nursing care plan for venous stasis ulcer

Examine for fecal and urinary incontinence. Venous ulcers are leg ulcers caused by problems with blood flow (circulation) in your leg veins. Unlike the Unna boot, elastic compression therapy methods conform to changes in leg size and sustain compression during both rest and activity. 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. 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. It can also occur if something, such as a deep vein thrombosis or other clot, damages the valves inside the veins. Because bacterial colonization and infection may contribute to poor healing, systemic antibiotics are often used to treat venous ulcers. 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. 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. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Chronic venous insufficiency (CVI) is a potentially debilitating disorder associated with serious complications such as lower extremity venous ulcers. To compile a patients baseline set of observations. 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. This quiz will test your knowledge on both peripheral arterial disease (PAD) and peripheral venous . She moved into our skilled nursing home care facility 3 days ago. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Treat venous stasis ulcers per order. Venous ulcers are the most common lower extremity wounds in the United States. Venous stasis ulcers often present as shallow, irregular, well-defined ulcers with fibrinous material at the base at the distal end of the legs across the medial surface. This is often used alongside compression therapy to reduce swelling. The pressure ulcer needs to be taken into consideration as a potential cause during the septic workup. 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). mostly non-infectious condition in association with venous insufficiency and atrophy of the skin of the lower leg during long . Compression therapy helps prevent reflux, decreases release of inflammatory cytokines, and reduces fluid leakage from capillaries, thereby controlling lower extremity edema and VSU recurrence. Tell the healthcare provider if you have ever had an allergic reaction to contrast liquid. Further evaluation with biopsy or referral to a subspecialist is warranted if ulcer healing stalls or the ulcer has an atypical appearance. Leg elevation when used in combination with compression therapy is also considered standard of care. Examine the patients skin all over his or her body. . Inelastic compression wraps, most commonly zinc oxideimpregnated Unna boots, provide high compression only during ambulation and muscle contraction. 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. The disease has shown a worldwide rising incidence as the worlds population ages. Potential Nursing Interventions: (3 minimum) 1. Unna boots have limited capacity for fluid absorption in patients with highly exudative ulcers and are best used for early, small, dry ulcers and for venous dermatitis because of the skin soothing effects of zinc oxide.30, Stockings. Women aging from 40 to 49 years old may present symptoms of venous insufficiency. Venous ulcers, or stasis ulcers, account for 80 percent of lower extremity ulcerations.1 Less common etiologies for lower extremity ulcerations include arterial insufficiency; prolonged pressure; diabetic neuropathy; and systemic illness such as rheumatoid arthritis, vasculitis, osteomyelitis, and skin malignancy.2 The overall prevalence of venous ulcers in the United States is approximately 1 percent.1 Venous ulcers are more common in women and older persons.36 The primary risk factors are older age, obesity, previous leg injuries, deep venous thrombosis, and phlebitis.7, Venous ulcers are often recurrent, and open ulcers can persist from weeks to many years.810 Severe complications include cellulitis, osteomyelitis, and malignant change.3 Although the overall prevalence is relatively low, the refractory nature of these ulcers increase the risk of morbidity and mortality, and have a significant impact on patient quality of life.11,12 The financial burden of venous ulcers is estimated to be $2 billion per year in the United States.13,14, The pathophysiology of venous ulcers is not entirely clear. Venous stasis ulcers are often on the ankle or calf and are painful and red. Mechanical debridement (wet-to-dry dressings, pulsed lavage, whirlpool) has fallen out of favor. The legs should be placed in an elevated position, ideally at 30 degrees to the heart, while lying down. 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. Immobile clients will need to be repositioned frequently to reduce the chance of breakdown in the intact parts. 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). Suspected osteomyelitis warrants an evaluation for arterial disease and consideration of intravenous antibiotics to treat the underlying infection. 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. This will enable the client to apply new knowledge right away, improving retention. This prevents overdistention and quickly empties the superficial and tibial veins, which reduces tissue swelling and boosts venous return. We and our partners use cookies to Store and/or access information on a device. What is the most appropriate intervention for this diagnosis? Guidelines suggest cleansing of the affected leg should be kept simple, using warm tap water or saline. Males experience a lower overall incidence than females do. 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). These measures facilitate venous return and help reduce edema. Ackley, Nursing Diagnosis Handbook, Page 153 Nursing CLINICAL WORKSHEET Dat e: 10/2/2022 Student Name: Michele Tokar Assigned vSim: Vernon Russell Initia ls: VR Diagnosis: Right sided ischemic Position the patient back in his or her comfortable or desired posture. Poor prognostic factors include large ulcer size and prolonged duration. The recommended regimen is 30 minutes, three or four times per day. The current plan of care is focused on promoting wound healing, improving venous return, and preventing skin breakdown. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. 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. The nursing management of patients with venous leg ulcers Recommendations 30 10.0 Drug treatments 10.4 There is no evidence that aspirin increases the healing of venous leg ulcers. This is a common treatment for venous ulcers and can decrease the chance that a healed ulcer will return. 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. This provides the best conditions for the ulcer to heal. Duplex Ultrasound 2 Irrigate in the shower or bathe in buckets or bowls lined with a clean plastic bag to reduce the risk of cross-infection. Cellulitis or sepsis may develop in complicated wounds, necessitating antibiotic therapy. They usually develop on the inside of the leg, between the and the ankle. Compression stockings are removed at night and should be replaced every six months because of loss of compression with regular washing. 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. 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. 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. Color duplex ultrasonography is recommended to assess for deep and superficial venous reflux and obstruction. Pentoxifylline (Trental) is effective when used with compression therapy for venous ulcers, and may be useful as monotherapy. 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. It might be necessary to apply the prescription antibiotic cream or ointment directly to the affected area. Interventions for Venous Insufficiency Encourage the patient to elevate the legs above the level of the heart several times per day. She found a passion in the ER and has stayed in this department for 30 years. 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. 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. Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with reco Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). Although the main goal of treatment is ulcer healing, secondary goals include reduction of edema and prevention of recurrence. 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. As fluid leaking from dysfunctional veins accumulates into surrounding tissues, the flesh surrounding the area becomes irritated, inflamed, and begins to break down. The first step is to remove any debris or dead tissue from the ulcer, wash and dry it, and apply an appropriate dressing. In addition, the Unna boot may lead to a foul smell from the accumulation of exudate from the ulcer, requiring frequent reapplications.2, Elastic. Nursing care plans: Diagnoses, interventions, & outcomes. 2 In some studies, 50% of patients had venous ulcers that persisted for more than 9 months, and 20% had ulcers that did not Although numerous treatment methods are available, they have variable effectiveness and limited data to support their use. Signs of venous disease, such as varicose veins, edema, or venous dermatitis, may be present. Clean, persistent wounds that are not healing may benefit from palliative wound care. Copyright 2010 by the American Academy of Family Physicians. Venous ulcers are large and irregularly shaped with well-defined borders and a shallow, sloping edge. Chronic venous insufficiency can develop from common conditions such as varicose veins. Nursing Interventions 1. 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. Over time, as the veins become increasingly weak, they have more trouble sending blood to the heart. 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. Other associated findings include telangiectasias, corona phlebectatica, atrophie blanche, lipodermatosclerosis, and inverted champagne-bottle deformity of the lower leg. In comparison to a single long walk, short, regular walks are healthier for the extremities and the prevention of pulmonary problems. 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. Figure 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. 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. Exercise should be encouraged to improve calf muscle pump function.35,54 Good social support and self-efficacy have also been shown to help prevent venous ulcer recurrence.35, This article updates a previous article on this topic by Collins and Seraj.55. Dressings are often used under compression bandages to promote faster healing and prevent adherence of the bandage to the ulcer. It has been estimated that active VU have To diagnose chronic venous insufficiency, your NYU Langone doctor asks about your health history to determine the extent of your symptoms. 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 . Nursing Times [online issue]; 115: 6, 24-28. However, there are few high-quality studies that directly evaluate the effect of debridement versus no debridement or the superiority of one type of debridement on the rate of venous ulcer healing.3640 In addition, most wounds with significant necrotic tissue should be evaluated for arterial insufficiency because purely venous ulcers rarely need much debridement. The ultimate aim is to promote evidence-based nursing care among patients with venous leg ulcer. Citation: Atkin L (2019) Venous leg ulcer prevention 1: identifying patients who are at risk. Compression therapy Treatment focuses on preventing new ulcers, controlling edema, and reducing venous hypertension through compression therapy. Abstract. Effective treatments include topical silver sulfadiazine and oral antibiotics. Oral zinc therapy has been shown to decrease healing time in patients with pilonidal sinus. 1 The incidence of venous ulceration increases with age, and women are three times more likely than men to develop venous leg ulcers. How to Cure Venous Leg Ulcers Mark Whiteley. What intervention should the nurse implement to promote healing and prevent infection? 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. Possible causes of venous ulcers include inflammatory processes resulting in leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema. 11.0 Low level laser treatment 11.1 There is no evidence that low level laser therapy speeds the healing of venous leg ulcers. 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. Aspirin (300 mg per day) is effective when used with compression therapy for venous ulcers. 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. 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. 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. Conclusion Granulation tissue and fibrin are often present in the ulcer base. Venous hypertension as a result of venous reflux (incompetence) or obstruction is thought to be the primary underlying mechanism for venous ulcer formation. Calf muscle contraction and intraluminal valves increase prograde flow while preventing blood reflux under normal circumstances. Venous stasis ulcers may develop spontaneously or after affected skin is scratched or injured. document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. By. Continue with Recommended Cookies, Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions. Characteristic differences in clinical presentation and physical examination findings can help differentiate venous ulcers from other lower extremity ulcers (Table 1).2 The diagnosis of venous ulcers is generally clinical; however, tests such as ankle-brachial index, color duplex ultrasonography, plethysmography, and venography may be helpful if the diagnosis is unclear.1518. Continuous stress to the skins' integrity will eventually cause skin breakdowns. Referral to a wound subspecialist should be considered for ulcers that are large, of prolonged duration, or refractory to conservative measures. Conclusion 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. Search dates: November 12, 2018; December 27, 2018; January 8, 2019; and March 21, 2019. The most common method of inelastic compression therapy is the Unna boot, a zinc oxideimpregnated, moist bandage that hardens after application. Traditional negative pressure wound therapy systems are bulky and cannot be used with compression therapy. 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. Gently remove dry skin scales from the legs, particularly around the ulcer edges to allow new growth of epithelium. 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. The patient will continue to be free of systemic or local infections as shown by the lack of profuse, foul-smelling wound exudate. RNspeak. Nursing Diagnosis: Acute Pain related to pressure ulcers as evidenced by a pain level of 10/10, restlessness, and irritability, especially during wound care secondary to venous stasis ulcers. As an Amazon Associate I earn from qualifying purchases. Encourage the patient to refrain from scratching the injured regions. A clinical severity score based on the CEAP (clinical, etiology, anatomy, and pathophysiology) classification system can guide the assessment of chronic venous disorders. Saunders comprehensive review for the NCLEX-RN examination. SAGE Knowledge. Pentoxifylline. Wash the sores with the recommended cleanser to instruct the caregiver about good wound hygiene. You will undertake clinical handover and complete a nursing care plan. A) Provide a high-calorie, high-protein diet. Start providing wound care according to the decubitus ulcers development. Human skin grafting may be used for patients with large or refractory venous ulcers. Oral antibiotics are preferred, and therapy should be limited to two weeks unless evidence of wound infection persists.1, Hyperbaric Oxygen Therapy.

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