Table 2 includes treatment options for venous ulcers.1622, Removal of necrotic tissue by debridement has been used to expedite wound healing. No revisions are needed. Elastic bandages (e.g., Profore) are alternatives to compression stockings. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Examine the patients skin all over his or her body. 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. Nursing Diagnosis: Risk for Infection related to poor circulation and oxygen delivery and ischemia secondary to venous pressure ulcers. She found a passion in the ER and has stayed in this department for 30 years. As the patient is experiencing pain, have him or her score it on a scale of 0 to 10 and describe it. Guidelines suggest cleansing of the affected leg should be kept simple, using warm tap water or saline. . 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. To compile a patients baseline set of observations. 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. 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. 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. Calf muscle contraction and intraluminal valves increase prograde flow while preventing blood reflux under normal circumstances. Hyperbaric oxygen therapy has also been proposed as an adjunctive therapy for chronic wound healing because of potential anti-inflammatory and antibacterial effects, and its benefits in healing diabetic foot ulcers. It can eventually lead to ulcerations or skin breakage on the skin making the person prone infections. Nursing Diagnosis: Ineffective Tissue Perfusion (multiple organs) related to hyperviscosity of blood. Debridement may be sharp, enzymatic, mechanical, larval, or autolytic. Compression therapy helps prevent reflux, decreases release of inflammatory cytokines, and reduces fluid leakage from capillaries, thereby controlling lower extremity edema and VSU recurrence. Color duplex ultrasonography is recommended to assess for deep and superficial venous reflux and obstruction. 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. As long as the heart can handle it, up the patients daily fluid intake to at least 1500 to 2000 mL. . SUSAN BONKEMEYER MILLAN, MD, RUN GAN, MD, AND PETRA E. TOWNSEND, MD. The primary risk factors for venous ulcer development are older age, obesity, previous leg injuries, deep venous thrombosis, and phlebitis. 1 The incidence of venous ulceration increases with age, and women are three times more likely than men to develop venous leg ulcers. Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with reco Ulcers are open skin sores. A) Provide a high-calorie, high-protein diet. Venous ulcers are leg ulcers caused by problems with blood flow (circulation) in your leg veins. She has worked in Medical-Surgical, Telemetry, ICU and the ER. 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). 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. Patients treated with debridement at each physician's office visit had significant reduction in wound size compared with those not treated with debridement.20. Poor prognostic factors include large ulcer size and prolonged duration. Peripheral vascular disease is the impediment of blood flow within the peripheral vascular system due to vessel damage, which mainly affects the lower extremities. Venous hypertension as a result of venous reflux (incompetence) or obstruction is thought to be the primary underlying mechanism for venous ulcer formation. Cellulitis or sepsis may develop in complicated wounds, necessitating antibiotic therapy. Statins have vasoactive and anti-inflammatory effects. 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. RNspeak. Abstract. 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. Gently remove dry skin scales from the legs, particularly around the ulcer edges to allow new growth of epithelium. Venous stasis ulcers are often on the ankle or calf and are painful and red. Granulation tissue and fibrin are often present in the ulcer base. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). 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. The ultimate aim is to promote evidence-based nursing care among patients with venous leg ulcer. 2 Irrigate in the shower or bathe in buckets or bowls lined with a clean plastic bag to reduce the risk of cross-infection. Wound, Ostomy, and Continence . 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. -. Leg elevation when used in combination with compression therapy is also considered standard of care. This provides the best conditions for the ulcer to heal. It has been estimated that active VU have It can also occur if something, such as a deep vein thrombosis or other clot, damages the valves inside the veins. These measures facilitate venous return and help reduce edema. Venous ulcers are large and irregularly shaped with well-defined borders and a shallow, sloping edge. Manage Settings Encouraging the patient through physical therapy to get out of bed and sit down and carry out the necessary exercises. Ulcers heal from their edges toward their centers and their bases up. Affect 9% of patients admitted to hospital and 23% of those admitted to nursing homes. Evidence has not shown that any one dressing is superior when used with appropriate compression therapy. Oral antibiotics are recommended to treat venous ulcers only in cases of suspected cellulitis. Anna Curran. Unlike the Unna boot, elastic compression therapy methods conform to changes in leg size and sustain compression during both rest and activity. 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. Encourage performing simple exercises and getting out of bed to sit on a chair. 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. Nonhealing ulcers also raise your risk of amputation. A clinical severity score based on the CEAP (clinical, etiology, anatomy, and pathophysiology) classification system can guide the assessment of chronic venous disorders. All Rights Reserved. Preamble. Continuous stress to the skins' integrity will eventually cause skin breakdowns. Your doctor may also recommend certain diagnostic imaging tests. Venous ulcers are usually recurrent, and an open ulcer can persist for weeks to many years. 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. The patient will employ behaviors that will enhance tissue perfusion. 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 and shallow with well-defined borders and are often located over bony prominences. ANTICIPATED NURSING INTERVENTIONS Venous Stasis Ulcer = malfunctioning venous valves causing pressure in the veins to increase o Pathophysiology: Venous (or stasis) ulceration is initiated by venous hypertension that develops because of inadequate calf muscle pump action o Risk factors: Diabetes mellitus Congestive heart failure Peripheral . Start performing active or passive exercises while in bed, including occasionally rotating, flexing, and extending the feet. The legs should be placed in an elevated position, ideally at 30 degrees to the heart, while lying down. Causes of Venous Leg Ulcers The speci c cause of venous ulcers is poor venous return. She has brown hyperpigmentation on both lower legs with +2 oedema. Compression stockings are removed at night and should be replaced every six months because of loss of compression with regular washing. Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). This article reviews the incidence and pathophysiology of CVI, nursing assessment, diagnosis and interventions, and patient education needed to manage the disease and prevent . Venous stasis ulcers are wounds caused by the accumulation of fluid that commonly accompanies vein disorders. Suspected osteomyelitis warrants an evaluation for arterial disease and consideration of intravenous antibiotics to treat the underlying infection. Normally, when you get a cut or scrape, your body's healing process starts working to close the wound. Please follow your facilities guidelines, policies, and procedures. 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. The disease has shown a worldwide rising incidence as the worlds population ages. Inelastic compression therapy provides high working pressure during ambulation and muscle contraction, but no resting pressure. Make a chart for wound care. 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 ). Compression therapy is beneficial for venous ulcer treatment and is the standard of care. 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. Compression therapy has been proven beneficial for venous ulcer treatment and is the standard of care. At-home wound healing can be accelerated by providing proper wound care and bandaging the damaged regions to stop pressure injury from getting worse. Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. Valves in the veins prevent backflow, but failure of the valves results in increased pressure in the veins. mostly non-infectious condition in association with venous insufficiency and atrophy of the skin of the lower leg during long . 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. The first step is to remove any debris or dead tissue from the ulcer, wash and dry it, and apply an appropriate dressing. 2010. Specific written plans are necessary for long-term management to improve treatment adherence. Isolating the wound from the perineal region can occasionally be challenging.