nursing care plan for venous stasis ulcer

Saunders comprehensive review for the NCLEX-RN examination. Venous ulcers are large and irregularly shaped with well-defined borders and a shallow, sloping edge. Venous stasis ulcers may develop spontaneously or after affected skin is scratched or injured. Most venous ulcers occur on the leg, above the ankle. The patient will employ behaviors that will enhance tissue perfusion. Pressure Ulcer/Pressure Injury Nursing Care Plan. Enzymatic debridement using collagenase has been shown to effectively remove nonviable tissue. Leg ulcer may be of a mixed arteriovenous origin. Chronic venous insufficiency (CVI) is a potentially debilitating disorder associated with serious complications such as lower extremity venous ulcers. The student can make adjustments as soon as they receive feedback, as opposed to practicing the skill incorrectly. The 10-point pain scale is a widely used, precise, and efficient pain rating measure. 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. Dressings are beneficial for venous ulcer healing, but no dressing has been shown to be superior. 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. They also support healthy organ function and raise well-being in general. This usually needs to be changed 1 to 3 times a week. 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 information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. Potential Nursing Interventions: (3 minimum) 1. This content is owned by the AAFP. Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. Venous ulcers are believed to account for approximately 70% to 90% of chronic leg ulcers. 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. Copyright 2010 by the American Academy of Family Physicians. 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. These ulcers are caused by poor circulation, diabetes and other conditions. The patient will continue to be free of systemic or local infections as shown by the lack of profuse, foul-smelling wound exudate. They do not penetrate the deep fascia. Care Plan Provider: Jessie Nguyen Date: 10/05/2020 Early endovenous ablation to correct superficial venous reflux improves ulcer healing rates. See permissionsforcopyrightquestions and/or permission requests. If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Poor prognostic factors include large ulcer size and prolonged duration. Compression therapy is beneficial for venous ulcer treatment and is the standard of care. 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. Valves in the veins prevent backflow, but failure of the valves results in increased pressure in the veins. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). The first step is to remove any debris or dead tissue from the ulcer, wash and dry it, and apply an appropriate dressing. They typically occur around the medial malleolus, tend to be shallow and moist, and may be malodorous (especially when poorly cared for) or painful. Pentoxifylline (Trental) is effective when used with compression therapy for venous ulcers, and may be useful as monotherapy. On physical examination, venous ulcers are generally irregular and shallow with well-defined borders and are often located over bony prominences. Color duplex ultrasonography is recommended to assess for deep and superficial venous reflux and obstruction. To encourage numbing of the pain and patient comfort without the danger of an overdose. In comparison to a single long walk, short, regular walks are healthier for the extremities and the prevention of pulmonary problems. There are many cellular and tissue-based products approved for the treatment of refractory venous ulcers, including allografts, animal-derived extracellular matrix products, human-derived cellular products, and human amniotic membranederived products. Immobile clients will need to be repositioned frequently to reduce the chance of breakdown in the intact parts. 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. Provide analgesics or other painkillers as directed, at least 30 minutes before caring for a wound. This provides the best conditions for the ulcer to heal. Dehydration makes blood more viscous and causes venous stasis, which makes thrombus development more likely. 11.0 Low level laser treatment 11.1 There is no evidence that low level laser therapy speeds the healing of venous leg ulcers. 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. Treat venous stasis ulcers per order. Surgical management may be considered for ulcers. Traditional negative pressure wound therapy systems are bulky and cannot be used with compression therapy. If necessary, recommend the physical therapy team. Color duplex ultrasonography is recommended in patients with venous ulcers to assess for venous reflux and obstruction. Nursing Diagnosis: Ineffective Tissue Perfusion (multiple organs) related to hyperviscosity of blood. BACKGROUND Primary DX: venous stasis ulcer on right medial malleolus and chronic venous insufficiency. If you have a venous leg ulcer, you may also have: swollen ankles (oedema) discolouration or darkening of the skin around the ulcer Anna Curran. Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). 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. Traditional conservative management of venous ulcers usually entails compression therapy, leg elevation to reduce edema, and dressings on the wound. Venous incompetence and associated venous hypertension are thought to be the primary mechanisms for ulcer formation. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. Choice of knee-high, thigh-high, toes-in, or toes-out compression stockings depends on patient preference. Affect 9% of patients admitted to hospital and 23% of those admitted to nursing homes. It might be necessary to apply the prescription antibiotic cream or ointment directly to the affected area. Buy on Amazon. Leg elevation. She has brown hyperpigmentation on both lower legs with +2 oedema. 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. No one dressing type has been shown to be superior when used with appropriate compression therapy. Inelastic compression wraps, most commonly zinc oxideimpregnated Unna boots, provide high compression only during ambulation and muscle contraction. On physical examination, venous ulcers are generally irregular and shallow (Figure 1). Provide information about local wound care to the patient and the caregiver, and then let them watch a demonstration. 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. Granulation tissue and fibrin are often present in the ulcer base. Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). Compression therapy has been proven beneficial for venous ulcer treatment and is the standard of care. Severe complications include infection and malignant change. 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). Teach the caretaker how to properly care for the afflicted regions of the wounds if the patient is to be discharged. Patient who needs wound care for a chronic venous stasis ulcer on the lower leg. Nursing Interventions 1. On physical examination, venous ulcers are generally irregular, shallow, and located over bony prominences. A group of nurse judges experienced in the treatment of venous ulcer validated 84 nursing diagnoses and outcomes, and 306 interventions. Patients who are severely malnourished (serum albumin 2.5 mg/dl) are more likely to acquire an infection from a pressure ulcer. Chronic venous ulcers significantly impact quality of life. 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. There are numerous online resources for lay education. 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. Author disclosure: No relevant financial affiliations. 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 ). This content is owned by the AAFP. Referral to a wound subspecialist should be considered for ulcers that are large, of prolonged duration, or refractory to conservative measures. We and our partners use cookies to Store and/or access information on a device. Some of our partners may process your data as a part of their legitimate business interest without asking for consent. Calf muscle contraction and intraluminal valves increase prograde flow while preventing blood reflux under normal circumstances. Here are three (3) nursing care plans (NCP) and nursing diagnosis for pressure ulcers (bedsores): ADVERTISEMENTS Impaired Skin Integrity Risk For Infection Risk For Ineffective Health Maintenance 1. She found a passion in the ER and has stayed in this department for 30 years. 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. St. Louis, MO: Elsevier. 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. 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). Venous ulcers are the most common type of chronic lower extremity ulcers, affecting 1% to 3% of the U.S. population. Please follow your facilities guidelines, policies, and procedures. Of the diagnoses developed, 62 are included in ICNP and 23 are new diagnoses, not included. At-home wound healing can be accelerated by providing proper wound care and bandaging the damaged regions to stop pressure injury from getting worse. Arterial pulse examination and measurement of ankle-brachial index are recommended for all patients with suspected venous ulcers. Venous stasis ulcers are often on the ankle or calf and are painful and red. This will enable the client to apply new knowledge right away, improving retention. Venous leg ulcers are open, often painful, sores in the skin that take more than 2 weeks to heal. More analgesics should be given as needed or as directed. Author: Leanne Atkin lecturer practitioner/vascular nurse consultant, School of Human and Health Sciences, University of Huddersfield and Mid Yorkshire Trust. 1, 28 Goals of compression therapy. Elderly people are more frequently affected. Date of admission: 11/07/ Current orders: . Duplex Ultrasound 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. Once the ulcer has healed, continued use of compression stockings is recommended indefinitely. Patient information: See related handout on venous ulcers, written by the authors of this article. 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. The synthetic prostacyclin iloprost is a vasodilator that inhibits platelet aggregation. A more recent article on venous ulcers is available. 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. 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. 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. The recurrence of an ulcer in the same area is highly suggestive of venous ulcer. 1 The incidence of venous ulceration increases with age, and women are three times more likely than men to develop venous leg ulcers. He or she also performs a physical exam to look for swelling, skin changes, varicose veins, or ulcers on the leg. 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. To prevent the infection from getting worse, it is best to discourage the youngster from scratching the sores, even if they are just mildly itchy. Encourage deep breathing exercises and pursed lip breathing. 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. 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. Causes of Venous Leg Ulcers The speci c cause of venous ulcers is poor venous return. Nursing Times [online issue]; 115: 6, 24-28. 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. The recommended regimen is 30 minutes, three or four times per day. 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. Based on a clinical practice guideline on disease-oriented outcome, Based on a clinical practice guideline and clinical review on disease-oriented outcome, Based on a clinical practice guideline on disease-oriented outcome and systematic review of moderate-quality evidence, Based on a clinical practice guideline on disease-oriented outcome and review article, Based on a clinical practice guideline on disease-oriented outcome, commentary, and Cochrane review of randomized controlled trials, Based on one randomized controlled trial of more than 400 patients, Most common type of chronic lower extremity ulcer, Venous hypertension due to chronic venous insufficiency. They usually develop on the inside of the leg, between the and the ankle. If not treated, increased pressure and excess fluid in the affected area can cause an open sore to form. 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. Professional Skills in Nursing: A Guide for the Common Foundation Programme. nous insufficiency and ambulatory venous hypertension. arterial pulse examination, and measurement of ankle-brachial index is recommended for all patients with suspected venous ulcers. Specific written plans are necessary for long-term management to improve treatment adherence. 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. Eventually non-healing or slow-healing wounds may form, often on the . 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. Removal of necrotic tissue and bacterial burden through debridement has long been used in wound care to enhance healing. Figure 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 diagnoses handbook: An evidence-based guide to planning care. Venous ulcers commonly occur in the gaiter area of the lower leg. 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. Compression therapy is a standard treatment modality for initial and long-term treatment of venous ulcers in patients without concomitant arterial disease. 34. Leg elevation minimizes edema in patients with venous insufficiency and is recommended as adjunctive therapy for venous ulcers. Venous thromboembolism occurs majorly in two ways like pulmonary embolism and deep vein thrombosis. Preamble. They can affect any area of the skin. Effective treatments include topical silver sulfadiazine and oral antibiotics. Venous stasis ulcers may be treated with gauze impregnated with a zinc oxide tincture (Unna boot). SUSAN BONKEMEYER MILLAN, MD, RUN GAN, MD, AND PETRA E. TOWNSEND, MD. Abstract. Search dates: November 12, 2018; December 27, 2018; January 8, 2019; and March 21, 2019. 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. Possible causes of venous ulcers include inflammatory processes resulting in leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema. This means they can't stop blood which should be headed upward to your heart from being pulled down by gravity. A deep vein thrombosis nursing care plan includes assessment of the body parts, appropriate intervention, prevention, and patient education to prevent thromboembolism. 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. Table 2 includes treatment options for venous ulcers.1622, Removal of necrotic tissue by debridement has been used to expedite wound healing. Other associated findings include telangiectasias, corona phlebectatica, atrophie blanche, lipodermatosclerosis, and inverted champagne-bottle deformity of the lower leg.

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