nursing care plan for venous stasis ulcer

arterial pulse examination, and measurement of ankle-brachial index is recommended for all patients with suspected venous ulcers. 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 ). 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. 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. This article has been double-blind peer reviewed Copyright 2010 by the American Academy of Family Physicians. Compared with compression plus a simple dressing, one study showed that advanced therapies can shorten healing time and improve healing rates.52, Skin Grafting. The 10-point pain scale is a widely used, precise, and efficient pain rating measure. Encouraging the patient through physical therapy to get out of bed and sit down and carry out the necessary exercises. Patients treated with debridement at each physician's office visit had significant reduction in wound size compared with those not treated with debridement.20. 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. Pentoxifylline (Trental) is effective when used with compression therapy for venous ulcers, and may be useful as monotherapy. The most common method of inelastic compression therapy is the Unna boot, a zinc oxideimpregnated, moist bandage that hardens after application. Valves in the veins prevent backflow, but failure of the valves results in increased pressure in the veins. Debridement may be sharp, enzymatic, mechanical, larval, or autolytic. These ulcers are caused by poor circulation, diabetes and other conditions. Start performing active or passive exercises while in bed, including occasionally rotating, flexing, and extending the feet. Anna Curran. Early venous ablation and surgical intervention to correct superficial venous reflux can improve healing and decrease recurrence rates. 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). He or she also performs a physical exam to look for swelling, skin changes, varicose veins, or ulcers on the leg. 34. This content is owned by the AAFP. document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. Venous ulcers, or stasis ulcers, account for 80 percent of lower extremity ulcerations.1 Less common etiologies for lower extremity ulcerations include arterial insufficiency; prolonged pressure; diabetic neuropathy; and systemic illness such as rheumatoid arthritis, vasculitis, osteomyelitis, and skin malignancy.2 The overall prevalence of venous ulcers in the United States is approximately 1 percent.1 Venous ulcers are more common in women and older persons.36 The primary risk factors are older age, obesity, previous leg injuries, deep venous thrombosis, and phlebitis.7, Venous ulcers are often recurrent, and open ulcers can persist from weeks to many years.810 Severe complications include cellulitis, osteomyelitis, and malignant change.3 Although the overall prevalence is relatively low, the refractory nature of these ulcers increase the risk of morbidity and mortality, and have a significant impact on patient quality of life.11,12 The financial burden of venous ulcers is estimated to be $2 billion per year in the United States.13,14, The pathophysiology of venous ulcers is not entirely clear. 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. But they most often occur on the legs. Although intermittent pneumatic compression is more effective than no compression, its effectiveness compared with other forms of compression is unclear. Nursing Times [online issue]; 115: 6, 24-28. 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. Venous ulcers are leg ulcers caused by problems with blood flow (circulation) in your leg veins. Affect 9% of patients admitted to hospital and 23% of those admitted to nursing homes. Guidelines suggest cleansing of the affected leg should be kept simple, using warm tap water or saline. Compression stockings are removed at night, and should be replaced every six months because they lose pressure with regular washing.2. Copyright 2023 American Academy of Family Physicians. The disease has shown a worldwide rising incidence as the worlds population ages. 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. Women aging from 40 to 49 years old may present symptoms of venous insufficiency. 2010. An example of data being processed may be a unique identifier stored in a cookie. Removal of necrotic tissue and bacterial burden through debridement has long been used in wound care to enhance healing. The patient will demonstrate improved tissue perfusion as evidenced by adequate peripheral pulses, absence of edema, and normal skin color and temperature. Unlike the Unna boot, elastic compression therapy methods conform to changes in leg size and sustain compression during both rest and activity. Dressings are beneficial for venous ulcer healing, but no dressing has been shown to be superior. 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. Risk Factors Trauma Thrombosis Inflammation Embolism 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. (2020). The current plan of care is focused on promoting wound healing, improving venous return, and preventing skin breakdown. 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. Eventually non-healing or slow-healing wounds may form, often on the .

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