive venous duplex ultrasonography, arterial pulse examination, and measurement of ankle-brachial index is recommended for all patients with suspected venous ulcers.1 Color duplex ultrasonography is recommended to assess for deep and superficial venous reflux and obstruction.1,15 Because standard therapy for venous ulcers can be harmful in patients with ischemia, additional ultrasound evaluation to assess arterial blood flow is indicated when the ankle-brachial index is abnormal and in the presence of certain comorbid conditions such as diabetes mellitus, chronic kidney disease, or other conditions that lead to vascular calcification.1 Further evaluation with biopsy or referral to a subspecialist is warranted if ulcer healing stalls or the ulcer has an atypical appearance.1,5, Treatment options for venous ulcers include conservative management, mechanical modalities, medications, advanced wound therapy, and surgical options. Removal of necrotic tissue and bacterial burden through debridement has long been used in wound care to enhance healing. It allows time for the nursing team to evaluate the wound and the condition of the leg. Physically restricting circulation reduces blood flow and heightens venous stasis in the pelvic, popliteal, and leg veins, causing swelling and discomfort to worsen. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Table 2 includes treatment options for venous ulcers.1622, Removal of necrotic tissue by debridement has been used to expedite wound healing. Dressings are recommended to cover venous ulcers and promote moist wound healing. 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. 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. Wash the sores with the recommended cleanser to instruct the caregiver about good wound hygiene. Oral antibiotics are recommended to treat venous ulcers only in cases of suspected cellulitis. Compression stockings Wearing compression stockings all day is often the first approach to try. Debridement may be sharp (e.g., using curette or scissors), enzymatic, mechanical, biologic (i.e., using larvae), or autolytic. Buy on Amazon. Slough with granulation tissue comprises the base of the wound, with moderate to heavy exudate. Contrast liquid is injected into the catheter to help the veins show up better in the pictures. 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. Venous ulcers are believed to account for approximately 70% to 90% of chronic leg ulcers. Author: Leanne Atkin lecturer practitioner/vascular nurse consultant, School of Human and Health Sciences, University of Huddersfield and Mid Yorkshire Trust. Over time, as the veins become increasingly weak, they have more trouble sending blood to the heart. They can affect any area of the skin. Examine the clients and the caregivers comprehension of the long-term nature of wound healing. Other associated findings include telangiectasias, corona phlebectatica, atrophie blanche, lipodermatosclerosis, and inverted champagne-bottle deformity of the lower leg. All Rights Reserved. Compression therapy is a standard treatment modality for initial and long-term treatment of venous ulcers in patients without concomitant arterial disease. 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. 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. The most common method of inelastic compression therapy is the Unna boot, a zinc oxideimpregnated, moist bandage that hardens after application. Dressings are beneficial for venous ulcer healing, but no dressing has been shown to be superior. It might be necessary to apply the prescription antibiotic cream or ointment directly to the affected area. Debridement may be sharp, enzymatic, mechanical, larval, or autolytic. The recurrence of an ulcer in the same area is highly suggestive of venous ulcer. 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. 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. It can related to the age as well as the body surface of the . This quiz will test your knowledge on both peripheral arterial disease (PAD) and peripheral venous . To encourage ideal patient comfort and lessen agitation/anxiety. Otherwise, scroll down to view this completed care plan. 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. 2010. 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 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. If you have a venous leg ulcer, you may also have: swollen ankles (oedema) discolouration or darkening of the skin around the ulcer 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. Isolating the wound from the perineal region can occasionally be challenging. Venous stasis ulcers are wounds caused by the accumulation of fluid that commonly accompanies vein disorders. Ulcers heal from their edges toward their centers and their bases up. The patient will demonstrate improved tissue perfusion as evidenced by adequate peripheral pulses, absence of edema, and normal skin color and temperature. Most venous ulcers occur on the leg, above the ankle. Manage Settings 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. Some evidence supports the use of cadexomer iodine to improve healing of venous ulcers, but evidence for other agents is lacking.38. 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.. These ulcers are caused by poor circulation, diabetes and other conditions. . The consent submitted will only be used for data processing originating from this website. In diabetic patients, distal symmetric neuropathy and peripheral . Copyright 2023 American Academy of Family Physicians. List of orders: 1.Enalapril 10 mg 1 tab daily 2.Furosemide 40 mg 1 tab daily in the morning 3.K-lor 20 meq 1 tab daily in the morning 4.TED hose on in AM and off in PM 5.Regular diet, NAS 6.Refer to Wound care Services 7.I & O every shift 8.Vital signs every shift 9.Refer to Social Services for safe discharge planning QUESTIONS BELOW ARE NOT FOR Anna Curran. Severe complications include cellulitis, osteomyelitis, and malignant change. Surgical management may be considered for ulcers. Patients experience poor quality of life as a result of pain and immobility, and they require advanced levels of wound care. This provides the best conditions for the ulcer to heal. Compression therapy Treatment focuses on preventing new ulcers, controlling edema, and reducing venous hypertension through compression therapy. Patient who needs wound care for a chronic venous stasis ulcer on the lower leg. Although numerous treatment methods are available, they have variable effectiveness and limited data to support their use. Venous incompetence and associated venous hypertension are thought to be the primary mechanisms for ulcer formation. 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. The treatment goal for venous ulcers is to reduce the edema, promote ulcer healing, and prevent a recurrence of the ulcer. (2020). Further evaluation with biopsy or referral to a subspecialist is warranted for venous ulcers if healing stalls or the ulcer has an atypical appearance. Compression therapy reduces swelling and encourages healthy blood circulation. Pentoxifylline. . The oldest term for pressure ulcers is decubitus, which evolved into decubitus ulcers or ischemic ulcer s in the 1950s. Make a chart for wound care. Venous hypertension as a result of venous reflux (incompetence) or obstruction is thought to be the primary underlying mechanism for venous ulcer formation. Examine the clients and the caregivers wound-care knowledge and skills in the area. 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. The patient will employ behaviors that will enhance tissue perfusion. Venous Ulcers. There is inconsistent evidence concerning the benefits and harms of oral aspirin in the treatment of venous ulcers.40,41, Statins. 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). Citation: Atkin L (2019) Venous leg ulcer prevention 1: identifying patients who are at risk. such as venous ulcers and lymphoedema, concomitant bacterial and fungal colonisation or infection may be present. Venous ulcers (also known as venous stasis ulcers or nonhealing wounds) are open wounds around the ankle or lower leg. Nursing Times [online issue]; 115: 6, 24-28. The primary risk factors for venous ulcer development are older age, obesity, previous leg injuries, deep venous thrombosis, and phlebitis. Arterial pulse examination and measurement of ankle-brachial index are recommended for all patients with suspected venous ulcers. Buy on Amazon, Silvestri, L. A. Venous ulcers are usually recurrent, and an open ulcer can persist for weeks to many years. Surgical management may be considered for ulcers that are large in size, of prolonged duration, or refractory to conservative measures. Poor venous return is due to damage of the valves in leg veins that facilitate the return of the blood to the heart.
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