nursing care plan for venous stasis ulcer

She moved into our skilled nursing home care facility 3 days ago. Multicomponent compression systems comprised of various layers are more effective than single-component systems, and elastic systems are more effective than nonelastic systems.28, Important barriers to the use of compression therapy include wound drainage, pain, application or donning difficulty, physical impairment (weakness, obesity, decreased range of motion), and leg shape deformity (leading to compression material rolling down the leg or wrinkling). A) Provide a high-calorie, high-protein diet. Copyright 2023 American Academy of Family Physicians. Traditional negative pressure wound therapy systems are bulky and cannot be used with compression therapy. Wound, Ostomy, and Continence . The ultimate aim is to promote evidence-based nursing care among patients with venous leg ulcer. Less often, patients have arterial leg ulcer resulting from peripheral arterial occlusive disease, the most common cause of which is arteriosclerosis. 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. 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. Venous stasis ulcers are wounds that are slow to heal. Ulcers are open skin sores. 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). document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. 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). 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. 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. Topical negative pressure, also called vacuum-assisted closure, has been shown to help reduce wound depth and volume compared with a hydrocolloid gel and gauze regimen for wounds of any etiology.30 However, clinically meaningful outcomes, such as healing time, have not yet been adequately studied. By. 1, 28 Goals of compression therapy. 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). If necessary, recommend the physical therapy team. Compression therapy. C) Irrigate the wound with hydrogen peroxide once daily. Copyright 2019 by the American Academy of Family Physicians. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. All Rights Reserved. This content is owned by the AAFP. Care Plan Provider: Jessie Nguyen Date: 10/05/2020 A yellow, fibrous tissue may cover the ulcer and have an irregular border. To view the purposes they believe they have legitimate interest for, or to object to this data processing use the vendor list link below. Chronic Renal Failure CRF Nursing NCLEX Review and Nursing Care Plan, Newborn Hypoglycemia Nursing Diagnosis and Nursing Care Plan, Strep Throat Nursing Diagnosis and Care Plan. Elderly people are more frequently affected. Examine the clients and the caregivers comprehension of pressure ulcer development prevention. 2 Irrigate in the shower or bathe in buckets or bowls lined with a clean plastic bag to reduce the risk of cross-infection. 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. It has been estimated that active VU have Compression stockings are removed at night, and should be replaced every six months because they lose pressure with regular washing.2. Its essential to keep the impacted areas clean by washing them with the recommended cleanser. This means they can't stop blood which should be headed upward to your heart from being pulled down by gravity. Copyright 2023 American Academy of Family Physicians. Surgical management may be considered for ulcers. Any delay in care increases the risk of infection, sepsis, amputation, skin cancers, and death. They usually develop on the inside of the leg, between the and the ankle. Cellulitis or sepsis may develop in complicated wounds, necessitating antibiotic therapy. Guidelines suggest cleansing of the affected leg should be kept simple, using warm tap water or saline. o LPN education and scope of practice includes wound care. Patients typically experience no pain to mild pain in the extremity, which is relieved with elevation. Compression therapy has been proven beneficial for venous ulcer treatment and is the standard of care. Abstract: Chronic venous insufficiency (CVI) is a potentially debilitating disorder associated with serious complications such as lower extremity venous ulcers. Nursing Interventions 1. Intermittent Pneumatic Compression. A systematic review of hyperbaric oxygen therapy in patients with chronic wounds found only one trial that addressed venous ulcers. Elastic bandages (e.g., Profore) are alternatives to compression stockings. At-home wound healing can be accelerated by providing proper wound care and bandaging the damaged regions to stop pressure injury from getting worse. 11.0 Low level laser treatment 11.1 There is no evidence that low level laser therapy speeds the healing of venous leg ulcers. If you have a venous leg ulcer, you may also have: swollen ankles (oedema) discolouration or darkening of the skin around the ulcer Traditional conservative management of venous ulcers usually entails compression therapy, leg elevation to reduce edema, and dressings on the wound. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Compression stockings Wearing compression stockings all day is often the first approach to try. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). 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. 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. 1 The incidence of venous ulceration increases with age, and women are three times more likely than men to develop venous leg ulcers. Inelastic compression therapy provides high working pressure during ambulation and muscle contraction, but no resting pressure. 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. On physical examination, venous ulcers are generally irregular, shallow, and located over bony prominences. Timely specialized care is necessary to prevent complications, like infections that can become life-threatening. Make a chart for wound care. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Venous ulcers are believed to account for approximately 70% to 90% of chronic leg ulcers. 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. Pressure Ulcer/Pressure Injury Nursing Care Plan. Current evidence supports treatment of venous ulcers with compression therapy, exercise, dressings, pentoxifylline, and tissue products. Although the main goal of treatment is ulcer healing, secondary goals include reduction of edema and prevention of recurrence. Shallow, exudative ulcer with granulating base and presence of fibrin; commonly located over bony prominences such as the gaiter area (over the medial malleolus; Associated findings include edema, telangiectasias, corona phlebectatica, atrophie blanche (atrophic, white scarring; Typically, a deep ulcer located on the anterior leg, distal dorsal foot, or toes; dry, fibrous base with poor granulation tissue and eschar; exposure of tendons, Associated findings include abnormal distal pulses, cold extremities, and prolonged venous filling time, Most commonly a result of diabetes mellitus or neurologic disorder, Peripheral neuropathy and concomitant peripheral arterial disease; associated foot deformities and abnormal gait with uneven distribution of foot pressure; repetitive mechanical trauma, Deep ulcer, usually on the plantar surface over a bony prominence and surrounded by callus, Usually occurs in people with limited mobility, Prolonged areas of high pressure and shear forces, Area of erythema, erosion, or ulceration; usually located over bony prominences such as the sacrum, coccyx, heels, and hips, Standard care; recommended for at least one hour per day at least six days per week to prevent recurrence, Recommended to cover ulcers and promote moist wound healing, Oral antibiotic treatment is warranted if infection is suspected, Improves healing with or without compression therapy, Early endovenous ablation to correct superficial venous reflux may increase healing rates and prevent recurrence, Primary therapy for large ulcers (larger than 25 cm, Calcium alginate with or without silver, hydrofiber with or without silver, super absorbent dressing, surgical pad, Releases free iodine when exposed to wound exudate, Hydrophilic fibers between low-adherent contact layers, Gel-forming agents in an adhesive compound laminated onto a flexible, water-resistant outer film or foam, Alginate to increase fluid absorption, with or without an adhesive border, multiple shapes and sizes, Starch polymer and water that can absorb or rehydrate, Variable absorption, silicone or nonsilicone coating, With or without an adhesive border, with or without a silicone contact layer, multiple shapes and sizes, Oil emulsion gauze, petrolatum gauze, petrolatum with bismuth gauze, Possible antimicrobial and anti-inflammatory properties; absorption based on associated dressing material or gel, Gel, paste, hydrocolloid, alginate, or adhesive foam, Chlorhexidine (Peridex), antimicrobial dyes, or hydrophobic layer, Antimicrobial dyes in a flexible or solid foam pad; hydrophobic layer available as a ribbon, pad, swab, or gel, Permeable to water vapor and oxygen but not to water or microorganisms, With or without an absorbent center or adhesive border, Collagen matrix dressing with or without silver, Silver ions (thought to be antimicrobial), Silver hydrocolloid, silver mesh, nonadhesive, calcium alginate, other forms, Silicone polymer in a nonadherent layer, moderately absorbent. You will undertake clinical handover and complete a nursing care plan. This article reviews the incidence and pathophysiology of CVI, nursing assessment, diagnosis and interventions, and patient education needed to manage the disease and prevent . Gently remove dry skin scales from the legs, particularly around the ulcer edges to allow new growth of epithelium. Make careful to perform range-of-motion exercises if the client is bedridden. Determine whether the client has unexplained sepsis. RNspeak. Venous ulcers are leg ulcers caused by problems with blood flow (circulation) in your leg veins. Some of our partners may process your data as a part of their legitimate business interest without asking for consent. BACKGROUND Primary DX: venous stasis ulcer on right medial malleolus and chronic venous insufficiency. (2020). Compression stockings are removed at night and should be replaced every six months because of loss of compression with regular washing. They can affect any area of the skin. Saunders comprehensive review for the NCLEX-RN examination. Compression therapy helps prevent reflux, decreases release of inflammatory cytokines, and reduces fluid leakage from capillaries, thereby controlling lower extremity edema and VSU recurrence. 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. Professional Skills in Nursing: A Guide for the Common Foundation Programme. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. It can also occur if something, such as a deep vein thrombosis or other clot, damages the valves inside the veins. Contrast liquid is injected into the catheter to help the veins show up better in the pictures. Surgical management may be considered for ulcers that are large in size, of prolonged duration, or refractory to conservative measures. 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. 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. RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. Intermittent pneumatic compression therapy comprises a pump that delivers air to inflatable and deflatable sleeves that embrace extremities, providing intermittent compression.7,23 The benefits of intermittent pneumatic compression are less clear than that of standard continuous compression. This content is owned by the AAFP. The student can make adjustments as soon as they receive feedback, as opposed to practicing the skill incorrectly. Patient who needs wound care for a chronic venous stasis ulcer on the lower leg. Intermittent pneumatic compression may be considered when there is generalized, refractory edema from venous insufficiency; lymphatic obstruction; and significant ulceration of the lower extremity. Buy on Amazon. When seated in a chair or bed, raise the patients legs as needed. There are numerous online resources for lay education. Nursing Diagnosis: Ineffective Tissue Perfusion (multiple organs) related to hyperviscosity of blood. What intervention should the nurse implement to promote healing and prevent infection? Citation: Atkin L (2019) Venous leg ulcer prevention 1: identifying patients who are at risk. Compression therapy is a standard treatment modality for initial and long-term treatment of venous ulcers in patients without concomitant arterial disease. Calf muscle contraction and intraluminal valves increase prograde flow while preventing blood reflux under normal circumstances. Pentoxifylline is effective when used as monotherapy or with compression therapy for venous ulcers. St. Louis, MO: Elsevier. We and our partners use cookies to Store and/or access information on a device. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. Venous stasis ulcers are often on the ankle or calf and are painful and red.

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