nursing care plan for venous stasis ulcer
In diabetic patients, distal symmetric neuropathy and peripheral . 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. Encourage the patient to refrain from scratching the injured regions. These actions are intended to improve overall muscle tone and strength, as well as boost venous return from the lower extremities and decrease venous stasis. 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. Venous leg ulcers are open, often painful, sores in the skin that take more than 2 weeks to heal. Care Plan Provider: Jessie Nguyen Date: 10/05/2020 Leg elevation requires raising lower extremities above the level of the heart, with the aim of reducing edema, improving microcirculation and oxygen delivery, and hastening ulcer healing. 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. Nursing Interventions 1. 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. These ulcers are caused by poor circulation, diabetes and other conditions. They also support healthy organ function and raise well-being in general. Professional Skills in Nursing: A Guide for the Common Foundation Programme. Provide analgesics or other painkillers as directed, at least 30 minutes before caring for a wound. Dehydration makes blood more viscous and causes venous stasis, which makes thrombus development more likely. They usually develop on the inside of the leg, between the and the ankle. These venoactive drugs theoretically work by improving venous tone and decreasing capillary permeability. The term bedsores indicate the association of wounds with a stay in bed, which ignores the potential occurrence . Compression stockings Wearing compression stockings all day is often the first approach to try. Venous ulcers are the most common type of chronic lower extremity ulcers, affecting 1% to 3% of the U.S. population. Associated findings include lower extremity varicosities, edema, venous dermatitis, and lipodermatosclerosis. They do not penetrate the deep fascia. Conclusion This article reviews the incidence and pathophysiology of CVI, nursing assessment, diagnosis and interventions, and patient education needed to manage the disease and prevent . Venous ulcers are leg ulcers caused by problems with blood flow (circulation) in your leg veins. A clinical severity score based on the CEAP (clinical, etiology, anatomy, and pathophysiology) classification system can guide the assessment of chronic venous disorders. Wash the sores with the recommended cleanser to instruct the caregiver about good wound hygiene. Peripheral Vascular Disease NCLEX Questions - Registered Nurse RN Pressure Ulcer/Pressure Injury Nursing Care Plan - RN speak Eventually non-healing or slow-healing wounds may form, often on the . She received her RN license in 1997. Evidence has not shown that any one dressing is superior when used with appropriate compression therapy. document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. SUSAN BONKEMEYER MILLAN, MD, RUN GAN, MD, AND PETRA E. TOWNSEND, MD. The patient will demonstrate increased tolerance to activity. Because bacterial colonization and infection may contribute to poor healing, systemic antibiotics are often used to treat venous ulcers. No one dressing type has been shown to be superior when used with appropriate compression therapy. The Peristomal Skin Assessment Guide for Clinicians is a mobile tool that provides basic guidance to clinicians on identifying and treating peristomal skin complications, including instructions for patient care and conditions that warrant referral to a WOC/NSWOC (Nurse Specialized in Wound, Ostomy and Continence). 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. Nursing Care of the Patient with Venous Disease - Fort HealthCare Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. The legs should be placed in an elevated position, ideally at 30 degrees to the heart, while lying down. A) Provide a high-calorie, high-protein diet. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. As an Amazon Associate I earn from qualifying purchases. Venous stasis ulcers are often on the ankle or calf and are painful and red. It can eventually lead to ulcerations or skin breakage on the skin making the person prone infections. Clinical Tools | WOCN Society Compression stockings are removed at night, and should be replaced every six months because they lose pressure with regular washing.2. Copyright 2010 by the American Academy of Family Physicians. 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 causes blood to collect and pool in the vein, leading to swelling in the lower leg. Valves in the veins prevent backflow, but failure of the valves results in increased pressure in the veins. 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. Provide information about local wound care to the patient and the caregiver, and then let them watch a demonstration. A catheter is guided into the vein. Venous ulcers are the most common lower extremity wounds in the United States. If necessary, recommend the physical therapy team. To encourage ideal patient comfort and lessen agitation/anxiety. 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. Venous ulcers are large and irregularly shaped with well-defined borders and a shallow, sloping edge. Duplex Ultrasound On physical examination, venous ulcers are generally irregular and shallow with well-defined borders and are often located over bony prominences. Women aging from 40 to 49 years old may present symptoms of venous insufficiency. 3 Pressure Ulcer (Bedsores) Nursing Care Plans - Nurseslabs Poor venous return is due to damage of the valves in leg veins that facilitate the return of the blood to the heart. 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. Otherwise, scroll down to view this completed care plan. 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). 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. Venous leg ulcer - Treatment - NHS St. Louis, MO: Elsevier. Examine the clients and the caregivers comprehension of the long-term nature of wound healing. Copyright 2019 by the American Academy of Family Physicians. Venous stasis ulcers may be treated with gauze impregnated with a zinc oxide tincture (Unna boot). Oral antibiotics are preferred, and therapy should be limited to two weeks unless evidence of wound infection persists.1, Hyperbaric Oxygen 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. You will undertake clinical handover and complete a nursing care plan. Granulation tissue and fibrin are often present in the ulcer base. 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). A systematic review of hyperbaric oxygen therapy in patients with chronic wounds found only one trial that addressed venous ulcers. By. Venous ulcers are believed to account for approximately 70% to 90% of chronic leg ulcers. After administering the analgesic, give the patient 30 to 60 minutes to rate their acute pain again. Its healing can take between four and six weeks, after their initial onset (1). The patient will verbalize an ability to adapt sufficiently to the existing condition. Learn how your comment data is processed. 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. 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. Your doctor may also recommend certain diagnostic imaging tests. Nursing Times [online issue]; 115: 6, 24-28. St. Louis, MO: Elsevier. 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. Examine the patients vital statistics. The recurrence of an ulcer in the same area is highly suggestive of venous ulcer. The first step is to remove any debris or dead tissue from the ulcer, wash and dry it, and apply an appropriate dressing. Even under perfect conditions, a pressure ulcer may take weeks or months to heal. To encourage numbing of the pain and patient comfort without the danger of an overdose. This prevents overdistention and quickly empties the superficial and tibial veins, which reduces tissue swelling and boosts venous return. On physical examination, venous ulcers are generally irregular and shallow (Figure 1). 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. Debridement may be sharp (e.g., using curette or scissors), enzymatic, mechanical, biologic (i.e., using larvae), or autolytic. PDF Learning Package Assessment and Management of Venous Leg Ulcers - RNAO Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. Effective treatments include topical silver sulfadiazine and oral antibiotics. This quiz will test your knowledge on both peripheral arterial disease (PAD) and peripheral venous . Intermittent pneumatic compression may be considered when there is generalized, refractory edema from venous insufficiency; lymphatic obstruction; and significant ulceration of the lower extremity. Oral antibiotics are recommended to treat venous ulcers only in cases of suspected cellulitis. Isolating the wound from the perineal region can occasionally be challenging. Search dates: November 12, 2018; December 27, 2018; January 8, 2019; and March 21, 2019. An example of data being processed may be a unique identifier stored in a cookie. 2 Irrigate in the shower or bathe in buckets or bowls lined with a clean plastic bag to reduce the risk of cross-infection. Chronic venous insufficiency (CVI) is a potentially debilitating disorder associated with serious complications such as lower extremity venous ulcers. Dressings are recommended to cover venous ulcers and promote moist wound healing. Peripheral vascular disease (PVD) NCLEX review questions for nursing students! This is often used alongside compression therapy to reduce swelling. Ineffective Tissue Perfusion Nursing Diagnosis & Care Plan This content is owned by the AAFP. Venous stasis ulcers are wounds caused by the accumulation of fluid that commonly accompanies vein disorders. A yellow, fibrous tissue may cover the ulcer and have an irregular border. The 10-point pain scale is a widely used, precise, and efficient pain rating measure. We and our partners use cookies to Store and/or access information on a device. Referral to a wound subspecialist should be considered for ulcers that are large, of prolonged duration, or refractory to conservative measures. Compression therapy helps prevent reflux, decreases release of inflammatory cytokines, and reduces fluid leakage from capillaries, thereby controlling lower extremity edema and VSU recurrence. 11.0 Low level laser treatment 11.1 There is no evidence that low level laser therapy speeds the healing of venous leg ulcers. Over time, as the veins become increasingly weak, they have more trouble sending blood to the heart. Some evidence supports the use of cadexomer iodine to improve healing of venous ulcers, but evidence for other agents is lacking.38. The patient will demonstrate improved tissue perfusion as evidenced by adequate peripheral pulses, absence of edema, and normal skin color and temperature. See permissionsforcopyrightquestions and/or permission requests. 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.