Copyright 2023 American Academy of Family Physicians. This article has been double-blind peer reviewed The disease has shown a worldwide rising incidence as the worlds population ages. It has been estimated that active VU have 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. 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. Nursing care planning and management for ineffective tissue perfusion is directed at removing vasoconstricting factors, improving peripheral blood flow, reducing metabolic demands on the body, patient's participation, and understanding the disease process and its treatment, and preventing complications. Valves in the veins prevent backflow, but failure of the valves results in increased pressure in the veins. Stockings or bandages can be used; however, elastic wraps (e.g., Ace wraps) are not recommended because they do not provide enough pressure.45 Compression stockings are graded, with the greatest pressure at the ankle and gradually decreasing pressure toward the knee and thigh (pressure should be at least 20 to 30 mm Hg, and preferably 30 to 44 mm Hg). Tiny valves in the veins can fail. Risk factors for the development of venous ulcers include age 55 years or older, family history of chronic venous insufficiency, higher body mass index, history of pulmonary embolism or superficial/deep venous thrombosis, lower extremity skeletal or joint disease, higher number of pregnancies, parental history of ankle ulcers, physical inactivity, history of ulcers, severe lipodermatosclerosis, and venous reflux in deep veins. Venous stasis ulcers are often on the ankle or calf and are painful and red. Nursing care plans: Diagnoses, interventions, & outcomes. Provide information about local wound care to the patient and the caregiver, and then let them watch a demonstration. Encouraging the patient through physical therapy to get out of bed and sit down and carry out the necessary exercises. The patient verbalized 2 exercise regimens to improve venous return to help promote wound healing within 12-hour shift by elevated her legs and had antiembolism stockings on all day, continue to reevaluate or educate patient. Patients treated with debridement at each physician's office visit had significant reduction in wound size compared with those not treated with debridement.20. Nursing Care Plan for: Impaired Skin Integrity, Risk for Skin Breakdown, Altered Skin Integrity, and Risk for Pressure Ulcers. Nursing Interventions 1. 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. Timely specialized care is necessary to prevent complications, like infections that can become life-threatening. Preamble. Signs of chronic venous insufficiency, such as: The patient will verbalize an understanding of the aspects of home care for venous stasis ulcers such as pressure relief and wound management. Venous ulcers are open skin lesions that occur in an area affected by venous hypertension.1 The prevalence of venous ulcers in the United States ranges from 1% to 3%.2,3 In the United States, 10% to 35% of adults have chronic venous insufficiency, and 4% of adults 65 years or older have venous ulcers.4 Risk factors for venous ulcers include age 55 years or older, family history of chronic venous insufficiency, higher body mass index, history of pulmonary embolism or superficial/deep venous thrombosis, lower extremity skeletal or joint disease, higher number of pregnancies, parental history of ankle ulcers, physical inactivity, history of ulcers, severe lipodermatosclerosis (panniculitis that leads to skin induration or hardening, increased pigmentation, swelling, and redness), and venous reflux in deep veins.5 Poor prognostic signs for healing include ulcer duration longer than three months, ulcer length of 10 cm (3.9 in) or more, presence of lower limb arterial disease, advanced age, and elevated body mass index.6, Complications of venous ulcers include infections and skin cancers such as squamous cell carcinoma.7,8 Venous ulcers are a major cause of morbidity and can lead to high medical costs.3 Economic and personal impacts include frequent visits to health care facilities, loss of productivity, increased disability, discomfort, need for dressing changes, and recurrent hospitalizations. These ulcers are caused by poor circulation, diabetes and other conditions. After administering the analgesic, give the patient 30 to 60 minutes to rate their acute pain again. What is the most appropriate intervention for this diagnosis? Otherwise, scroll down to view this completed care plan. Early venous ablation and surgical intervention to correct superficial venous reflux can improve healing and decrease recurrence rates. We and our partners use data for Personalised ads and content, ad and content measurement, audience insights and product development. Associated findings include lower extremity varicosities, edema, venous dermatitis, and lipodermatosclerosis. She has worked in Medical-Surgical, Telemetry, ICU and the ER. 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). 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. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). Contraindications to compression therapy include significant arterial insufficiency and uncompensated congestive heart failure.29, Elastic. Goals and Outcomes The student can make adjustments as soon as they receive feedback, as opposed to practicing the skill incorrectly. Venous incompetence and associated venous hypertension are thought to be the primary mechanisms for ulcer formation. Venous stasis commonly presents as a dull ache or pain in the lower extremities, swelling that subsides with elevation, eczematous changes of the surrounding skin, and varicose veins.2 Venous ulcers often occur over bony prominences, particularly the gaiter area (over the medial malleolus). Intermittent pneumatic compression may be considered when there is generalized, refractory edema from venous insufficiency; lymphatic obstruction; and significant ulceration of the lower extremity. 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. Encourage the patient to refrain from scratching the injured regions. As soon as the client is allowed to leave the bed, assist with a progressive return to ambulation. 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. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. The primary risk factors for venous ulcer development are older age, obesity, previous leg injuries, deep venous thrombosis, and phlebitis. Aspirin. Your care team may include doctors who specialize in blood vessel (vascular . Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. Leg elevation minimizes edema in patients with venous insufficiency and is recommended as adjunctive therapy for venous ulcers. Compression therapy Treatment focuses on preventing new ulcers, controlling edema, and reducing venous hypertension through compression therapy. See permissionsforcopyrightquestions and/or permission requests. Make careful to perform range-of-motion exercises if the client is bedridden. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. The patient will demonstrate increased tolerance to activity. The healing capacity of the pressure damage is maximized by providing the appropriate wound care following the stage of the decubitus ulcer. The patient will demonstrate improved tissue perfusion as evidenced by adequate peripheral pulses, absence of edema, and normal skin color and temperature. Evidence has not shown that any one dressing is superior when used with appropriate compression therapy. Caused by vein problems, these make up the majority of vascular ulcers. 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.. Venous stasis ulcers are wounds that are slow to heal. 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. Any delay in care increases the risk of infection, sepsis, amputation, skin cancers, and death. Along with the materials given, provide written instructions. Your doctor may also recommend certain diagnostic imaging tests. 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. Some evidence supports the use of cadexomer iodine to improve healing of venous ulcers, but evidence for other agents is lacking.38. Normally, when you get a cut or scrape, your body's healing process starts working to close the wound. They typically occur around the medial malleolus, tend to be shallow and moist, and may be malodorous (especially when poorly cared for) or painful. (2020). The first step is to remove any debris or dead tissue from the ulcer, wash and dry it, and apply an appropriate dressing. St. Louis, MO: Elsevier. For wound closure to be effective, leg edema must be reduced. Wash the sores with the recommended cleanser to instruct the caregiver about good wound hygiene. What intervention should the nurse implement to promote healing and prevent infection? A deep vein thrombosis nursing care plan includes assessment of the body parts, appropriate intervention, prevention, and patient education to prevent thromboembolism. Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). SAGE Knowledge. It can related to the age as well as the body surface of the . Copyright 2023 American Academy of Family Physicians. When seated in a chair or bed, raise the patients legs as needed. Medical-surgical nursing: Concepts for interprofessional collaborative care. Stasis ulcers. They typically occur in people with vein issues. The patient will employ behaviors that will enhance tissue perfusion. Although intermittent pneumatic compression is more effective than no compression, its effectiveness compared with other forms of compression is unclear. Leg elevation when used in combination with compression therapy is also considered standard of care. Author: Leanne Atkin lecturer practitioner/vascular nurse consultant, School of Human and Health Sciences, University of Huddersfield and Mid Yorkshire Trust. 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. In comparison to a single long walk, short, regular walks are healthier for the extremities and the prevention of pulmonary problems. arterial pulse examination, and measurement of ankle-brachial index is recommended for all patients with suspected venous ulcers. 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. How to Cure Venous Leg Ulcers Mark Whiteley. Compression stockings are removed at night, and should be replaced every six months because they lose pressure with regular washing.2. Learn how your comment data is processed. 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. Statins have vasoactive and anti-inflammatory effects. 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. Some of our partners may process your data as a part of their legitimate business interest without asking for consent. Severe complications include infection and malignant change. The consent submitted will only be used for data processing originating from this website. 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. Peripheral vascular disease (PVD) NCLEX review questions for nursing students! Surgical management may be considered for ulcers. Even under perfect conditions, a pressure ulcer may take weeks or months to heal. Of the diagnoses developed, 62 are included in ICNP and 23 are new diagnoses, not included. 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.. 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. 2 Irrigate in the shower or bathe in buckets or bowls lined with a clean plastic bag to reduce the risk of cross-infection. Venous ulcers are large and irregularly shaped with well-defined borders and a shallow, sloping edge. 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. It can be used as secondary therapy for ulcers that do not heal with standard care.22, Like conservative therapies, the goal of operative and endovascular management of venous ulcers (i.e., endovenous ablation, ligation, subfascial endoscopic perforator surgery, and sclerotherapy) is to improve healing and prevent ulcer recurrence. Chronic venous insufficiency can develop from common conditions such as varicose veins. Enzymatic debridement using collagenase has been shown to effectively remove nonviable tissue. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. The synthetic prostacyclin iloprost is a vasodilator that inhibits platelet aggregation. 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. Over time, the breakdown of tissues combined with the lack of oxygen . Other findings include lower extremity varicosities; edema; venous dermatitis associated with hyperpigmentation and hemosiderosis or hemoglobin deposition in the skin; and lipodermatosclerosis associated with thickening and fibrosis of normal adipose tissue under skin. Risk Factors Trauma Thrombosis Inflammation Embolism 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. They usually develop on the inside of the leg, between the and the ankle. All Rights Reserved. There are numerous online resources for lay education. Surgical options for treatment of venous insufficiency include ablation of the saphenous vein; interruption of the perforating veins with subfascial endoscopic surgery; treatment of iliac vein obstruction with stenting; and removal of incompetent superficial veins with phlebectomy, stripping, sclerotherapy, or laser therapy.19,35,40, In one study, ablative superficial venous surgery reduced the rate of venous ulcer recurrence at 12 months by more than one half, compared with compression therapy alone.42 In another study, surgical management led to an ulcer healing rate of 88 percent, with only a 13 percent recurrence rate over 10 months.43 There is no evidence demonstrating the superiority of surgery over medical management; however, evaluation for possible surgical intervention should occur early.44.