nursing care plan for venous stasis ulcer

This content is owned by the AAFP. Normally, when you get a cut or scrape, your body's healing process starts working to close the wound. Figure For wound closure to be effective, leg edema must be reduced. Chronic venous insufficiency can develop from common conditions such as varicose veins. In diabetic patients, distal symmetric neuropathy and peripheral . Conclusion Patients treated with debridement at each physician's office visit had significant reduction in wound size compared with those not treated with debridement.20. She moved into our skilled nursing home care facility 3 days ago. Start providing wound care according to the decubitus ulcers development. These venoactive drugs theoretically work by improving venous tone and decreasing capillary permeability. As soon as the client is allowed to leave the bed, assist with a progressive return to ambulation. They also support healthy organ function and raise well-being in general. 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. Nursing Times [online issue]; 115: 6, 24-28. Ulcers are open skin sores. Most venous ulcers occur on the leg, above the ankle. 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.. Assist client with position changes to reduce risk of orthostatic BP changes. Enzymatic debridement using collagenase has been shown to effectively remove nonviable tissue. Like pentoxifylline therapy, aspirin (300 mg per day) combined with compression therapy has been shown to increase ulcer healing time and reduce ulcer size, compared with compression therapy alone.32 In general, adding aspirin therapy to compression bandages is recommended in the treatment of venous ulcers as long as there are no contraindications to its use. Nursing Care of the Patient with Venous Disease - Fort HealthCare 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. Granulation tissue and fibrin are often present in the ulcer base. 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. What intervention should the nurse implement to promote healing and prevent infection? To encourage numbing of the pain and patient comfort without the danger of an overdose. Most patients have venous leg ulcer due to chronic venous insufficiency. Traditional negative pressure wound therapy systems are bulky and cannot be used with compression therapy. The venous stasis ulcer is covered with a hydrocolloid dressing, . The patient will verbalize an ability to adapt sufficiently to the existing condition. Slough with granulation tissue comprises the base of the wound, with moderate to heavy exudate. Copyright 2010 by the American Academy of Family Physicians. The most common method of inelastic compression therapy is the Unna boot, a zinc oxideimpregnated, moist bandage that hardens after application. What is the most appropriate intervention for this diagnosis? Inelastic. Chronic venous insufficiency (CVI) is a potentially debilitating disorder associated with serious complications such as lower extremity venous ulcers. Sacral wounds are most susceptible to infection from urine or feces contamination due to their closeness to the perineum. Unlike the Unna boot, elastic compression therapy methods conform to changes in leg size and sustain compression during both rest and activity. Anna Curran. Leg elevation. All Rights Reserved. Evidence has not shown that any one dressing is superior when used with appropriate compression therapy.18 Types of dressings are summarized in Table 3.37, Topical antiseptics, including cadexomer iodine (Iodosorb), povidone-iodine (Betadine), peroxide-based preparations, honey-based preparations, and silver, have been used to treat venous ulcers. As fluid leaking from dysfunctional veins accumulates into surrounding tissues, the flesh surrounding the area becomes irritated, inflamed, and begins to break down. Venous ulcers are the most common lower extremity wounds in the United States. Examine for fecal and urinary incontinence. Peripheral vascular disease is the impediment of blood flow within the peripheral vascular system due to vessel damage, which mainly affects the lower extremities. St. Louis, MO: Elsevier. Some evidence supports the use of cadexomer iodine to improve healing of venous ulcers, but evidence for other agents is lacking.38. 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 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 ). Granulation tissue and fibrin are typically present in the ulcer base. 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). 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. Nursing Care Plan for: Impaired Skin Integrity, Risk for Skin Breakdown, Altered Skin Integrity, and Risk for Pressure Ulcers. Compression stockings Wearing compression stockings all day is often the first approach to try. C) Irrigate the wound with hydrogen peroxide once daily. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. 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. 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. Contrast liquid is injected into the catheter to help the veins show up better in the pictures. Two prospective randomized controlled trials reviewed the effect of sharp debridement on the healing of venous ulcers. Duplex Ultrasound The nurse is caring for a patient with a large venous leg ulcer. 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. Intermittent pneumatic compression may be considered when there is generalized, refractory edema from venous insufficiency; lymphatic obstruction; and significant ulceration of the lower extremity. Venous stasis ulcers are wounds caused by the accumulation of fluid that commonly accompanies vein disorders. The 10-point pain scale is a widely used, precise, and efficient pain rating measure. Clean, persistent wounds that are not healing may benefit from palliative wound care. Pentoxifylline (Trental) is effective when used with compression therapy for venous ulcers, and may be useful as monotherapy. Any delay in care increases the risk of infection, sepsis, amputation, skin cancers, and death. Compression therapy helps prevent reflux, decreases release of inflammatory cytokines, and reduces fluid leakage from capillaries, thereby controlling lower extremity edema and VSU recurrence. 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. Because of limited evidence and no long-term benefit, hyperbaric oxygen therapy is not recommended for treatment of venous ulcers.47, Negative Pressure Wound Therapy. Patient information: See related handout on venous ulcers. Removal of necrotic tissue and bacterial burden through debridement has long been used in wound care to enhance healing. Compression therapy is a standard treatment modality for initial and long-term treatment of venous ulcers in patients without concomitant arterial disease. Color duplex ultrasonography is recommended in patients with venous ulcers to assess for venous reflux and obstruction. Debridement may be sharp, enzymatic, mechanical, larval, or autolytic. To evaluate whether a treatment is effective. This content is owned by the AAFP. Human skin grafting may be used for patients with large or refractory venous ulcers. Otherwise, scroll down to view this completed care plan. Venous ulcers are believed to account for approximately 70% to 90% of chronic leg ulcers. Its essential to keep the impacted areas clean by washing them with the recommended cleanser. Abstract. 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. Early venous ablation and surgical intervention to correct superficial venous reflux can improve healing and decrease recurrence rates. 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. 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. St. Louis, MO: Elsevier. 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. Chronic Renal Failure CRF Nursing NCLEX Review and Nursing Care Plan, Newborn Hypoglycemia Nursing Diagnosis and Nursing Care Plan, Strep Throat Nursing Diagnosis and Care Plan. Aspirin (300 mg per day) is effective when used with compression therapy for venous ulcers. 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. Pentoxifylline. Venous ulcers, or stasis ulcers, account for 80 percent of lower extremity ulcerations.1 Less common etiologies for lower extremity ulcerations include arterial insufficiency; prolonged pressure; diabetic neuropathy; and systemic illness such as rheumatoid arthritis, vasculitis, osteomyelitis, and skin malignancy.2 The overall prevalence of venous ulcers in the United States is approximately 1 percent.1 Venous ulcers are more common in women and older persons.36 The primary risk factors are older age, obesity, previous leg injuries, deep venous thrombosis, and phlebitis.7, Venous ulcers are often recurrent, and open ulcers can persist from weeks to many years.810 Severe complications include cellulitis, osteomyelitis, and malignant change.3 Although the overall prevalence is relatively low, the refractory nature of these ulcers increase the risk of morbidity and mortality, and have a significant impact on patient quality of life.11,12 The financial burden of venous ulcers is estimated to be $2 billion per year in the United States.13,14, The pathophysiology of venous ulcers is not entirely clear. 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. 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. They do not penetrate the deep fascia. Over time, the breakdown of tissues combined with the lack of oxygen . Copyright 2023 American Academy of Family Physicians. 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. Venous incompetence and associated venous hypertension are thought to be the primary mechanisms for ulcer formation. Although numerous treatment methods are available, they have variable effectiveness and limited data to support their use. 2 Irrigate in the shower or bathe in buckets or bowls lined with a clean plastic bag to reduce the risk of cross-infection. 2 In some studies, 50% of patients had venous ulcers that persisted for more than 9 months, and 20% had ulcers that did . . 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 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. It can eventually lead to ulcerations or skin breakage on the skin making the person prone infections. The patient will demonstrate improved tissue perfusion as evidenced by adequate peripheral pulses, absence of edema, and normal skin color and temperature. 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. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). Professional Skills in Nursing: A Guide for the Common Foundation Programme. Nonhealing ulcers also raise your risk of amputation. Valves in the veins prevent backflow, but failure of the valves results in increased pressure in the veins. 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. A group of nurse judges experienced in the treatment of venous ulcer validated 84 nursing diagnoses and outcomes, and 306 interventions. On physical examination, venous ulcers are generally irregular, shallow, and located over bony prominences. Compression therapy Treatment focuses on preventing new ulcers, controlling edema, and reducing venous hypertension through compression therapy. Make a chart for wound care. See permissionsforcopyrightquestions and/or permission requests. Cellulitis or sepsis may develop in complicated wounds, necessitating antibiotic therapy. 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. Tell the healthcare provider if you have ever had an allergic reaction to contrast liquid. Four trials showed that pentoxifylline alone improved healing compared with placebo alone.19 Common adverse effects of pentoxifylline include nausea, gastrointestinal discomfort, headaches, dizziness, and prolonged bleeding time. August 9, 2022 Modified date: August 21, 2022. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). 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. Encourage performing simple exercises and getting out of bed to sit on a chair. 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. Learn how your comment data is processed. Traditional conservative management of venous ulcers usually entails compression therapy, leg elevation to reduce edema, and dressings on the wound. Venous ulcers (also known as venous stasis ulcers or nonhealing wounds) are open wounds around the ankle or lower leg. Pentoxifylline (Trental) is an inhibitor of platelet aggregation, which reduces blood viscosity and, in turn, improves microcirculation. 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. Venous leg ulcers are open, often painful, sores in the skin that take more than 2 weeks to heal. Further evaluation with biopsy or referral to a subspecialist is warranted for venous ulcers if healing stalls or the ulcer has an atypical appearance. arterial pulse examination, and measurement of ankle-brachial index is recommended for all patients with suspected venous ulcers. 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. The patient will continue to be free of systemic or local infections as shown by the lack of profuse, foul-smelling wound exudate. Choice of knee-high, thigh-high, toes-in, or toes-out compression stockings depends on patient preference. Examine the clients and the caregivers comprehension of the long-term nature of wound healing. Preamble. The first step is to remove any debris or dead tissue from the ulcer, wash and dry it, and apply an appropriate dressing. To view the purposes they believe they have legitimate interest for, or to object to this data processing use the vendor list link below. Your doctor may also recommend certain diagnostic imaging tests. It can related to the age as well as the body surface of the . It might be necessary to apply the prescription antibiotic cream or ointment directly to the affected area. Dressings are recommended to cover venous ulcers and promote moist wound healing. Encouraging the patient through physical therapy to get out of bed and sit down and carry out the necessary exercises. Venous hypertension as a result of venous reflux (incompetence) or obstruction is thought to be the primary underlying mechanism for venous ulcer formation. Patients typically experience no pain to mild pain in the extremity, which is relieved with elevation. Historically, trials comparing venous intervention plus compression with compression alone for venous ulcers showed that surgery reduced recurrence but did not improve healing.53 Recent trials show faster healing of venous ulcers when early endovenous ablation to correct superficial venous reflux is performed in conjunction with compression therapy, compared with compression alone or with delayed intervention if the ulcer did not heal after six months.21 The most common complications of endovenous ablation were pain and deep venous thrombosis.21, The recurrence rate of venous ulcers has been reported as high as 70%.35 Venous intervention and long-term use of compression stockings are important for preventing recurrence, and leg elevation can be beneficial when used with compression stockings. A recent meta-analysis showed that elastic compression therapy is more effective than inelastic therapy.46 In addition, high compression has been proven more effective than low compression, and multilayer bandages are more effective than single layer.23,45,47 The disadvantage of multilayer compression bandages is that they require skilled application in the physician's office one or two times per week, depending on drainage. Patients who are severely malnourished (serum albumin 2.5 mg/dl) are more likely to acquire an infection from a pressure ulcer. 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. such as venous ulcers and lymphoedema, concomitant bacterial and fungal colonisation or infection may be present. It allows time for the nursing team to evaluate the wound and the condition of the leg. This is often used alongside compression therapy to reduce swelling. Nursing diagnoses handbook: An evidence-based guide to planning care. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). Aspirin. Start performing active or passive exercises while in bed, including occasionally rotating, flexing, and extending the feet.

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