Early endovenous ablation to correct superficial venous reflux improves ulcer healing rates. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. 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. Aspirin (300 mg per day) is effective when used with compression therapy for venous ulcers. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Copyright 2023 American Academy of Family Physicians. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. 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. Wound, Ostomy, and Continence . They do not penetrate the deep fascia. Your care team may include doctors who specialize in blood vessel (vascular . Nursing Times [online issue]; 115: 6, 24-28. Causes of Venous Leg Ulcers The speci c cause of venous ulcers is poor venous return. What intervention should the nurse implement to promote healing and prevent infection? (2020). Aspirin. Its healing can take between four and six weeks, after their initial onset (1). 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. 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. Determine whether the client has unexplained sepsis. Examine the patients vital statistics. 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. Inelastic compression therapy provides high working pressure during ambulation and muscle contraction, but no resting pressure. Examine the clients and the caregivers comprehension of the long-term nature of wound healing. There is inconsistent evidence concerning the benefits and harms of oral aspirin in the treatment of venous ulcers.40,41, Statins. 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. Venous ulcers (also known as venous stasis ulcers or nonhealing wounds) are open wounds around the ankle or lower leg. Nursing Care of the Patient with Venous Disease - Fort HealthCare Calf muscle contraction and intraluminal valves increase prograde flow while preventing blood reflux under normal circumstances. Venous leg ulcers are open, often painful, sores in the skin that take more than 2 weeks to heal. Venous stasis ulcers are wounds caused by the accumulation of fluid that commonly accompanies vein disorders. o LPN education and scope of practice includes wound care. Choice of knee-high, thigh-high, toes-in, or toes-out compression stockings depends on patient preference. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process and help nursing students pass the NCLEX exams. 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. 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. Professional Skills in Nursing: A Guide for the Common Foundation Programme. They do not heal for weeks or months and sometimes longer. Most venous ulcers occur on the leg, above the ankle. 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. Leg ulcer may be of a mixed arteriovenous origin. 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. Examine the patients skin all over his or her body. Assist client with position changes to reduce risk of orthostatic BP changes. Buy on Amazon, Silvestri, L. A. Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with reco Although intermittent pneumatic compression is more effective than no compression, its effectiveness compared with other forms of compression is unclear. If not treated, increased pressure and excess fluid in the affected area can cause an open sore to form. Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). 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. 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). 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. Chronic venous ulcers significantly impact quality of life. Your doctor may also recommend certain diagnostic imaging tests. Pentoxifylline (Trental) is an inhibitor of platelet aggregation, which reduces blood viscosity and, in turn, improves microcirculation. But they most often occur on the legs. 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. Conclusion The patient will employ behaviors that will enhance tissue perfusion. 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. Leg elevation. Mechanical debridement (wet-to-dry dressings, pulsed lavage, whirlpool) has fallen out of favor. 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. BACKGROUND Primary DX: venous stasis ulcer on right medial malleolus and chronic venous insufficiency. 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 10-point pain scale is a widely used, precise, and efficient pain rating measure. On physical examination, venous ulcers are generally irregular and shallow with well-defined borders and are often located over bony prominences. 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. They also support healthy organ function and raise well-being in general. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). RNspeak. Enzymatic debridement using collagenase has been shown to effectively remove nonviable tissue. 1 The incidence of venous ulceration increases with age, and women are three times more likely than men to develop venous leg ulcers. 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. Oral zinc therapy has been shown to decrease healing time in patients with pilonidal sinus. The treatment goal for venous ulcers is to reduce the edema, promote ulcer healing, and prevent a recurrence of the ulcer. 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. In addition, the Unna boot may lead to a foul smell from the accumulation of exudate from the ulcer, requiring frequent reapplications.2, Elastic. The ultimate aim is to promote evidence-based nursing care among patients with venous leg ulcer. There are many cellular and tissue-based products approved for the treatment of refractory venous ulcers, including allografts, animal-derived extracellular matrix products, human-derived cellular products, and human amniotic membranederived products. . Severe complications include infection and malignant change. Venous ulcers are large and irregularly shaped with well-defined borders and a shallow, sloping edge. There is currently insufficient high-quality data to support the use of topical negative pressure for venous ulcers.30 In addition, the therapy generally has not been used in clinical practice because of the challenge in administering both topical negative pressure and a compression dressing on the affected leg. Guidelines suggest cleansing of the affected leg should be kept simple, using warm tap water or saline. 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. 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. Compression therapy is a standard treatment modality for initial and long-term treatment of venous ulcers in patients without concomitant arterial disease. Over time, the breakdown of tissues combined with the lack of oxygen . Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). Nursing Diagnosis: Acute Pain related to pressure ulcers as evidenced by a pain level of 10/10, restlessness, and irritability, especially during wound care secondary to venous stasis ulcers. Stasis ulcers. On physical examination, venous ulcers are generally irregular, shallow, and located over bony prominences. Table 2 includes treatment options for venous ulcers.1622, Removal of necrotic tissue by debridement has been used to expedite wound healing. 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. See permissionsforcopyrightquestions and/or permission requests. Nursing interventions in venous, arterial and mixed leg ulcers. Tiny valves in the veins can fail. . The primary risk factors for venous ulcer development are older age, obesity, previous leg injuries, deep venous thrombosis, and phlebitis. Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). Copyright 2019 by the American Academy of Family Physicians. Once the ulcer has healed, continued use of compression stockings is recommended indefinitely. The pressure ulcer needs to be taken into consideration as a potential cause during the septic workup. Encourage deep breathing exercises and pursed lip breathing. The highest CEAP severity score is applied to patients with ulcers that are active, chronic (greater than three months' duration, and especially greater than 12 months' duration), and large (larger than 6 cm in diameter).19,20 Poor prognostic factors for venous ulcers include large size and prolonged duration.21,22. To view the purposes they believe they have legitimate interest for, or to object to this data processing use the vendor list link below. Inelastic compression wraps, most commonly zinc oxideimpregnated Unna boots, provide high compression only during ambulation and muscle contraction. 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. To evaluate whether a treatment is effective. c. It has been estimated that active VU have Chronic venous insufficiency can develop from common conditions such as varicose veins. Contrast liquid is injected into the catheter to help the veins show up better in the pictures. This usually needs to be changed 1 to 3 times a week. The patient will demonstrate increased tolerance to activity. Compression therapy helps prevent reflux, decreases release of inflammatory cytokines, and reduces fluid leakage from capillaries, thereby controlling lower extremity edema and VSU recurrence. This prevents overdistention and quickly empties the superficial and tibial veins, which reduces tissue swelling and boosts venous return. Position the patient back in his or her comfortable or desired posture. 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. Venous ulcers are the most common type of chronic lower extremity ulcers, affecting 1% to 3% of the U.S. population. This quiz will test your knowledge on both peripheral arterial disease (PAD) and peripheral venous . Peripheral vascular disease (PVD) NCLEX review questions for nursing students! 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.