nursing care plan for venous stasis ulcer

VLUs are the result of chronic venous insufficiency (CVI) in the legs. The student can make adjustments as soon as they receive feedback, as opposed to practicing the skill incorrectly. PDF Nursing Care Plan For Bleeding Esophageal Varices 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. 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). Compression stockings are removed at night and should be replaced every six months because of loss of compression with regular washing. 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. Inelastic compression therapy provides high working pressure during ambulation and muscle contraction, but no resting pressure. Citation: Atkin L (2019) Venous leg ulcer prevention 1: identifying patients who are at risk. 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. Nursing Interventions 1. Negative pressure wound therapy is not recommended as a primary treatment of venous ulcers.48 There may be a future role for newer, ultraportable, single-use systems that can be used underneath compression devices.49,50, Venous ulcers that do not improve within four weeks of standard wound care should prompt consideration of adjunctive treatment options.51, Cellular and Tissue-Based Products. The disease has shown a worldwide rising incidence as the worlds population ages. 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. 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. Nursing Care Plan for: Impaired Skin Integrity, Risk for Skin Breakdown, Altered Skin Integrity, and Risk for Pressure Ulcers. 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. 2 In some studies, 50% of patients had venous ulcers that persisted for more than 9 months, and 20% had ulcers that did . Venous ulcers commonly occur in the gaiter area of the lower leg. Intermittent Pneumatic Compression. Nursing Interventions in Prevention and Healing of Leg Ulcers B) Apply a clean occlusive dressing once daily and whenever soiled. Of the diagnoses developed, 62 are included in ICNP and 23 are new diagnoses, not included. Venous Ulcers | Johns Hopkins Medicine Her Waterlow Scale is 16, and her skin is intact except for the venous stasis ulcer on the right medial malleolus. 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 ). 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. Women aging from 40 to 49 years old may present symptoms of venous insufficiency. Make a chart for wound care. Inelastic. [List of diagnostic tests and procedures in leg ulcer] - PubMed 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. 2 Irrigate in the shower or bathe in buckets or bowls lined with a clean plastic bag to reduce the risk of cross-infection. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. Chronic venous insufficiency: A review for nurses : Nursing2022 - LWW 11.0 Low level laser treatment 11.1 There is no evidence that low level laser therapy speeds the healing of venous leg ulcers. PVD can be related to an arterial or venous issue. 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. The venous stasis ulcer is covered with a hydrocolloid dressing, . 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. The patient will continue to be free of systemic or local infections as shown by the lack of profuse, foul-smelling wound exudate. A more recent article on venous ulcers is available. They can affect any area of the skin. The 10-point pain scale is a widely used, precise, and efficient pain rating measure. Peripheral Vascular Disease (PVD) Nursing Management & Care Plan - RNpedia They typically occur around the medial malleolus, tend to be shallow and moist, and may be malodorous (especially when poorly cared for) or painful. 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. There is inconsistent evidence concerning the benefits and harms of oral aspirin in the treatment of venous ulcers.40,41, Statins. Start performing active or passive exercises while in bed, including occasionally rotating, flexing, and extending the feet. nous insufficiency and ambulatory venous hypertension. 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. Nursing Diagnosis: Ineffective Tissue Perfusion (multiple organs) related to hyperviscosity of blood. 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. Venous stasis ulcers are wounds caused by the accumulation of fluid that commonly accompanies vein disorders. History of superficial or deep venous thrombosis, pulmonary embolism, and ulcer recurrence should be ascertained with comorbid conditions. There are numerous online resources for lay education. Buy on Amazon. To evaluate whether a treatment is effective. Assessment and Management of Patients With Hematologic Disorders The current plan of care is focused on promoting wound healing, improving venous return, and preventing skin breakdown. 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. 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. 34. 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. 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. After administering the analgesic, give the patient 30 to 60 minutes to rate their acute pain again. The legs should be placed in an elevated position, ideally at 30 degrees to the heart, while lying down. Evidence has not shown that any one dressing is superior when used with appropriate compression therapy.18 Types of dressings are summarized in Table 3.37, Topical antiseptics, including cadexomer iodine (Iodosorb), povidone-iodine (Betadine), peroxide-based preparations, honey-based preparations, and silver, have been used to treat venous ulcers. Arterial pulse examination and measurement of ankle-brachial index are recommended for all patients with suspected venous ulcers. A clinical severity score based on the CEAP (clinical, etiology, anatomy, and pathophysiology) classification system can guide the assessment of chronic venous disorders. workbook.pdf - 1809NRS: Effective Nursing Practice Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. Possible causes of venous ulcers include inflammatory processes resulting in leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema. Evidence has not shown that any one dressing is superior when used with appropriate compression therapy. Learn how your comment data is processed. Managing leg ulcers in primary care | Nursing in Practice A yellow, fibrous tissue may cover the ulcer and have an irregular border. 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. Encouraging the patient through physical therapy to get out of bed and sit down and carry out the necessary exercises. 1, 28 Goals of compression therapy. arterial pulse examination, and measurement of ankle-brachial index is recommended for all patients with suspected venous ulcers. -. This prevents overdistention and quickly empties the superficial and tibial veins, which reduces tissue swelling and boosts venous return. Color duplex ultrasonography is recommended to assess for deep and superficial venous reflux and obstruction. Copyright 2019 by the American Academy of Family Physicians. Recognizing and Healing Venous Stasis Ulcers | Vegas Valley Vein Blood backs up in the veins, building up pressure. Managing venous leg ulcers - Independent Nurse There is no evidence that collagenase is superior to sharp debridement.23 Larval therapy using maggots is an effective method of debridement with added potential for disinfection, stimulation of healing, and biofilm inhibition and eradication.24,25 Potential barriers to larval debridement include patient acceptability and pain.26,27 Autolytic debridement uses moisture-retentive dressings and may be used in addition to other forms of debridement. Leg elevation. No revisions are needed. A group of nurse judges experienced in the treatment of venous ulcer validated 84 nursing diagnoses and outcomes, and 306 interventions. Date of admission: 11/07/ Current orders: . 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 patient will demonstrate increased tolerance to activity. Nonhealing ulcers also raise your risk of amputation. PDF Nursing Interventions Aimed at Persons with Venous Ulcers: an How to Cure Venous Leg Ulcers Mark Whiteley. Isolating the wound from the perineal region can occasionally be challenging. Debridement may be sharp, enzymatic, mechanical, larval, or autolytic. This means they can't stop blood which should be headed upward to your heart from being pulled down by gravity. Its healing can take between four and six weeks, after their initial onset (1). The consent submitted will only be used for data processing originating from this website. 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. Choice of knee-high, thigh-high, toes-in, or toes-out compression stockings depends on patient preference. Venous Ulcers: Diagnosis and Treatment | AAFP 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. Chronic venous insufficiency: A review for nurses | CE Article Dehydration makes blood more viscous and causes venous stasis, which makes thrombus development more likely. To view the purposes they believe they have legitimate interest for, or to object to this data processing use the vendor list link below. Tell the healthcare provider if you have ever had an allergic reaction to contrast liquid. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. Managing venous stasis ulcers - Wound Care Advisor Surgical management may be considered for ulcers. The nurse is caring for a patient with a large venous leg ulcer. More analgesics should be given as needed or as directed. St. Louis, MO: Elsevier. 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. By. Print. Continuous stress to the skins' integrity will eventually cause skin breakdowns. 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. Causes of Venous Leg Ulcers The speci c cause of venous ulcers is poor venous return. 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. This will enable the client to apply new knowledge right away, improving retention. SUSAN BONKEMEYER MILLAN, MD, RUN GAN, MD, AND PETRA E. TOWNSEND, MD. Mechanical debridement (wet-to-dry dressings, pulsed lavage, whirlpool) has fallen out of favor. Ulcers heal from their edges toward their centers and their bases up. It has been estimated that active VU have They typically occur in people with vein issues. Its essential to keep the impacted areas clean by washing them with the recommended cleanser. 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. Debridement may be sharp (e.g., using curette or scissors), enzymatic, mechanical, biologic (i.e., using larvae), or autolytic. Otherwise, scroll down to view this completed care plan. Examine the clients and the caregivers wound-care knowledge and skills in the area. 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. 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. Slough with granulation tissue comprises the base of the wound, with moderate to heavy exudate. 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. Continue with Recommended Cookies, Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions. Author: Leanne Atkin lecturer practitioner/vascular nurse consultant, School of Human and Health Sciences, University of Huddersfield and Mid Yorkshire Trust. If you have a venous leg ulcer, you may also have: swollen ankles (oedema) discolouration or darkening of the skin around the ulcer