Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. Unless the client is immunocompromised or diabetic, a fever is defined as a temperature above 100.4 degrees F (38 degrees C), which indicates the presence of an illness. Impaired Skin Integrity ADVERTISEMENTS Impaired Skin Integrity Nursing Diagnosis Impaired Skin Integrity May be related to Chronic disease state. Compression therapy Treatment focuses on preventing new ulcers, controlling edema, and reducing venous hypertension through compression therapy. such as venous ulcers and lymphoedema, concomitant bacterial and fungal colonisation or infection may be present. Any delay in care increases the risk of infection, sepsis, amputation, skin cancers, and death. 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. Oral antibiotics are preferred, and therapy should be limited to two weeks unless evidence of wound infection persists.1, Hyperbaric Oxygen Therapy. Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). 2010. Leg elevation requires raising lower extremities above the level of the heart, with the aim of reducing edema, improving microcirculation and oxygen delivery, and hastening ulcer healing. Start performing active or passive exercises while in bed, including occasionally rotating, flexing, and extending the feet. 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. Some of our partners may process your data as a part of their legitimate business interest without asking for consent. This usually needs to be changed 1 to 3 times a week. Patient information: See related handout on venous ulcers. 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. Valves in the veins prevent backflow, but failure of the valves results in increased pressure in the veins. In comparison to a single long walk, short, regular walks are healthier for the extremities and the prevention of pulmonary problems. These actions are intended to improve overall muscle tone and strength, as well as boost venous return from the lower extremities and decrease venous stasis. Males experience a lower overall incidence than females do. Start providing wound care according to the decubitus ulcers development. 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. On physical examination, venous ulcers are generally irregular and shallow with well-defined borders and are often located over bony prominences. Nursing diagnoses handbook: An evidence-based guide to planning care. A) Provide a high-calorie, high-protein diet. A simple non-sticky dressing will be used to dress your ulcer. Contrast liquid is injected into the catheter to help the veins show up better in the pictures. St. Louis, MO: Elsevier. PVD can be related to an arterial or venous issue. 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. Peripheral vascular disease is the impediment of blood flow within the peripheral vascular system due to vessel damage, which mainly affects the lower extremities. Make a chart for wound care. 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. Associated findings include lower extremity varicosities, edema, venous dermatitis, and lipodermatosclerosis. 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. She received her RN license in 1997. Between 75 % and 80 % of all lower limb ulcers is of venous etiology, their prevalence ranges between 0.5 % and 2.7 %, and increase with age (2, 3). Severe complications include cellulitis, osteomyelitis, and malignant change. On physical examination, venous ulcers are generally irregular and shallow (Figure 1). Make careful to perform range-of-motion exercises if the client is bedridden. Immobile clients will need to be repositioned frequently to reduce the chance of breakdown in the intact parts. 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. See permissionsforcopyrightquestions and/or permission requests. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. The patient will continue to be free of systemic or local infections as shown by the lack of profuse, foul-smelling wound exudate. A group of nurse judges experienced in the treatment of venous ulcer validated 84 nursing diagnoses and outcomes, and 306 interventions. 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. This will enable the client to apply new knowledge right away, improving retention. 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. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. Early venous ablation and surgical intervention to correct superficial venous reflux can improve healing and decrease recurrence rates. Venous stasis ulcers are often on the ankle or calf and are painful and red. 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. Possible causes of venous ulcers include inflammatory processes resulting in leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema. Encourage the patient to refrain from scratching the injured regions. This, again, helps in the movement of venous blood to the heart.This also prevents the build-up of liquid in the legs that leads to swelling. Copyright 2019 by the American Academy of Family Physicians. Patient information: See related handout on venous ulcers, written by the authors of this article. Determine whether the client has unexplained sepsis. She found a passion in the ER and has stayed in this department for 30 years. 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. 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. Calf muscle contraction and intraluminal valves increase prograde flow while preventing blood reflux under normal circumstances. Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. Preamble. Anna Curran. Of the diagnoses developed, 62 are included in ICNP and 23 are new diagnoses, not included. Current evidence supports treatment of venous ulcers with compression therapy, exercise, dressings, pentoxifylline, and tissue products. 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. Desired Outcome: The patient will verbally report their level of pain as 0 out of 10. Venous stasis ulcers may develop spontaneously or after affected skin is scratched or injured. 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. 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 patient will maintain their normal body temperature. Venous thromboembolism occurs majorly in two ways like pulmonary embolism and deep vein thrombosis. 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. Granulation tissue and fibrin are often present in the ulcer base. Leg ulcer may be of a mixed arteriovenous origin. Physically restricting circulation reduces blood flow and heightens venous stasis in the pelvic, popliteal, and leg veins, causing swelling and discomfort to worsen. Suspected osteomyelitis warrants an evaluation for arterial disease and consideration of intravenous antibiotics to treat the underlying infection. Unlike the Unna boot, elastic compression therapy methods conform to changes in leg size and sustain compression during both rest and activity. 34. To assess the size and extent of decubitus ulcers, as well as any affected areas that need specific care or wound treatment. Over time, the breakdown of tissues combined with the lack of oxygen . Specific written plans are necessary for long-term management to improve treatment adherence. Conclusion Encouraging the patient through physical therapy to get out of bed and sit down and carry out the necessary exercises. They also support healthy organ function and raise well-being in general. Examine the clients and the caregivers wound-care knowledge and skills in the area. 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. For wound closure to be effective, leg edema must be reduced. 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. 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. 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. Compression stockings Wearing compression stockings all day is often the first approach to try. No one dressing type has been shown to be superior when used with appropriate compression therapy. 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. 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. Chronic venous insufficiency can pose a more serious result if not given proper medical attention. Surgical management may be considered for ulcers that are large in size, of prolonged duration, or refractory to conservative measures. To encourage ideal patient comfort and lessen agitation/anxiety. As fluid leaking from dysfunctional veins accumulates into surrounding tissues, the flesh surrounding the area becomes irritated, inflamed, and begins to break down. Continue with Recommended Cookies, Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions. Contrast venography is a procedure used to show the veins on x-ray pictures. Enzymatic debridement using collagenase has been shown to effectively remove nonviable tissue. The 10-point pain scale is a widely used, precise, and efficient pain rating measure. The patient will demonstrate increased tolerance to activity. Citation: Atkin L (2019) Venous leg ulcer prevention 1: identifying patients who are at risk. Intermittent pneumatic compression may be considered when there is generalized, refractory edema from venous insufficiency; lymphatic obstruction; and significant ulceration of the lower extremity. This prevents overdistention and quickly empties the superficial and tibial veins, which reduces tissue swelling and boosts venous return. Chronic venous insufficiency can develop from common conditions such as varicose veins. Granulation tissue and fibrin are typically present in the ulcer base. They can affect any area of the skin. Statins have vasoactive and anti-inflammatory effects. 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 ). Venous leg ulcers are open, often painful, sores in the skin that take more than 2 weeks to heal. Normally, when you get a cut or scrape, your body's healing process starts working to close the wound. Aspirin. Manage Settings When seated in a chair or bed, raise the patients legs as needed. Causes of Venous Leg Ulcers The speci c cause of venous ulcers is poor venous return. 11.0 Low level laser treatment 11.1 There is no evidence that low level laser therapy speeds the healing of venous leg ulcers. We and our partners use data for Personalised ads and content, ad and content measurement, audience insights and product development. Slough with granulation tissue comprises the base of the wound, with moderate to heavy exudate. The nurse is caring for a patient with a large venous leg ulcer. 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. . This causes blood to collect and pool in the vein, leading to swelling in the lower leg. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Compression therapy is a standard treatment modality for initial and long-term treatment of venous ulcers in patients without concomitant arterial disease. 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. Copyright 2023 American Academy of Family Physicians. Author: Leanne Atkin lecturer practitioner/vascular nurse consultant, School of Human and Health Sciences, University of Huddersfield and Mid Yorkshire Trust. 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). Ulcers heal from their edges toward their centers and their bases up. Compression therapy is beneficial for venous ulcer treatment and is the standard of care. 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. They typically occur in people with vein issues. The primary risk factors for venous ulcer development are older age, obesity, previous leg injuries, deep venous thrombosis, and phlebitis. Arterial pulse examination and measurement of ankle-brachial index are recommended for all patients with suspected venous ulcers. Timely specialized care is necessary to prevent complications, like infections that can become life-threatening. Clean, persistent wounds that are not healing may benefit from palliative wound care. Once the ulcer has healed, continued use of compression stockings is recommended indefinitely. 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. 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. Encourage deep breathing exercises and pursed lip breathing. Most venous ulcers occur on the leg, above the ankle. It has been estimated that active VU have Traditional negative pressure wound therapy systems are bulky and cannot be used with compression therapy. Goals and Outcomes Otherwise, scroll down to view this completed care plan. August 9, 2022 Modified date: August 21, 2022. The most common method of inelastic compression therapy is the Unna boot, a zinc oxideimpregnated, moist bandage that hardens after application. Please follow your facilities guidelines, policies, and procedures. Learn how your comment data is processed. Evidence has not shown that any one dressing is superior when used with appropriate compression therapy. 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. This provides the best conditions for the ulcer to heal. Its healing can take between four and six weeks, after their initial onset (1). 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. Pentoxifylline. Most patients have venous leg ulcer due to chronic venous insufficiency. If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. The pressure ulcer needs to be taken into consideration as a potential cause during the septic workup. An example of data being processed may be a unique identifier stored in a cookie. 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. It can related to the age as well as the body surface of the . RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. A deep vein thrombosis nursing care plan includes assessment of the body parts, appropriate intervention, prevention, and patient education to prevent thromboembolism. Unna boots have limited capacity for fluid absorption in patients with highly exudative ulcers and are best used for early, small, dry ulcers and for venous dermatitis because of the skin soothing effects of zinc oxide.30, Stockings. 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. To diagnose chronic venous insufficiency, your NYU Langone doctor asks about your health history to determine the extent of your symptoms. 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 They do not penetrate the deep fascia. Venous ulcers are the most common type of chronic lower extremity ulcers, affecting 1% to 3% of the U.S. population. Nonhealing ulcers also raise your risk of amputation. To compile a patients baseline set of observations. The recurrence of an ulcer in the same area is highly suggestive of venous ulcer. Inelastic. It allows time for the nursing team to evaluate the wound and the condition of the leg. 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 ultimate aim is to promote evidence-based nursing care among patients with venous leg ulcer. Figure Venous hypertension as a result of venous reflux (incompetence) or obstruction is thought to be the primary underlying mechanism for venous ulcer formation. Provide information about local wound care to the patient and the caregiver, and then let them watch a demonstration. Venous incompetence and associated venous hypertension are thought to be the primary mechanisms for ulcer formation.