nursing care plan for venous stasis ulcer

Causes of Venous Leg Ulcers The speci c cause of venous ulcers is poor venous return. Other associated findings include telangiectasias, corona phlebectatica, atrophie blanche, lipodermatosclerosis, and inverted champagne-bottle deformity of the lower leg. On physical examination, venous ulcers are generally irregular and shallow (Figure 1). Possible causes of venous ulcers include inflammatory processes resulting in leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema. Pressure Ulcer/Pressure Injury Nursing Care Plan - RN speak Pressure Ulcer/Pressure Injury Nursing Care Plan. Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with reco The primary risk factors for venous ulcer development are older age, obesity, previous leg injuries, deep venous thrombosis, and phlebitis. Peripheral Vascular Disease (PVD) Nursing Management & Care Plan - RNpedia This hemorheologic agent affects microcirculation and oxygenation, and can be used effectively as monotherapy or with compression therapy for venous ulcers.1,39 In seven randomized controlled trials, pentoxifylline plus compression improved healing of venous ulcers compared with placebo plus compression. 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. Chronic venous insufficiency: A review for nurses : Nursing2022 - LWW This provides the best conditions for the ulcer to heal. Color duplex ultrasonography is recommended in patients with venous ulcers to assess for venous reflux and obstruction. They do not heal for weeks or months and sometimes longer. 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 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). Encourage deep breathing exercises and pursed lip breathing. 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 Venous Leg Ulcers Treatment | 3M US | 3M Health Care 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. PDF Nursing Interventions Aimed at Persons with Venous Ulcers: an Contrast venography is a procedure used to show the veins on x-ray pictures. nous insufficiency and ambulatory venous hypertension. B) Apply a clean occlusive dressing once daily and whenever soiled. Interventions for Venous Insufficiency Encourage the patient to elevate the legs above the level of the heart several times per day. Clinical Tools | WOCN Society It might be necessary to apply the prescription antibiotic cream or ointment directly to the affected area. Statins have vasoactive and anti-inflammatory effects. This will enable the client to apply new knowledge right away, improving retention. Compression therapy is a standard treatment modality for initial and long-term treatment of venous ulcers in patients without concomitant arterial disease. The student can make adjustments as soon as they receive feedback, as opposed to practicing the skill incorrectly. Leg elevation minimizes edema in patients with venous insufficiency and is recommended as adjunctive therapy for venous ulcers. Venous ulcers commonly occur in the gaiter area of the lower leg. . Leg elevation. Two prospective randomized controlled trials reviewed the effect of sharp debridement on the healing of venous ulcers. Even under perfect conditions, a pressure ulcer may take weeks or months to heal. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. The term bedsores indicate the association of wounds with a stay in bed, which ignores the potential occurrence . 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. Chronic venous insufficiency can pose a more serious result if not given proper medical attention. This content is owned by the AAFP. Any delay in care increases the risk of infection, sepsis, amputation, skin cancers, and death. It can also occur if something, such as a deep vein thrombosis or other clot, damages the valves inside the veins. In one study, patients with venous ulcers used more medical resources than those without, and their annual per-patient health expenditures were increased by $6,391 for those with Medicare and $7,030 for those with private health insurance. 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. More analgesics should be given as needed or as directed. Elderly people are more frequently affected. A systematic review of hyperbaric oxygen therapy in patients with chronic wounds found only one trial that addressed venous ulcers. 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. To assess the size and extent of decubitus ulcers, as well as any affected areas that need specific care or wound treatment. By. Males experience a lower overall incidence than females do. Venous Ulcers | Johns Hopkins Medicine 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. Conclusion Cellulitis or sepsis may develop in complicated wounds, necessitating antibiotic therapy. Manage Settings Compression therapy reduces swelling and encourages healthy blood circulation. Start performing active or passive exercises while in bed, including occasionally rotating, flexing, and extending the feet. Assist client with position changes to reduce risk of orthostatic BP changes. St. Louis, MO: Elsevier. To encourage ideal patient comfort and lessen agitation/anxiety. Suspected osteomyelitis warrants an evaluation for arterial disease and consideration of intravenous antibiotics to treat the underlying infection. Peripheral Vascular Disease NCLEX Questions - Registered Nurse RN The patient will demonstrate improved tissue perfusion as evidenced by adequate peripheral pulses, absence of edema, and normal skin color and temperature. Compression therapy Treatment focuses on preventing new ulcers, controlling edema, and reducing venous hypertension through compression therapy. RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. 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 wide range of dressings are available, including hydrocolloids (e.g., Duoderm), foams, hydrogels, pastes, and simple nonadherent dressings.14,28 A meta-analysis of 42 randomized controlled trials (RCTs) with a total of more than 1,000 patients showed no significant difference among dressing types.29 Furthermore, the more expensive hydrocolloid dressings were not shown to have a healing benefit over the lower-cost simple nonadherent dressings. Ineffective Tissue Perfusion Nursing Diagnosis & Care Plan PDF Nursing Care of the Patient with Venous Disease - Fort HealthCare Venous ulcers - self-care: MedlinePlus Medical Encyclopedia 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. Stasis Ulcer: Vascular Ulcer Causes, Symptoms and Treatment Eventually non-healing or slow-healing wounds may form, often on the . If necessary, recommend the physical therapy team. Calf muscle contraction and intraluminal valves increase prograde flow while preventing blood reflux under normal circumstances. 2 In some studies, 50% of patients had venous ulcers that persisted for more than 9 months, and 20% had ulcers that did . Arterial pulse examination and measurement of ankle-brachial index are recommended for all patients with suspected venous ulcers. (2020). Women aging from 40 to 49 years old may present symptoms of venous insufficiency. 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. If you have a venous leg ulcer, you may also have: swollen ankles (oedema) discolouration or darkening of the skin around the ulcer 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. Professional Skills in Nursing: A Guide for the Common Foundation Programme. ANTICIPATED NURSING INTERVENTIONS Venous Stasis Ulcer = malfunctioning venous valves causing pressure in the veins to increase o Pathophysiology: Venous (or stasis) ulceration is initiated by venous hypertension that develops because of inadequate calf muscle pump action o Risk factors: Diabetes mellitus Congestive heart failure Peripheral . Physically restricting circulation reduces blood flow and heightens venous stasis in the pelvic, popliteal, and leg veins, causing swelling and discomfort to worsen. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. Copyright 2023 American Academy of Family Physicians. 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. Compression therapy is a standard treatment modality for initial and long-term treatment of venous ulcers in patients without concomitant arterial disease. 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. 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. workbook.pdf - 1809NRS: Effective Nursing Practice St. Louis, MO: Elsevier. Otherwise, scroll down to view this completed care plan. The nursing management of patients with venous leg ulcers - SlideShare 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. 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). Most patients have venous leg ulcer due to chronic venous insufficiency. Preamble. In diabetic patients, distal symmetric neuropathy and peripheral . The specialists of the Vascular Ulcer and Wound Healing Clinic diagnose and treat people with persistent wounds (ulcers) at the Gonda Vascular Center on Mayo Clinic's campus in Minnesota. Debridement may be sharp (e.g., using curette or scissors), enzymatic, mechanical, biologic (i.e., using larvae), or autolytic. 2016 AHA/ACC Guideline on the Management of Patients With Lower 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. PDF Learning Package Assessment and Management of Venous Leg Ulcers - RNAO Copyright 2019 by the American Academy of Family Physicians. She has worked in Medical-Surgical, Telemetry, ICU and the ER. 2 In some studies, 50% of patients had venous ulcers that persisted for more than 9 months, and 20% had ulcers that did not 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. Nursing Diagnosis: Ineffective Tissue Perfusion (multiple organs) related to hyperviscosity of blood. 17 Patient information: See related handout on venous ulcers, written by the authors of this article. These measures facilitate venous return and help reduce edema. The nurse is caring for a patient with a large venous leg ulcer. Early venous ablation and surgical intervention to correct superficial venous reflux can improve healing and decrease recurrence rates. Over time, as the veins become increasingly weak, they have more trouble sending blood to the heart. Common drugs in this class include saponins (e.g., horse chestnut seed extract), flavonoids (e.g., rutosides, diosmin, hesperidin), and micronized purified flavonoid fraction.43 Although phlebotonics may improve edema and other signs and symptoms of chronic venous insufficiency (e.g., trophic disorders, cramps, restless legs, swelling, paresthesia), there was no difference in venous ulcer healing when compared with placebo.44, Antibiotics. 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. Dressings are recommended to cover venous ulcers and promote moist wound healing. St. Louis, MO: Elsevier. What is the most appropriate intervention for this diagnosis? Figure On physical examination, venous ulcers are generally irregular and shallow with well-defined borders and are often located over bony prominences. Nursing Diagnosis For Pressure Ulcers The Unna boot improves healing rates compared with placebo or hydroactive dressings.22,26 However, a 2009 Cochrane review found that adding a component of elastic compression therapy is more effective than inelastic compression therapy alone.45 Also, because of its inelasticity, the Unna boot does not conform to changes in leg size and may be uncomfortable to wear. Examine the patients vital statistics. Enzymatic debridement using collagenase has been shown to effectively remove nonviable tissue. 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. 2 Irrigate in the shower or bathe in buckets or bowls lined with a clean plastic bag to reduce the risk of cross-infection. Start providing wound care according to the decubitus ulcers development. Diagnosis and Treatment of Venous Ulcers - WoundSource Encourage the patient to refrain from scratching the injured regions. 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. 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. Venous leg ulcer - Symptoms - NHS Venous leg ulcer prevention 1: identifying patients who - Nursing Times Tell the healthcare provider if you have ever had an allergic reaction to contrast liquid. . 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. Examine the patients skin all over his or her body. Create Concept Map and a Care Plan for impaired skin. - ITProSpt 2010. We and our partners use data for Personalised ads and content, ad and content measurement, audience insights and product development. Clean, persistent wounds that are not healing may benefit from palliative wound care. 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. 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. Peripheral vascular disease (PVD) NCLEX review questions for nursing students! They should not be used in nonambulatory patients or in those with arterial compromise. As long as the heart can handle it, up the patients daily fluid intake to at least 1500 to 2000 mL. [List of diagnostic tests and procedures in leg ulcer] - PubMed This content is owned by the AAFP. Traditional conservative management of venous ulcers usually entails compression therapy, leg elevation to reduce edema, and dressings on the wound. 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. Venous Stasis Ulcer Nursing Diagnosis and Nursing Care Plan Diagnosis and Treatment of Venous Ulcers | AAFP Stockings or bandages can be used; however, elastic wraps (e.g., Ace wraps) are not recommended because they do not provide enough pressure.45 Compression stockings are graded, with the greatest pressure at the ankle and gradually decreasing pressure toward the knee and thigh (pressure should be at least 20 to 30 mm Hg, and preferably 30 to 44 mm Hg). Less often, patients have arterial leg ulcer resulting from peripheral arterial occlusive disease, the most common cause of which is arteriosclerosis. 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. Venous Ulcer Assessment and Management: Using the Updated CE There is inconsistent evidence concerning the benefits and harms of oral aspirin in the treatment of venous ulcers.40,41, Statins. Venous Ulcer Symptoms and Treatment | UPMC 1, 28 Goals of compression therapy. In comparison to a single long walk, short, regular walks are healthier for the extremities and the prevention of pulmonary problems. Make careful to perform range-of-motion exercises if the client is bedridden. Continuous stress to the skins' integrity will eventually cause skin breakdowns. Saunders comprehensive review for the NCLEX-RN examination. For wound closure to be effective, leg edema must be reduced. 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. Author: Leanne Atkin lecturer practitioner/vascular nurse consultant, School of Human and Health Sciences, University of Huddersfield and Mid Yorkshire Trust. Patients treated with debridement at each physician's office visit had significant reduction in wound size compared with those not treated with debridement.20. The venous stasis ulcer is covered with a hydrocolloid dressing, . Duplex Ultrasound The patient will verbalize an ability to adapt sufficiently to the existing condition. C) Irrigate the wound with hydrogen peroxide once daily. Managing leg ulcers in primary care | Nursing in Practice Chronic Venous Insufficiency and Postphlebitic Syndrome Nursing Diagnosis: Risk for Infection related to poor circulation and oxygen delivery and ischemia secondary to venous pressure ulcers. This article has been double-blind peer reviewed 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. RACGP - Management of venous leg ulcers in general practice - a 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. Severe complications include cellulitis, osteomyelitis, and malignant change. 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. Inelastic compression therapy provides high working pressure during ambulation and muscle contraction, but no resting pressure. Compression therapy is beneficial for venous ulcer treatment and is the standard of care. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. To encourage numbing of the pain and patient comfort without the danger of an overdose. Learn how your comment data is processed. Your care team may include doctors who specialize in blood vessel (vascular . Nursing Care Plan for: Impaired Skin Integrity, Risk for Skin Breakdown, Altered Skin Integrity, and Risk for Pressure Ulcers. On physical examination, venous ulcers are generally irregular, shallow, and located over bony prominences. Tiny valves in the veins can fail. arterial pulse examination, and measurement of ankle-brachial index is recommended for all patients with suspected venous ulcers.