Aspirin (300 mg per day) is effective when used with compression therapy for venous ulcers. Pressure Ulcer/Pressure Injury Nursing Care Plan. The synthetic prostacyclin iloprost is a vasodilator that inhibits platelet aggregation. 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. A yellow, fibrous tissue may cover the ulcer and have an irregular border. 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.. 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. Its essential to keep the impacted areas clean by washing them with the recommended cleanser. RNspeak. Even under perfect conditions, a pressure ulcer may take weeks or months to heal. 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. 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 ). Tell the healthcare provider if you have ever had an allergic reaction to contrast liquid. Examine the patients vital statistics. 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. Examine the patients skin all over his or her body. Because bacterial colonization and infection may contribute to poor healing, systemic antibiotics are often used to treat venous ulcers. Early venous ablation and surgical intervention to correct superficial venous reflux can improve healing and decrease recurrence rates. Chronic venous insufficiency can develop from common conditions such as varicose veins. A deep vein thrombosis nursing care plan includes assessment of the body parts, appropriate intervention, prevention, and patient education to prevent thromboembolism. Your doctor may also recommend certain diagnostic imaging tests. Without clear evidence to support the use of one dressing over another, the choice of dressings for venous ulcers can be guided by cost, ease of application, and patient and physician preference.29. . If necessary, recommend the physical therapy team. Her Waterlow Scale is 16, and her skin is intact except for the venous stasis ulcer on the right medial malleolus. Compression therapy has been proven beneficial for venous ulcer treatment and is the standard of care. 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. Citation: Atkin L (2019) Venous leg ulcer prevention 1: identifying patients who are at risk. Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). Nursing Care Plan for: Impaired Skin Integrity, Risk for Skin Breakdown, Altered Skin Integrity, and Risk for Pressure Ulcers. Encourage the patient to refrain from scratching the injured regions. Nursing Diagnosis: Ineffective Tissue Perfusion (multiple organs) related to hyperviscosity of blood. Venous incompetence and associated venous hypertension are thought to be the primary mechanisms for ulcer formation. 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. Copyright 2010 by the American Academy of Family Physicians. A group of nurse judges experienced in the treatment of venous ulcer validated 84 nursing diagnoses and outcomes, and 306 interventions. Venous ulcers are believed to account for approximately 70% to 90% of chronic leg ulcers. 11.0 Low level laser treatment 11.1 There is no evidence that low level laser therapy speeds the healing of venous leg ulcers. Patient information: See related handout on venous ulcers. . The oldest term for pressure ulcers is decubitus, which evolved into decubitus ulcers or ischemic ulcer s in the 1950s. In addition, the Unna boot may lead to a foul smell from the accumulation of exudate from the ulcer, requiring frequent reapplications.2, Elastic. C) Irrigate the wound with hydrogen peroxide once daily. If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. 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. Arterial pulse examination and measurement of ankle-brachial index are recommended for all patients with suspected venous ulcers. To assess the size and extent of decubitus ulcers, as well as any affected areas that need specific care or wound treatment. Nursing interventions in venous, arterial and mixed leg ulcers. 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. 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. Traditional conservative management of venous ulcers usually entails compression therapy, leg elevation to reduce edema, and dressings on the wound. Statins have vasoactive and anti-inflammatory effects. There are numerous online resources for lay education. Over time, the breakdown of tissues combined with the lack of oxygen . If you have a venous leg ulcer, you may also have: swollen ankles (oedema) discolouration or darkening of the skin around the ulcer Venous ulcer, also known as stasis ulcer, is the most common etiology of lower extremity ulceration, affecting approximately 1 percent of the U.S. population. They do not heal for weeks or months and sometimes longer. Remind the client not to cross their legs or hyperextend their knees in positions where they are seated with their legs hanging or lying jackknife. Venous stasis ulcers are wounds caused by the accumulation of fluid that commonly accompanies vein disorders. The most common method of inelastic compression therapy is the Unna boot, a zinc oxideimpregnated, moist bandage that hardens after application. Two prospective randomized controlled trials reviewed the effect of sharp debridement on the healing of venous ulcers. Leg ulcer may be of a mixed arteriovenous origin. Intermittent pneumatic compression therapy comprises a pump that delivers air to inflatable and deflatable sleeves that embrace extremities, providing intermittent compression.7,23 The benefits of intermittent pneumatic compression are less clear than that of standard continuous compression. These measures facilitate venous return and help reduce edema. We can define pressure ulcers as localized areas of necrosis that tend to occur when soft tissue is compressed between two planes, one bony prominences of the patient and other external surface. On physical examination, venous ulcers are generally irregular and shallow with well-defined borders and are often located over bony prominences. 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. 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. nous insufficiency and ambulatory venous hypertension. Its healing can take between four and six weeks, after their initial onset (1). The healing capacity of the pressure damage is maximized by providing the appropriate wound care following the stage of the decubitus ulcer. Venous ulcers commonly occur in the gaiter area of the lower leg. 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. Detailed Description: The study takes place in home-care in two Finnish municipality, which are similar size and staff structure and working ideology are basically the same. On initial assessment, it is crucial to cover the history of health: associated co-morbidities, habitual therapy, psycho-emotional state, influence of odour on social life, nutritional state, presence and intensity of pain and individual treatment preference. Compression stockings are removed at night, and should be replaced every six months because they lose pressure with regular washing.2. This causes blood to collect and pool in the vein, leading to swelling in the lower leg. By. Further evaluation with biopsy or referral to a subspecialist is warranted for venous ulcers if healing stalls or the ulcer has an atypical appearance. Pentoxifylline (Trental) is effective when used with compression therapy for venous ulcers, and may be useful as monotherapy. 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. But they most often occur on the legs. Oral zinc therapy has been shown to decrease healing time in patients with pilonidal sinus. This content is owned by the AAFP. Duplex Ultrasound Buy on Amazon. Potential Nursing Interventions: (3 minimum) 1. The ultimate aim is to promote evidence-based nursing care among patients with venous leg ulcer. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. As soon as the client is allowed to leave the bed, assist with a progressive return to ambulation. She has brown hyperpigmentation on both lower legs with +2 oedema. 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. 1 The incidence of venous ulceration increases with age, and women are three times more likely than men to develop venous leg ulcers. Dehydration makes blood more viscous and causes venous stasis, which makes thrombus development more likely. The primary risk factors for venous ulcer development are older age, obesity, previous leg injuries, deep venous thrombosis, and phlebitis. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. Nursing Care of the Patient with Venous Disease - Fort HealthCare Venous ulcers, also known as venous stasis ulcers are open sores in the skin that occur where the valves in the veins don't work properly and there is ongoing high pressure in the veins. Elderly people are more frequently affected. 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. Human skin grafting may be used for patients with large or refractory venous ulcers. Normally, when you get a cut or scrape, your body's healing process starts working to close the wound. They do not penetrate the deep fascia. 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. Tiny valves in the veins can fail. Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with reco 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 What is the most appropriate intervention for this diagnosis? It might be necessary to apply the prescription antibiotic cream or ointment directly to the affected area. Table 2 includes treatment options for venous ulcers.1622, Removal of necrotic tissue by debridement has been used to expedite wound healing. Venous ulcers are the most common type of chronic lower extremity ulcers, affecting 1% to 3% of the U.S. population. SUSAN BONKEMEYER MILLAN, MD, RUN GAN, MD, AND PETRA E. TOWNSEND, MD. 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. The legs should be placed in an elevated position, ideally at 30 degrees to the heart, while lying down. Examine for fecal and urinary incontinence. Debridement may be sharp (e.g., using curette or scissors), enzymatic, mechanical, biologic (i.e., using larvae), or autolytic. Affect 9% of patients admitted to hospital and 23% of those admitted to nursing homes. Situation: Mrs. Morrow is an obese, 80-year-old white female who developed a venous stasis ulcer on her right medial malleolus while still living at home. The treatment goal for venous ulcers is to reduce the edema, promote ulcer healing, and prevent a recurrence of the ulcer. Make a chart for wound care. 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. The recommended regimen is 30 minutes, three or four times per day. These venoactive drugs theoretically work by improving venous tone and decreasing capillary permeability. Enzymatic debridement using collagenase has been shown to effectively remove nonviable tissue. Early endovenous ablation to correct superficial venous reflux improves ulcer healing rates. Further evaluation with biopsy or referral to a subspecialist is warranted if ulcer healing stalls or the ulcer has an atypical appearance. 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. Author disclosure: No relevant financial affiliations. Wash the sores with the recommended cleanser to instruct the caregiver about good wound hygiene. As long as the heart can handle it, up the patients daily fluid intake to at least 1500 to 2000 mL. 1 The incidence of venous ulceration increases with age, and women are three times more likely than men to develop venous leg ulcers. 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). Care Plan/Nursing Diagnosis Template Potential Nursing Diagnosis (Priority) At risk for ineffective peripheral tissue perfusion related to DVT and evidenced by venous stasis ulcer on right medial malleolus (Wayne, 2022). St. Louis, MO: Elsevier. The 10-point pain scale is a widely used, precise, and efficient pain rating measure. She received her RN license in 1997. Although the main goal of treatment is ulcer healing, secondary goals include reduction of edema and prevention of recurrence. Multicomponent compression systems comprised of various layers are more effective than single-component systems, and elastic systems are more effective than nonelastic systems.28, Important barriers to the use of compression therapy include wound drainage, pain, application or donning difficulty, physical impairment (weakness, obesity, decreased range of motion), and leg shape deformity (leading to compression material rolling down the leg or wrinkling). A systematic review of hyperbaric oxygen therapy in patients with chronic wounds found only one trial that addressed venous ulcers. 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. 1, 28 Goals of compression therapy. Peripheral vascular disease is the impediment of blood flow within the peripheral vascular system due to vessel damage, which mainly affects the lower extremities. Assist client with position changes to reduce risk of orthostatic BP changes. 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. Guidelines suggest cleansing of the affected leg should be kept simple, using warm tap water or saline. Continue with Recommended Cookies, Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions. Once the ulcer has healed, continued use of compression stockings is recommended indefinitely. This will enable the client to apply new knowledge right away, improving retention. The cornerstone of treatment for venous leg ulcers is compression therapy, but dressings can aid with symptom control and optimise the local wound environment, promoting healing There is no evidence to support the superiority of one dressing type over another when applied under appropriate multilayer compression bandaging Compression therapy. Otherwise, scroll down to view this completed care plan. If not treated, increased pressure and excess fluid in the affected area can cause an open sore to form. Pressure Ulcer Nursing Care Plans Diagnosis and Interventions Pressure Ulcer NCLEX Review and Nursing Care Plans Pressure ulcers, sometimes called bedsores or Decubitus ulcers, are skin and tissue breakdown that arises from exertion of incessant pressure to the skin. Isolating the wound from the perineal region can occasionally be challenging.