Severe complications include infection and malignant change. Venous thromboembolism occurs majorly in two ways like pulmonary embolism and deep vein thrombosis. But they most often occur on the legs. In addition, the Unna boot may lead to a foul smell from the accumulation of exudate from the ulcer, requiring frequent reapplications.2, Elastic. These measures facilitate venous return and help reduce edema. It allows time for the nursing team to evaluate the wound and the condition of the leg. To assess the size and extent of decubitus ulcers, as well as any affected areas that need specific care or wound treatment. Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. This is often used alongside compression therapy to reduce swelling. Print. Compression therapy has been proven beneficial for venous ulcer treatment and is the standard of care. This article has been double-blind peer reviewed 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. The patient will employ behaviors that will enhance tissue perfusion. If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Pentoxifylline (Trental) is an inhibitor of platelet aggregation, which reduces blood viscosity and, in turn, improves microcirculation. Venous ulcers (also known as venous stasis ulcers or nonhealing wounds) are open wounds around the ankle or lower leg. The rationale for cleaning leg ulcers is the removal of any dry skin due to the wearing of bandages, it also removes any build-up of emollients that are being used. (2020). Author: Leanne Atkin lecturer practitioner/vascular nurse consultant, School of Human and Health Sciences, University of Huddersfield and Mid Yorkshire Trust. A) Provide a high-calorie, high-protein diet. 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. 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. Saunders comprehensive review for the NCLEX-RN examination. Mechanical debridement (wet-to-dry dressings, pulsed lavage, whirlpool) has fallen out of favor. Nursing Care of the Patient with Venous Disease - Fort HealthCare It is performed with autograft (skin or cells taken from another site on the same patient), allograft (skin or cells taken from another person), or artificial skin (human skin equivalent).41,42,49 However, skin grafting generally is not effective if there is persistent edema, which is common with venous insufficiency, and the underlying venous disease is not addressed.40 A recent Cochrane review found few high-quality studies to support the use of human skin grafting for the treatment of venous ulcers.41, The role of surgery is to reduce venous reflux, hasten healing, and prevent ulcer recurrence. 17 These ulcers are caused by poor circulation, diabetes and other conditions. 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. Traditional conservative management of venous ulcers usually entails compression therapy, leg elevation to reduce edema, and dressings on the wound. Debridement may be sharp, enzymatic, mechanical, larval, or autolytic. 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. As fluid leaking from dysfunctional veins accumulates into surrounding tissues, the flesh surrounding the area becomes irritated, inflamed, and begins to break down. 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. Early endovenous ablation to correct superficial venous reflux improves ulcer healing rates. BACKGROUND Primary DX: venous stasis ulcer on right medial malleolus and chronic venous insufficiency. 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. 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.. 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. History of superficial or deep venous thrombosis, pulmonary embolism, and ulcer recurrence should be ascertained with comorbid conditions. To view the purposes they believe they have legitimate interest for, or to object to this data processing use the vendor list link below. 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. 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 The 10-point pain scale is a widely used, precise, and efficient pain rating measure. As an Amazon Associate I earn from qualifying purchases. The first step is to remove any debris or dead tissue from the ulcer, wash and dry it, and apply an appropriate dressing. 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. Calf muscle contraction and intraluminal valves increase prograde flow while preventing blood reflux under normal circumstances. 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. Encourage performing simple exercises and getting out of bed to sit on a chair. She has brown hyperpigmentation on both lower legs with +2 oedema. Specific written plans are necessary for long-term management to improve treatment adherence. Venous ulcers are the most common type of chronic lower extremity ulcers, affecting 1% to 3% of the U.S. population. St. Louis, MO: Elsevier. 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. We and our partners use cookies to Store and/or access information on a device. Venous ulcers are large and irregularly shaped with well-defined borders and a shallow, sloping edge. 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. Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). The recurrence of an ulcer in the same area is highly suggestive of venous ulcer. Patients who are severely malnourished (serum albumin 2.5 mg/dl) are more likely to acquire an infection from a pressure ulcer. Medical-surgical nursing: Concepts for interprofessional collaborative care. A yellow, fibrous tissue may cover the ulcer and have an irregular border. The most common method of inelastic compression therapy is the Unna boot, a zinc oxideimpregnated, moist bandage that hardens after application. The recommended regimen is 30 minutes, three or four times per day. Nursing Diagnosis: Ineffective Tissue Perfusion (multiple organs) related to hyperviscosity of blood. Sacral wounds are most susceptible to infection from urine or feces contamination due to their closeness to the perineum. Tell the healthcare provider if you have ever had an allergic reaction to contrast liquid. Statins have vasoactive and anti-inflammatory effects. Inelastic compression wraps, most commonly zinc oxideimpregnated Unna boots, provide high compression only during ambulation and muscle contraction. Signs of venous disease, such as varicose veins, edema, or venous dermatitis, may be present. 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. No revisions are needed. 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. 11.0 Low level laser treatment 11.1 There is no evidence that low level laser therapy speeds the healing of venous leg ulcers. Color duplex ultrasonography is recommended to assess for deep and superficial venous reflux and obstruction. Chronic venous ulcers significantly impact quality of life. Topical negative pressure, also called vacuum-assisted closure, has been shown to help reduce wound depth and volume compared with a hydrocolloid gel and gauze regimen for wounds of any etiology.30 However, clinically meaningful outcomes, such as healing time, have not yet been adequately studied. The consent submitted will only be used for data processing originating from this website. Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with reco Slough with granulation tissue comprises the base of the wound, with moderate to heavy exudate. Nursing Times [online issue]; 115: 6, 24-28. 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. Further evaluation with biopsy or referral to a subspecialist is warranted for venous ulcers if healing stalls or the ulcer has an atypical appearance. Males experience a lower overall incidence than females do. On physical examination, venous ulcers are generally irregular and shallow with well-defined borders and are often located over bony prominences. However, a recent Cochrane review of 22 RCTs of systemic and topical antibiotics and antiseptics for venous ulcer treatment found no evidence that routine use of oral antibiotics improves healing rates.1 Studies comparing topical antibiotics and antiseptics, such as povidone-iodine solution (Betadine), peroxide-based preparations, ethacridine lactate (not available in the United States), and mupirocin (Bactroban), have found some evidence to support the use of the topical antiseptic agent cadexomer iodine (not available in the United States; a pooled estimate from two trials suggests an increased healing rate at four to six weeks compared with placebo).1 More high-quality data are needed to better evaluate the effectiveness of topical preparations, however.1. Removal of necrotic tissue and bacterial burden through debridement has long been used in wound care to enhance healing. Nursing Diagnosis: Risk for Infection related to poor circulation and oxygen delivery and ischemia secondary to venous pressure ulcers. Guidelines suggest cleansing of the affected leg should be kept simple, using warm tap water or saline. They usually develop on the inside of the leg, between the and the ankle. Goals and Outcomes Leg elevation minimizes edema in patients with venous insufficiency and is recommended as adjunctive therapy for venous ulcers. Risk Factors Trauma Thrombosis Inflammation Embolism 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. Dressings are beneficial for venous ulcer healing, but no dressing has been shown to be superior. To compile a patients baseline set of observations. Treat venous stasis ulcers per order. Symptoms of venous stasis ulcers include: Risk factors for venous stasis ulcers include the following: Diagnostic tests for venous stasis ulcers usually include: Compression therapy and direct wound management are the standard of care for VLUs. This content is owned by the AAFP. The current plan of care is focused on promoting wound healing, improving venous return, and preventing skin breakdown. Venous hypertension as a result of venous reflux (incompetence) or obstruction is thought to be the primary underlying mechanism for venous ulcer formation. Blood backs up in the veins, building up pressure. Although numerous treatment methods are available, they have variable effectiveness and limited data to support their use. We and our partners use data for Personalised ads and content, ad and content measurement, audience insights and product development. This content is owned by the AAFP. Compression stockings are removed at night and should be replaced every six months because of loss of compression with regular washing. A deep vein thrombosis nursing care plan includes assessment of the body parts, appropriate intervention, prevention, and patient education to prevent thromboembolism. Abstract. Choice of knee-high, thigh-high, toes-in, or toes-out compression stockings depends on patient preference. Gently remove dry skin scales from the legs, particularly around the ulcer edges to allow new growth of epithelium. Continue with Recommended Cookies, Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions. Make careful to perform range-of-motion exercises if the client is bedridden. Oral antibiotics are preferred, and therapy should be limited to two weeks unless evidence of wound infection persists.1, Hyperbaric Oxygen Therapy. They should not be used in nonambulatory patients or in those with arterial compromise. The treatment goal for venous ulcers is to reduce the edema, promote ulcer healing, and prevent a recurrence of the ulcer. Affect 9% of patients admitted to hospital and 23% of those admitted to nursing homes. 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. Oral antibiotics are recommended to treat venous ulcers only in cases of suspected cellulitis. 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.