nursing care plan for venous stasis ulcer

Compression stockings are removed at night and should be replaced every six months because of loss of compression with regular washing. Compression therapy reduces swelling and encourages healthy blood circulation. Arterial pulse examination and measurement of ankle-brachial index are recommended for all patients with suspected venous ulcers. Your doctor may also recommend certain diagnostic imaging tests. Tiny valves in the veins can fail. PVD can be related to an arterial or venous issue. RACGP - Management of venous leg ulcers in general practice - a On physical examination, venous ulcers are generally irregular and shallow (Figure 1). Nursing Diagnosis: Ineffective Tissue Perfusion (multiple organs) related to hyperviscosity of blood. On physical examination, venous ulcers are generally irregular, shallow, and located over bony prominences. 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 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 ). Compared with compression plus a simple dressing, one study showed that advanced therapies can shorten healing time and improve healing rates.52, Skin Grafting. 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. A more recent article on venous ulcers is available. Early venous ablation and surgical intervention to correct superficial venous reflux can improve healing and decrease recurrence rates. Teach the patient and the caretaker to report any of the following symptoms of wound infection: fever, malaise, chills, an unpleasant odor, and purulent drainage. Granulation tissue and fibrin are typically present in the ulcer base. This is a common treatment for venous ulcers and can decrease the chance that a healed ulcer will return. Compression therapy is a standard treatment modality for initial and long-term treatment of venous ulcers in patients without concomitant arterial disease. 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. . Leg elevation when used in combination with compression therapy is also considered standard of care. Venous ulcers are leg ulcers caused by problems with blood flow (circulation) in your leg veins. August 9, 2022 Modified date: August 21, 2022. 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. 4 Deep vein thrombosis nursing care plan - Nurse in nursing The most common method of inelastic compression therapy is the Unna boot, a zinc oxideimpregnated, moist bandage that hardens after application. Abstract: Chronic venous insufficiency (CVI) is a potentially debilitating disorder associated with serious complications such as lower extremity venous ulcers. 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. Of the diagnoses developed, 62 are included in ICNP and 23 are new diagnoses, not included. 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. An example of data being processed may be a unique identifier stored in a cookie. The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. 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. Although the main goal of treatment is ulcer healing, secondary goals include reduction of edema and prevention of recurrence. Patients experience poor quality of life as a result of pain and immobility, and they require advanced levels of wound care. Compression therapy helps prevent reflux, decreases release of inflammatory cytokines, and reduces fluid leakage from capillaries, thereby controlling lower extremity edema and VSU recurrence. Even under perfect conditions, a pressure ulcer may take weeks or months to heal. These venoactive drugs theoretically work by improving venous tone and decreasing capillary permeability. Venous Ulcer Symptoms and Treatment | UPMC It can also occur if something, such as a deep vein thrombosis or other clot, damages the valves inside the veins. Venous Ulcers | Johns Hopkins Medicine Any delay in care increases the risk of infection, sepsis, amputation, skin cancers, and death. The essential requirements of management are to debride the ulcer with appropriate precautions, choose dressings that maintain adequate moisture balance, apply graduated compression bandage after evaluation of the arterial circulation and address the patient's concerns, such as pain and offensive wound discharge. PDF Learning Package Assessment and Management of Venous Leg Ulcers - RNAO Although intermittent pneumatic compression is more effective than no compression, its effectiveness compared with other forms of compression is unclear. To encourage ideal patient comfort and lessen agitation/anxiety. Interventions for Venous Insufficiency Encourage the patient to elevate the legs above the level of the heart several times per day. Venous ulcers are the most common lower extremity wounds in the United States. The ultimate aim is to promote evidence-based nursing care among patients with venous leg ulcer. This quiz will test your knowledge on both peripheral arterial disease (PAD) and peripheral venous . The treatment goal for venous ulcers is to reduce the edema, promote ulcer healing, and prevent a recurrence of the ulcer. Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). Stasis Ulcer: Vascular Ulcer Causes, Symptoms and Treatment Anna Curran. The current plan of care is focused on promoting wound healing, improving venous return, and preventing skin breakdown. A catheter is guided into the vein. Pressure Ulcer/Pressure Injury Nursing Care Plan. Continuous stress to the skins' integrity will eventually cause skin breakdowns. The pressure ulcer needs to be taken into consideration as a potential cause during the septic workup. PDF Nursing Care Plan For Bleeding Esophageal Varices 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. The primary risk factors for venous ulcer development are older age, obesity, previous leg injuries, deep venous thrombosis, and phlebitis. A 25-year-population research found that it typically takes 5 years from the diagnosis of chronic venous insufficiency to the development of an ulcer. Start providing wound care according to the decubitus ulcers development. 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). 2 Irrigate in the shower or bathe in buckets or bowls lined with a clean plastic bag to reduce the risk of cross-infection. If you have a venous leg ulcer, you may also have: swollen ankles (oedema) discolouration or darkening of the skin around the ulcer Peripheral vascular disease is the impediment of blood flow within the peripheral vascular system due to vessel damage, which mainly affects the lower extremities. 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. It can eventually lead to ulcerations or skin breakage on the skin making the person prone infections. 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. Search dates: November 12, 2018; December 27, 2018; January 8, 2019; and March 21, 2019. Peripheral Vascular Disease (PVD) Nursing Management & Care Plan - RNpedia Provide analgesics or other painkillers as directed, at least 30 minutes before caring for a wound. We and our partners use cookies to Store and/or access information on a device. 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 SAGE Knowledge. The recommended regimen is 30 minutes, three or four times per day. Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. Examine the clients and the caregivers wound-care knowledge and skills in the area. Removal of necrotic tissue and bacterial burden through debridement has long been used in wound care to enhance healing. Males experience a lower overall incidence than females do. Immobile clients will need to be repositioned frequently to reduce the chance of breakdown in the intact parts. Nursing Interventions 1. Pressure Ulcer/Pressure Injury Nursing Care Plan - RN speak Impaired Skin Integrity ADVERTISEMENTS Impaired Skin Integrity Nursing Diagnosis Impaired Skin Integrity May be related to Chronic disease state. Chronic venous ulcers significantly impact quality of life. A simple non-sticky dressing will be used to dress your ulcer. Women aging from 40 to 49 years old may present symptoms of venous insufficiency. This content is owned by the AAFP. 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. Enzymatic debridement using collagenase has been shown to effectively remove nonviable tissue. A deep vein thrombosis nursing care plan includes assessment of the body parts, appropriate intervention, prevention, and patient education to prevent thromboembolism. Managing venous leg ulcers - Independent Nurse Oral zinc therapy has been shown to decrease healing time in patients with pilonidal sinus. 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. BACKGROUND Primary DX: venous stasis ulcer on right medial malleolus and chronic venous insufficiency. Leg ulcer may be of a mixed arteriovenous origin. Preamble. Compression therapy is beneficial for venous ulcer treatment and is the standard of care. See permissionsforcopyrightquestions and/or permission requests. Venous Ulcer Assessment and Management: Using the Updated CE 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. Compression therapy reduces edema, improves venous reflux, enhances healing of ulcers, and reduces pain.23 Success rates range from 30 to 60 percent at 24 weeks, and 70 to 85 percent after one year.22 After an ulcer has healed, lifelong maintenance of compression therapy may reduce the risk of recurrence.12,24,25 However, adherence to the therapy may be limited by pain; drainage; application difficulty; and physical limitations, including obesity and contact dermatitis.19 Contraindications to compression therapy include clinically significant arterial disease and uncompensated heart failure. In one study, intravenous iloprost (not available in the United States) used with elastic compression therapy significantly reduced healing time of venous ulcers compared with placebo.33 However, the medication is very costly and there are insufficient data to recommend its use.40, Zinc is a trace metal with potential anti-inflammatory effects. 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. Severe complications include infection and malignant change. Venous Stasis Ulcer - PATRICK SWAYZE Care Plan - WITH QUESTIONS.docx 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. Chronic venous insufficiency (CVI) is a potentially debilitating disorder associated with serious complications such as lower extremity venous ulcers. 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). such as venous ulcers and lymphoedema, concomitant bacterial and fungal colonisation or infection may be present. 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. 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. Chronic Venous Insufficiency and Postphlebitic Syndrome Ineffective Tissue Perfusion - Nursing Diagnosis & Care Plan They typically occur around the medial malleolus, tend to be shallow and moist, and may be malodorous (especially when poorly cared for) or painful. The patient will employ behaviors that will enhance tissue perfusion. Ulcers are open skin sores. Otherwise, scroll down to view this completed care plan. More analgesics should be given as needed or as directed. Make a chart for wound care. Compression therapy. 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. Saunders comprehensive review for the NCLEX-RN examination. 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. 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. 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 ulcers are usually recurrent, and an open ulcer can persist for weeks to many years. Chronic Venous Insufficiency | Penn Medicine (2020). Aspirin. They do not penetrate the deep fascia. Pentoxifylline (Trental) is an inhibitor of platelet aggregation, which reduces blood viscosity and, in turn, improves microcirculation. St. Louis, MO: Elsevier. Examine the patients vital statistics. 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.. Eventually non-healing or slow-healing wounds may form, often on the . Diagnosing Chronic Venous Insufficiency | NYU - NYU Langone Health Venous Ulcer Assessment and Management: Using the Updated CEAP workbook.pdf - 1809NRS: Effective Nursing Practice Physically restricting circulation reduces blood flow and heightens venous stasis in the pelvic, popliteal, and leg veins, causing swelling and discomfort to worsen. Managing leg ulcers in primary care | Nursing in Practice To compile a patients baseline set of observations. The venous stasis ulcer is covered with a hydrocolloid dressing, . 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. The recurrence of an ulcer in the same area is highly suggestive of venous ulcer. However, data to support its use for venous ulcers are limited.35, Overall, acute ulcers (duration of three months or less) have a 71 to 80 percent chance of healing, whereas chronic ulcers have only a 22 percent chance of healing after six months of treatment.7 Given the poor healing rates associated with chronic ulcers, surgical evaluation and management should be considered in patients with venous ulcers that are refractory to conservative therapies.48. Calf muscle contraction and intraluminal valves increase prograde flow while preventing blood reflux under normal circumstances. Leg elevation. Venous leg ulcer - Treatment - NHS They also support healthy organ function and raise well-being in general. document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. Evidence has not shown that any one dressing is superior when used with appropriate compression therapy. They should not be used in nonambulatory patients or in those with arterial compromise. Unlike the Unna boot, elastic compression therapy methods conform to changes in leg size and sustain compression during both rest and activity. Goals and Outcomes RNspeak. 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. 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. This usually needs to be changed 1 to 3 times a week. Nursing Diagnosis: Risk for Infection related to poor circulation and oxygen delivery and ischemia secondary to venous pressure ulcers. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. Two prospective randomized controlled trials reviewed the effect of sharp debridement on the healing of venous ulcers. Over time, as the veins become increasingly weak, they have more trouble sending blood to the heart. 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. Some evidence supports the use of cadexomer iodine to improve healing of venous ulcers, but evidence for other agents is lacking.38. Recognizing and Healing Venous Stasis Ulcers | Vegas Valley Vein Elastic bandages (e.g., Profore) are alternatives to compression stockings. Examine the clients and the caregivers comprehension of pressure ulcer development prevention. In one small study, leg elevation increased the laser Doppler flux (i.e., flow within veins) by 45 percent.27 Although leg elevation is most effective if performed for 30 minutes, three or four times per day, this duration of treatment may be difficult for patients to follow in real-world settings. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). Table 2 includes treatment options for venous ulcers.1622, Removal of necrotic tissue by debridement has been used to expedite wound healing. Risk Factors Trauma Thrombosis Inflammation Embolism See permissionsforcopyrightquestions and/or permission requests. Its healing can take between four and six weeks, after their initial onset (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. No one dressing type has been shown to be superior when used with appropriate compression therapy. 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. Copyright 2019 by the American Academy of Family Physicians. Patients who are severely malnourished (serum albumin 2.5 mg/dl) are more likely to acquire an infection from a pressure ulcer. 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.