nursing care plan for venous stasis ulcer

She moved into our skilled nursing home care facility 3 days ago. This provides the best conditions for the ulcer to heal. Patients experience poor quality of life as a result of pain and immobility, and they require advanced levels of wound care. Anna Curran. BACKGROUND Primary DX: venous stasis ulcer on right medial malleolus and chronic venous insufficiency. Leg elevation when used in combination with compression therapy is also considered standard of care. Search dates: November 12, 2018; December 27, 2018; January 8, 2019; and March 21, 2019. 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 The recurrence of an ulcer in the same area is highly suggestive of venous ulcer. Learn how your comment data is processed. Signs of venous disease, such as varicose veins, edema, or venous dermatitis, may be present. 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. Cellulitis or sepsis may develop in complicated wounds, necessitating antibiotic therapy. They typically occur around the medial malleolus, tend to be shallow and moist, and may be malodorous (especially when poorly cared for) or painful. Venous ulcers commonly occur in the gaiter area of the lower leg. Compression stockings can be used for ulcer healing and prevention of recurrence (recommended strength is at least 20 to 30 mm Hg, but 30 to 40 mm Hg is preferred).31,32 Donning stockings over dressings can be challenging. Venous stasis ulcers are often on the ankle or calf and are painful and red. 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. Referral to a wound subspecialist should be considered for ulcers that are large, of prolonged duration, or refractory to conservative measures. Nursing Interventions 1. Inelastic compression therapy provides high working pressure during ambulation and muscle contraction, but no resting pressure. No one dressing type has been shown to be superior when used with appropriate compression therapy. Gently remove dry skin scales from the legs, particularly around the ulcer edges to allow new growth of epithelium. arterial pulse examination, and measurement of ankle-brachial index is recommended for all patients with suspected venous ulcers. 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). Traditional negative pressure wound therapy systems are bulky and cannot be used with compression therapy. 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. Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. 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. Provide information about local wound care to the patient and the caregiver, and then let them watch a demonstration. Your care team may include doctors who specialize in blood vessel (vascular . 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. Further evaluation with biopsy or referral to a subspecialist is warranted for venous ulcers if healing stalls or the ulcer has an atypical appearance. Compared with compression plus a simple dressing, one study showed that advanced therapies can shorten healing time and improve healing rates.52, Skin Grafting. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). c. 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. Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). Treatment for venous stasis ulcer should usually include: The following lifestyle changes must be implemented to increase circulation and lower the risk of developing venous stasis ulcers: Nursing Diagnosis: Impaired Skin Integrity related to skin breakdown secondary to pressure ulcer as indicated by a pressure sore on the sacrum, a few days of sore discharge, pain, and soreness. Contrast liquid is injected into the catheter to help the veins show up better in the pictures. Oral zinc therapy has been shown to decrease healing time in patients with pilonidal sinus. The patient will employ behaviors that will enhance tissue perfusion. These measures facilitate venous return and help reduce edema. For patients who have difficulty donning the stockings, use of layered (additive) compression stockings; stockings with a Velcro or zippered closure; or donning aids, such as a donning butler (Figure 4), may be helpful.33, Intermittent Pneumatic Compression. Surgical management may be considered for ulcers that are large in size, of prolonged duration, or refractory to conservative measures. The consent submitted will only be used for data processing originating from this website. Abstract. Duplex Ultrasound Tell the healthcare provider if you have ever had an allergic reaction to contrast liquid. Conclusion C) Irrigate the wound with hydrogen peroxide once daily. By. PVD can be related to an arterial or venous issue. Venous leg ulcers are open, often painful, sores in the skin that take more than 2 weeks to heal. Current evidence supports treatment of venous ulcers with compression therapy, exercise, dressings, pentoxifylline, and tissue products. Granulation tissue and fibrin are often present in the ulcer base. Compression therapy is beneficial for venous ulcer treatment and is the standard of care. Abstract: Chronic venous insufficiency (CVI) is a potentially debilitating disorder associated with serious complications such as lower extremity venous ulcers. It can eventually lead to ulcerations or skin breakage on the skin making the person prone infections. Examine the patients skin all over his or her body. You will undertake clinical handover and complete a nursing care plan. The patient will demonstrate increased tolerance to activity. 2 In some studies, 50% of patients had venous ulcers that persisted for more than 9 months, and 20% had ulcers that did . Compression therapy reduces swelling and encourages healthy blood circulation. Venous ulcers are large and irregularly shaped with well-defined borders and a shallow, sloping edge. 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. The synthetic prostacyclin iloprost is a vasodilator that inhibits platelet aggregation. Chronic venous insufficiency can develop from common conditions such as varicose veins. 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. Compression therapy is a standard treatment modality for initial and long-term treatment of venous ulcers in patients without concomitant arterial disease. Enzymatic debridement using collagenase has been shown to effectively remove nonviable tissue. The oldest term for pressure ulcers is decubitus, which evolved into decubitus ulcers or ischemic ulcer s in the 1950s. Males experience a lower overall incidence than females do. Associated findings include lower extremity varicosities, edema, venous dermatitis, and lipodermatosclerosis. 34. 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. (2020). Traditional conservative management of venous ulcers usually entails compression therapy, leg elevation to reduce edema, and dressings on the wound. RNspeak. These are most common in your legs and feet as you age and happen because the valves in your leg veins can't do their job properly. Note: According to certain medical professionals, elevation may enhance thrombus release, raising the risk of embolization and reducing blood flow to the extremitys most distal part. 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. 2 Irrigate in the shower or bathe in buckets or bowls lined with a clean plastic bag to reduce the risk of cross-infection. Nursing Diagnosis: Ineffective Tissue Perfusion (multiple organs) related to hyperviscosity of blood. To encourage numbing of the pain and patient comfort without the danger of an overdose. This quiz will test your knowledge on both peripheral arterial disease (PAD) and peripheral venous . Nursing Times [online issue]; 115: 6, 24-28. Interventions for Venous Insufficiency Encourage the patient to elevate the legs above the level of the heart several times per day. See permissionsforcopyrightquestions and/or permission requests. Your doctor may also recommend certain diagnostic imaging tests. 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. The treatment goal for venous ulcers is to reduce the edema, promote ulcer healing, and prevent a recurrence of the ulcer. St. Louis, MO: Elsevier. Some evidence supports the use of cadexomer iodine to improve healing of venous ulcers, but evidence for other agents is lacking.38. Figure 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. . Author disclosure: No relevant financial affiliations. 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. History of superficial or deep venous thrombosis, pulmonary embolism, and ulcer recurrence should be ascertained with comorbid conditions. This content is owned by the AAFP. But they most often occur on the legs. Oral antibiotics are preferred, and therapy should be limited to two weeks unless evidence of wound infection persists.1, Hyperbaric Oxygen Therapy. Nursing Care Plan Description Peripheral artery disease ( PAD ), also known as peripheral vascular disease ( PVD ), peripheral artery occlusive disease, and peripheral obliterative arteriopathy, is a form of arteriosclerosis involving occlusion of arteries, most commonly in the lower extremities. Otherwise, scroll down to view this completed care plan. Continue with Recommended Cookies, Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions. 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. Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). Provide analgesics or other painkillers as directed, at least 30 minutes before caring for a wound. Chronic venous insufficiency (CVI) is a potentially debilitating disorder associated with serious complications such as lower extremity venous ulcers. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). Compression stockings Wearing compression stockings all day is often the first approach to try. Valves in the veins prevent backflow, but failure of the valves results in increased pressure in the veins. Timely specialized care is necessary to prevent complications, like infections that can become life-threatening. 1 The incidence of venous ulceration increases with age, and women are three times more likely than men to develop venous leg ulcers. Patients treated with debridement at each physician's office visit had significant reduction in wound size compared with those not treated with debridement.20. Patient who needs wound care for a chronic venous stasis ulcer on the lower leg. 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. Venous ulcers are believed to account for approximately 70% to 90% of chronic leg 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. He or she also performs a physical exam to look for swelling, skin changes, varicose veins, or ulcers on the leg. Affect 9% of patients admitted to hospital and 23% of those admitted to nursing homes. B) Apply a clean occlusive dressing once daily and whenever soiled. . 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. Human skin grafting may be used for patients with large or refractory venous ulcers. A catheter is guided into the vein. Nonhealing ulcers also raise your risk of amputation. 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. To compile a patients baseline set of observations. 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). 11.0 Low level laser treatment 11.1 There is no evidence that low level laser therapy speeds the healing of venous leg ulcers. They typically occur in people with vein issues. Teach the caretaker how to properly care for the afflicted regions of the wounds if the patient is to be discharged. Risk Factors Trauma Thrombosis Inflammation Embolism As an Amazon Associate I earn from qualifying purchases. Venous ulcers are believed to account for approximately 70% to 90% of chronic leg ulcers. Over time, as the veins become increasingly weak, they have more trouble sending blood to the heart. 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. A deep vein thrombosis nursing care plan includes assessment of the body parts, appropriate intervention, prevention, and patient education to prevent thromboembolism. Chronic venous insufficiency can pose a more serious result if not given proper medical attention. 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. Determine whether the client has unexplained sepsis. All Rights Reserved. 17 Most patients have venous leg ulcer due to chronic venous insufficiency. Early endovenous ablation to correct superficial venous reflux improves ulcer healing rates. 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. This article reviews the incidence and pathophysiology of CVI, nursing assessment, diagnosis and interventions, and patient education needed to manage the disease and prevent complications. Patient information: See related handout on venous ulcers. Monitor for complications a. Thromboembolic complications due to hyperviscosity, including DVT; MI & CVA b. Hemorrhage tendency is caused by venous and capillary distention and abnormal platelet function. They also support healthy organ function and raise well-being in general. Table 2 includes treatment options for venous ulcers.1622, Removal of necrotic tissue by debridement has been used to expedite wound healing. Ulcers are open skin sores. VLUs are the result of chronic venous insufficiency (CVI) in the legs. Guidelines suggest cleansing of the affected leg should be kept simple, using warm tap water or saline. This article reviews the incidence and pathophysiology of CVI, nursing assessment, diagnosis and interventions, and patient education needed to manage the disease and prevent . 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. Although the main goal of treatment is ulcer healing, secondary goals include reduction of edema and prevention of recurrence. On physical examination, venous ulcers are generally irregular and shallow (Figure 1). nous insufficiency and ambulatory venous hypertension. Medical-surgical nursing: Concepts for interprofessional collaborative care. Because bacterial colonization and infection may contribute to poor healing, systemic antibiotics are often used to treat venous ulcers. Venous ulcers (also known as venous stasis ulcers or nonhealing wounds) are open wounds around the ankle or lower leg. The pressure ulcer needs to be taken into consideration as a potential cause during the septic workup. Examine the patients vital statistics. A clinical severity score based on the CEAP (clinical, etiology, anatomy, and pathophysiology) classification system can guide the assessment of chronic venous disorders. Aspirin. Like pentoxifylline therapy, aspirin (300 mg per day) combined with compression therapy has been shown to increase ulcer healing time and reduce ulcer size, compared with compression therapy alone.32 In general, adding aspirin therapy to compression bandages is recommended in the treatment of venous ulcers as long as there are no contraindications to its use. 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. Encourage deep breathing exercises and pursed lip breathing. A more recent article on venous ulcers is available. 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. Blood flow from the legs to the heart is propelled by the pumping action of the calf muscle during flexion of the ankle (during walking, for example). Leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema contribute to venous ulcer development and impaired wound healing.2,14, Determining etiology is a critical step in the management of venous ulcers. 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. Poor venous return is due to damage of the valves in leg veins that facilitate the return of the blood to the heart. Granulation tissue and fibrin are typically present in the ulcer base. Most common type; women affected more than men; often occurs in older persons, Shallow, painful ulcer located over bony prominences, particularly the gaiter area (over medial malleolus); granulation tissue and fibrin present, Leg elevation, compression therapy, aspirin, pentoxifylline (Trental), surgical management, Associated findings include edema, venous dermatitis, varicosities, and lipodermatosclerosis, Associated with cardiac or cerebrovascular disease; patients may present with claudication, impotence, pain in distal foot; concomitant with venous disease in up to 25 percent of cases, Ulcers are commonly deep, located over bony prominences, round or punched out with sharply demarcated borders; yellow base or necrosis; exposure of tendons, Revascularization, antiplatelet medications, management of risk factors, Most common cause of foot ulcers, usually from diabetes mellitus, Usually occurs on plantar aspect of feet in patients with diabetes, neurologic disorders, or Hansen disease, Off-loading of pressure, topical growth factors; tissue-engineered skin, Usually occurs in patients with limited mobility, Tissue ischemia and necrosis secondary to prolonged pressure, Located over bony prominences; risk factors include excessive moisture and altered mental status, Off-loading of pressure; reduction of excessive moisture, sheer, and friction; adequate nutrition, Compression therapy (inelastic, elastic, intermittent pneumatic), Standard of care; proven benefit (benefit of intermittent pneumatic therapy is less clear); associated with decreased rate of ulcer recurrence, Standard of care when used with compression therapy; minimizes edema; recommended for 30 minutes, three or four times a day, Topical negative pressure (vacuum-assisted closure), No robust evidence regarding its use for venous ulcers, Effective when used with compression therapy; may be useful as monotherapy, Effective when used with compression therapy; dosage of 300 mg once per day, Intravenous administration (not available in the United States) may be beneficial, but data are insufficient to recommend its use; high cost limits use, Oral antibiotic treatment is warranted in cases of suspected cellulitis; routine use of systemic antibiotics provides no healing benefit; benefit of adding the topical antiseptic cadexomer iodine (not available in the United States) is unclear, May be beneficial when used with compression therapy; concern about infection transmission, May be beneficial for severe or refractory cases; associated with decreased rate of ulcer recurrence.

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