Pentoxifylline (Trental) is effective when used with compression therapy for venous ulcers, and may be useful as monotherapy. As the patient is experiencing pain, have him or her score it on a scale of 0 to 10 and describe it. A simple non-sticky dressing will be used to dress your ulcer. Possible causes of venous ulcers include inflammatory processes resulting in leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema. In addition, the Unna boot may lead to a foul smell from the accumulation of exudate from the ulcer, requiring frequent reapplications.2, Elastic. Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. Conclusion Make careful to perform range-of-motion exercises if the client is bedridden. 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 management may be considered for ulcers. Teach the patient and the caretaker to report any of the following symptoms of wound infection: fever, malaise, chills, an unpleasant odor, and purulent drainage. Author: Leanne Atkin lecturer practitioner/vascular nurse consultant, School of Human and Health Sciences, University of Huddersfield and Mid Yorkshire Trust. Patient information: See related handout on venous ulcers, written by the authors of this article. 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). Date of admission: 11/07/ Current orders: . The patient will demonstrate increased tolerance to activity. Preamble. Compression therapy. She has brown hyperpigmentation on both lower legs with +2 oedema. Some evidence supports the use of cadexomer iodine to improve healing of venous ulcers, but evidence for other agents is lacking.38. Pentoxifylline (400 mg three times per day) has been shown to be an effective adjunctive treatment for venous ulcers when added to compression therapy.31,40 Pentoxifylline may also be useful as monotherapy in patients who are unable to tolerate compression bandaging.31 The most common adverse effects are gastrointestinal (e.g., nausea, vomiting, diarrhea, heartburn, loss of appetite). They typically occur around the medial malleolus, tend to be shallow and moist, and may be malodorous (especially when poorly cared for) or painful. The patient will demonstrate improved tissue perfusion as evidenced by adequate peripheral pulses, absence of edema, and normal skin color and temperature. Patients who are severely malnourished (serum albumin 2.5 mg/dl) are more likely to acquire an infection from a pressure ulcer. Males experience a lower overall incidence than females do. Effective treatments include topical silver sulfadiazine and oral antibiotics. These venoactive drugs theoretically work by improving venous tone and decreasing capillary permeability. To compile a patients baseline set of observations. Abstract: Chronic venous insufficiency (CVI) is a potentially debilitating disorder associated with serious complications such as lower extremity venous ulcers. 1, 28 Goals of compression therapy. 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. They should not be used in nonambulatory patients or in those with arterial compromise. Patient information: See related handout on venous ulcers. All Rights Reserved. Pentoxifylline. Severe complications include infection and malignant change. Arterial pulse examination and measurement of ankle-brachial index are recommended for all patients with suspected venous ulcers. Impaired Skin Integrity ADVERTISEMENTS Impaired Skin Integrity Nursing Diagnosis Impaired Skin Integrity May be related to Chronic disease state. 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. 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. Examine the clients and the caregivers wound-care knowledge and skills in the area. Debridement may be sharp, enzymatic, mechanical, larval, or autolytic. Oral antibiotics are recommended to treat venous ulcers only in cases of suspected cellulitis. Venous leg ulcers are open, often painful, sores in the skin that take more than 2 weeks to heal. Compression therapy is a standard treatment modality for initial and long-term treatment of venous ulcers in patients without concomitant arterial disease. Severe complications include cellulitis, osteomyelitis, and malignant change. Even under perfect conditions, a pressure ulcer may take weeks or months to heal. Surgical management may be considered for ulcers that are large in size, of prolonged duration, or refractory to conservative measures. Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). 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. 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. Venous ulcers are leg ulcers caused by problems with blood flow (circulation) in your leg veins. The patient will verbalize an ability to adapt sufficiently to the existing condition. Venous stasis ulcers may be treated with gauze impregnated with a zinc oxide tincture (Unna boot). Further evaluation with biopsy or referral to a subspecialist is warranted if ulcer healing stalls or the ulcer has an atypical appearance. This quiz will test your knowledge on both peripheral arterial disease (PAD) and peripheral venous . 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. 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. 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. When seated in a chair or bed, raise the patients legs as needed. o LPN education and scope of practice includes wound care. document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. She received her RN license in 1997. 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. Please follow your facilities guidelines, policies, and procedures. Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. Chronic venous insufficiency (CVI) is a potentially debilitating disorder associated with serious complications such as lower extremity venous ulcers. Enzymatic debridement using collagenase has been shown to effectively remove nonviable tissue. 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. However, in a recent meta-analysis of six small studies, oral zinc had no beneficial effect in the treatment of venous ulcers.34, Bacterial colonization and superimposed bacterial infections are common in venous ulcers and contribute to poor wound healing. Nursing Interventions 1. 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. Manage Settings 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. It can be used as secondary therapy for ulcers that do not heal with standard care.22, Like conservative therapies, the goal of operative and endovascular management of venous ulcers (i.e., endovenous ablation, ligation, subfascial endoscopic perforator surgery, and sclerotherapy) is to improve healing and prevent ulcer recurrence. 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. 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. This is often used alongside compression therapy to reduce swelling. Ulcers heal from their edges toward their centers and their bases up. Aspirin. Risk factors for the development of venous ulcers include age 55 years or older, family history of chronic venous insufficiency, higher body mass index, history of pulmonary embolism or superficial/deep venous thrombosis, lower extremity skeletal or joint disease, higher number of pregnancies, parental history of ankle ulcers, physical inactivity, history of ulcers, severe lipodermatosclerosis, and venous reflux in deep veins. St. Louis, MO: Elsevier. Examine for fecal and urinary incontinence. Physically restricting circulation reduces blood flow and heightens venous stasis in the pelvic, popliteal, and leg veins, causing swelling and discomfort to worsen. 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. They do not heal for weeks or months and sometimes longer. On physical examination, venous ulcers are generally irregular and shallow (Figure 1). Venous ulcers are the most common type of chronic lower extremity ulcers, affecting 1% to 3% of the U.S. population. Eventually non-healing or slow-healing wounds may form, often on the . Compression therapy is beneficial for venous ulcer treatment and is the standard of care. Ulcers are open skin sores. 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. 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. We can define pressure ulcers as localized areas of necrosis that tend to occur when soft tissue is compressed between two planes, one bony prominences of the patient and other external surface. History of superficial or deep venous thrombosis, pulmonary embolism, and ulcer recurrence should be ascertained with comorbid conditions. Otherwise, scroll down to view this completed care plan. Inelastic compression therapy provides high working pressure during ambulation and muscle contraction, but no resting pressure. Copyright 2023 American Academy of Family Physicians. Provide information about local wound care to the patient and the caregiver, and then let them watch a demonstration. Risk Factors Trauma Thrombosis Inflammation Embolism Despite a number of studies to support its effectiveness as adjunctive therapy, and possibly as monotherapy, the cost-effectiveness of pentoxifylline has not been established. 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. 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. Elderly people are more frequently affected. Venous ulcers are believed to account for approximately 70% to 90% of chronic leg ulcers. The recurrence of an ulcer in the same area is highly suggestive of venous ulcer. 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. Associated findings include lower extremity varicosities, edema, venous dermatitis, and lipodermatosclerosis. 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. BACKGROUND Primary DX: venous stasis ulcer on right medial malleolus and chronic venous insufficiency. 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). Venous thromboembolism occurs majorly in two ways like pulmonary embolism and deep vein thrombosis. Continuous stress to the skins' integrity will eventually cause skin breakdowns. arterial pulse examination, and measurement of ankle-brachial index is recommended for all patients with suspected venous ulcers. What intervention should the nurse implement to promote healing and prevent infection? Learn how your comment data is processed. Gently remove dry skin scales from the legs, particularly around the ulcer edges to allow new growth of epithelium. To encourage ideal patient comfort and lessen agitation/anxiety. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Copyright 2023 American Academy of Family Physicians. RNspeak. Blood backs up in the veins, building up pressure. Venous stasis ulcers are wounds that are slow to heal. disorders peggy hoff rn mn university of north florida department of nursing review liver most versatile cells in the body, ncp esophageal varices pleural effusion free download as word doc doc or read online for free esophageal varices nursing care plan pallor etc symptoms may reflect color continued bleeding varices rupture b hb level of 12 18 g dl, hi im writing a careplan on a patient who had Mechanical debridement (wet-to-dry dressings, pulsed lavage, whirlpool) has fallen out of favor. 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. August 9, 2022 Modified date: August 21, 2022. 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. 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 content is owned by the AAFP. Because bacterial colonization and infection may contribute to poor healing, systemic antibiotics are often used to treat venous ulcers. On physical examination, venous ulcers are generally irregular, shallow, and located over bony prominences. Conclusion Poor prognostic factors include large ulcer size and prolonged duration. Assist client with position changes to reduce risk of orthostatic BP changes. 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. This usually needs to be changed 1 to 3 times a week. The primary risk factors for venous ulcer development are older age, obesity, previous leg injuries, deep venous thrombosis, and phlebitis. Valves in the veins prevent backflow, but failure of the valves results in increased pressure in the veins. Care Plan Provider: Jessie Nguyen Date: 10/05/2020 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. It can also occur if something, such as a deep vein thrombosis or other clot, damages the valves inside the veins. The consent submitted will only be used for data processing originating from this website. There is inconsistent evidence concerning the benefits and harms of oral aspirin in the treatment of venous ulcers.40,41, Statins. Leg elevation when used in combination with compression therapy is also considered standard of care. 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. Continue with Recommended Cookies, Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions. Wound, Ostomy, and Continence . 2 In some studies, 50% of patients had venous ulcers that persisted for more than 9 months, and 20% had ulcers that did . Treatment options for venous ulcers include conservative management, mechanical treatment, medications, and surgical options (Table 2).1,2,7,10,19,2244 In general, the goals of treatment are to reduce edema, improve ulcer healing, and prevent recurrence. The oldest term for pressure ulcers is decubitus, which evolved into decubitus ulcers or ischemic ulcer s in the 1950s. 2 In some studies, 50% of patients had venous ulcers that persisted for more than 9 months, and 20% had ulcers that did not 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. Saunders comprehensive review for the NCLEX-RN examination. Unlike the Unna boot, elastic compression therapy methods conform to changes in leg size and sustain compression during both rest and activity. Treat venous stasis ulcers per order. 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. Elastic bandages (e.g., Profore) are alternatives to compression stockings. 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. 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. Nursing Diagnosis: Ineffective Tissue Perfusion (multiple organs) related to hyperviscosity of blood. Statins have vasoactive and anti-inflammatory effects. Table 2 includes treatment options for venous ulcers.1622, Removal of necrotic tissue by debridement has been used to expedite wound healing. A) Provide a high-calorie, high-protein diet. Color duplex ultrasonography is recommended in patients with venous ulcers to assess for venous reflux and obstruction. Although numerous treatment methods are available, they have variable effectiveness and limited data to support their use. The current plan of care is focused on promoting wound healing, improving venous return, and preventing skin breakdown. 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 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.