nursing care plan for venous stasis ulcer nursing care plan for venous stasis ulcer

Mechanical debridement (wet-to-dry dressings, pulsed lavage, whirlpool) has fallen out of favor. We and our partners use cookies to Store and/or access information on a device. It can also occur if something, such as a deep vein thrombosis or other clot, damages the valves inside the veins. Because of limited evidence and no long-term benefit, hyperbaric oxygen therapy is not recommended for treatment of venous ulcers.47, Negative Pressure Wound Therapy. The nurse is caring for a patient with a large venous leg ulcer. Pentoxifylline is effective when used as monotherapy or with compression therapy for venous ulcers. BACKGROUND Primary DX: venous stasis ulcer on right medial malleolus and chronic venous insufficiency. Effective treatments include topical silver sulfadiazine and oral antibiotics. Referral to a wound subspecialist should be considered for ulcers that are large, of prolonged duration, or refractory to conservative measures. 2 Irrigate in the shower or bathe in buckets or bowls lined with a clean plastic bag to reduce the risk of cross-infection. The disease has shown a worldwide rising incidence as the worlds population ages. The patient will maintain their normal body temperature. SUSAN BONKEMEYER MILLAN, MD, RUN GAN, MD, AND PETRA E. TOWNSEND, MD. Encourage the patient to refrain from scratching the injured regions. Start providing wound care according to the decubitus ulcers development. Venous ulcers (also known as venous stasis ulcers or nonhealing wounds) are open wounds around the ankle or lower leg. Suspected osteomyelitis warrants an evaluation for arterial disease and consideration of intravenous antibiotics to treat the underlying infection. What intervention should the nurse implement to promote healing and prevent infection? Contrast liquid is injected into the catheter to help the veins show up better in the pictures. A more recent article on venous ulcers is available. 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. 1 The incidence of venous ulceration increases with age, and women are three times more likely than men to develop venous leg ulcers. Current evidence supports treatment of venous ulcers with compression therapy, exercise, dressings, pentoxifylline, and tissue products. If necessary, recommend the physical therapy team. Her Waterlow Scale is 16, and her skin is intact except for the venous stasis ulcer on the right medial malleolus. A catheter is guided into the vein. Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. Blood backs up in the veins, building up pressure. Although intermittent pneumatic compression is more effective than no compression, its effectiveness compared with other forms of compression is unclear. Print. arterial pulse examination, and measurement of ankle-brachial index is recommended for all patients with suspected venous ulcers. They typically occur in people with vein issues. Elastic bandages (e.g., Profore) are alternatives to compression stockings. 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). 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. To diagnose chronic venous insufficiency, your NYU Langone doctor asks about your health history to determine the extent of your symptoms. 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. As long as the heart can handle it, up the patients daily fluid intake to at least 1500 to 2000 mL. But they most often occur on the legs. By. 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. Surgical management may be considered for ulcers that are large in size, of prolonged duration, or refractory to conservative measures. Chronic venous insufficiency (CVI) is a potentially debilitating disorder associated with serious complications such as lower extremity venous ulcers. Examine the patients vital statistics. 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). 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). 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 are leg ulcers caused by problems with blood flow (circulation) in your leg veins. August 9, 2022 Modified date: August 21, 2022. Potential Nursing Interventions: (3 minimum) 1. Contrast venography is a procedure used to show the veins on x-ray pictures. Compression therapy reduces swelling and encourages healthy blood circulation. 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. The consent submitted will only be used for data processing originating from this website. Possible causes of venous ulcers include inflammatory processes resulting in leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema. Compared with compression plus a simple dressing, one study showed that advanced therapies can shorten healing time and improve healing rates.52, Skin Grafting. Patient who needs wound care for a chronic venous stasis ulcer on the lower leg. Encouraging the patient through physical therapy to get out of bed and sit down and carry out the necessary exercises. Immobile clients will need to be repositioned frequently to reduce the chance of breakdown in the intact parts. 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. Copyright 2010 by the American Academy of Family Physicians. He or she also performs a physical exam to look for swelling, skin changes, varicose veins, or ulcers on the leg. 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. Venous incompetence and associated venous hypertension are thought to be the primary mechanisms for ulcer formation. Leg ulcer may be of a mixed arteriovenous origin. Its healing can take between four and six weeks, after their initial onset (1). c. Traditional conservative management of venous ulcers usually entails compression therapy, leg elevation to reduce edema, and dressings on the wound. Patients experience poor quality of life as a result of pain and immobility, and they require advanced levels of wound care. 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. 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. 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. Surgical management may be considered for ulcers. Compression therapy. 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. Of the diagnoses developed, 62 are included in ICNP and 23 are new diagnoses, not included. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. To compile a patients baseline set of observations. These ulcers are caused by poor circulation, diabetes and other conditions. The healing capacity of the pressure damage is maximized by providing the appropriate wound care following the stage of the decubitus ulcer. 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 provides the best conditions for the ulcer to heal. Chronic venous ulcers significantly impact quality of life. If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. 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. Venous thromboembolism occurs majorly in two ways like pulmonary embolism and deep vein thrombosis. Abstract. As an Amazon Associate I earn from qualifying purchases. Learn how your comment data is processed. Manage Settings 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. Most patients have venous leg ulcer due to chronic venous insufficiency. 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. Further evaluation with biopsy or referral to a subspecialist is warranted if ulcer healing stalls or the ulcer has an atypical appearance. Intermittent Pneumatic Compression. St. Louis, MO: Elsevier. Self-care such as exercise, raising the legs when sitting or lying down, or wearing compression stockings can help ease the pain of varicose veins and might prevent them from getting worse. Stasis ulcers. Debridement may be sharp (e.g., using curette or scissors), enzymatic, mechanical, biologic (i.e., using larvae), or autolytic. Treat venous stasis ulcers per order. 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. A deep vein thrombosis nursing care plan includes assessment of the body parts, appropriate intervention, prevention, and patient education to prevent thromboembolism. 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. -. mostly non-infectious condition in association with venous insufficiency and atrophy of the skin of the lower leg during long . Nursing Diagnosis: Risk for Infection related to poor circulation and oxygen delivery and ischemia secondary to venous pressure ulcers. Choice of knee-high, thigh-high, toes-in, or toes-out compression stockings depends on patient preference. A clinical severity score based on the CEAP (clinical, etiology, anatomy, and pathophysiology) classification system can guide the assessment of chronic venous disorders. Oral zinc therapy has been shown to decrease healing time in patients with pilonidal sinus. Early venous ablation and surgical intervention to correct superficial venous reflux can improve healing and decrease recurrence rates. Pressure Ulcer/Pressure Injury Nursing Care Plan. St. Louis, MO: Elsevier. The pressure ulcer needs to be taken into consideration as a potential cause during the septic workup. 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. However, there are few high-quality studies that directly evaluate the effect of debridement versus no debridement or the superiority of one type of debridement on the rate of venous ulcer healing.3640 In addition, most wounds with significant necrotic tissue should be evaluated for arterial insufficiency because purely venous ulcers rarely need much debridement. She received her RN license in 1997. 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. Debridement may be sharp, enzymatic, mechanical, larval, or autolytic. They typically occur around the medial malleolus, tend to be shallow and moist, and may be malodorous (especially when poorly cared for) or painful. This usually needs to be changed 1 to 3 times a week. 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. 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. An example of data being processed may be a unique identifier stored in a cookie. Some of our partners may process your data as a part of their legitimate business interest without asking for consent. Dressings are recommended to cover venous ulcers and promote moist wound healing. In addition, the Unna boot may lead to a foul smell from the accumulation of exudate from the ulcer, requiring frequent reapplications.2, Elastic. Nursing diagnoses handbook: An evidence-based guide to planning care. Signs of venous disease, such as varicose veins, edema, or venous dermatitis, may be present. 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. Patient information: See related handout on venous ulcers. Poor prognostic signs for healing include ulcer duration longer than three months, initial ulcer length of 10 cm or more, presence of lower limb arterial disease, advanced age, and elevated body mass index. The ultimate aim is to promote evidence-based nursing care among patients with venous leg ulcer. They also support healthy organ function and raise well-being in general. To assess the size and extent of decubitus ulcers, as well as any affected areas that need specific care or wound treatment. This quiz will test your knowledge on both peripheral arterial disease (PAD) and peripheral venous . Position the patient back in his or her comfortable or desired posture. 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. 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. 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. Its essential to keep the impacted areas clean by washing them with the recommended cleanser. Otherwise, scroll down to view this completed care plan. Your doctor may also recommend certain diagnostic imaging tests. Venous stasis ulcers are often on the ankle or calf and are painful and red. 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). Chronic venous insufficiency can pose a more serious result if not given proper medical attention. 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. More analgesics should be given as needed or as directed. Saunders comprehensive review for the NCLEX-RN examination. 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. 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. She has brown hyperpigmentation on both lower legs with +2 oedema. Tell the healthcare provider if you have ever had an allergic reaction to contrast liquid. 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. The current plan of care is focused on promoting wound healing, improving venous return, and preventing skin breakdown. 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. This will enable the client to apply new knowledge right away, improving retention. Hyperbaric oxygen therapy has also been proposed as an adjunctive therapy for chronic wound healing because of potential anti-inflammatory and antibacterial effects, and its benefits in healing diabetic foot ulcers. Even under perfect conditions, a pressure ulcer may take weeks or months to heal. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. Colonization refers to the presence of replicating bacteria without a host reaction or clinical signs of infection.45 Colonized venous ulcers generally should not be treated with antibiotics. Nursing Times [online issue]; 115: 6, 24-28. These are most common in your legs and feet as you age and happen because the valves in your leg veins can't do their job properly. Women aging from 40 to 49 years old may present symptoms of venous insufficiency. At-home wound healing can be accelerated by providing proper wound care and bandaging the damaged regions to stop pressure injury from getting worse. Buy on Amazon. As the patient is experiencing pain, have him or her score it on a scale of 0 to 10 and describe it. Other associated findings include telangiectasias, corona phlebectatica, atrophie blanche, lipodermatosclerosis, and inverted champagne-bottle deformity of the lower leg. 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.