Pressure Ulcer/Pressure Injury Nursing Care Plan. Venous ulcers are the most common lower extremity wounds in the United States. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). Leg elevation. Granulation tissue and fibrin are typically present in the ulcer base. 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. She moved into our skilled nursing home care facility 3 days ago. It allows time for the nursing team to evaluate the wound and the condition of the leg. The 10-point pain scale is a widely used, precise, and efficient pain rating measure. Causes of Venous Leg Ulcers The speci c cause of venous ulcers is poor venous return. To prevent the infection from getting worse, it is best to discourage the youngster from scratching the sores, even if they are just mildly itchy. Desired Outcome: The patient will verbally report their level of pain as 0 out of 10. 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. Even under perfect conditions, a pressure ulcer may take weeks or months to heal. 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. Contrast venography is a procedure used to show the veins on x-ray pictures. Start providing wound care according to the decubitus ulcers development. Contrast liquid is injected into the catheter to help the veins show up better in the pictures. To evaluate whether a treatment is effective. Medical-surgical nursing: Concepts for interprofessional collaborative care. 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. 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. Table 2 includes treatment options for venous ulcers.1622, Removal of necrotic tissue by debridement has been used to expedite wound healing. Compression stockings Wearing compression stockings all day is often the first approach to try. The patient will verbalize an ability to adapt sufficiently to the existing condition. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. As soon as the client is allowed to leave the bed, assist with a progressive return to ambulation. Determine whether the client has unexplained sepsis. Other associated findings include telangiectasias, corona phlebectatica, atrophie blanche, lipodermatosclerosis, and inverted champagne-bottle deformity of the lower leg. Aspirin. 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. Arterial pulse examination and measurement of ankle-brachial index are recommended for all patients with suspected venous ulcers. A systematic review of hyperbaric oxygen therapy in patients with chronic wounds found only one trial that addressed venous ulcers. These ulcers are caused by poor circulation, diabetes and other conditions. 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. Venous stasis ulcers are wounds caused by the accumulation of fluid that commonly accompanies vein disorders. Encourage the patient to refrain from scratching the injured regions. Venous stasis ulcers may develop spontaneously or after affected skin is scratched or injured. More analgesics should be given as needed or as directed. 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. Patient information: See related handout on venous ulcers. Like pentoxifylline therapy, aspirin (300 mg per day) combined with compression therapy has been shown to increase ulcer healing time and reduce ulcer size, compared with compression therapy alone.32 In general, adding aspirin therapy to compression bandages is recommended in the treatment of venous ulcers as long as there are no contraindications to its use. It can related to the age as well as the body surface of the . 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. Blood backs up in the veins, building up pressure. 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. Continuous stress to the skins' integrity will eventually cause skin breakdowns. Possible causes of venous ulcers include inflammatory processes resulting in leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema. The oldest term for pressure ulcers is decubitus, which evolved into decubitus ulcers or ischemic ulcer s in the 1950s. Males experience a lower overall incidence than females do. Clean, persistent wounds that are not healing may benefit from palliative wound care. Position the patient back in his or her comfortable or desired posture. 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. Nursing care plans: Diagnoses, interventions, & outcomes. The recommended regimen is 30 minutes, three or four times per day. For wound closure to be effective, leg edema must be reduced. History of superficial or deep venous thrombosis, pulmonary embolism, and ulcer recurrence should be ascertained with comorbid conditions. 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. Preamble. Patients who are severely malnourished (serum albumin 2.5 mg/dl) are more likely to acquire an infection from a pressure ulcer. This means they can't stop blood which should be headed upward to your heart from being pulled down by gravity. Elderly people are more frequently affected. This provides the best conditions for the ulcer to heal. 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. The Unna boot improves healing rates compared with placebo or hydroactive dressings.22,26 However, a 2009 Cochrane review found that adding a component of elastic compression therapy is more effective than inelastic compression therapy alone.45 Also, because of its inelasticity, the Unna boot does not conform to changes in leg size and may be uncomfortable to wear. 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. Saunders comprehensive review for the NCLEX-RN examination. Mechanical debridement (wet-to-dry dressings, pulsed lavage, whirlpool) has fallen out of favor. Enzymatic debridement using collagenase has been shown to effectively remove nonviable tissue. o LPN education and scope of practice includes wound care. Encourage performing simple exercises and getting out of bed to sit on a chair. The pressure ulcer needs to be taken into consideration as a potential cause during the septic workup. 2 In some studies, 50% of patients had venous ulcers that persisted for more than 9 months, and 20% had ulcers that did not Timely specialized care is necessary to prevent complications, like infections that can become life-threatening. We and our partners use data for Personalised ads and content, ad and content measurement, audience insights and product development. They also support healthy organ function and raise well-being in general. Calf muscle contraction and intraluminal valves increase prograde flow while preventing blood reflux under normal circumstances. August 9, 2022 Modified date: August 21, 2022. On physical examination, venous ulcers are generally irregular, shallow, and located over bony prominences. In comparison to a single long walk, short, regular walks are healthier for the extremities and the prevention of pulmonary problems. 17 This will enable the client to apply new knowledge right away, improving retention. In one study, intravenous iloprost (not available in the United States) used with elastic compression therapy significantly reduced healing time of venous ulcers compared with placebo.33 However, the medication is very costly and there are insufficient data to recommend its use.40, Zinc is a trace metal with potential anti-inflammatory effects. 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. Calf muscle contraction and intraluminal valves increase prograde flow while preventing blood reflux under normal circumstances. 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 ). Examine the clients and the caregivers comprehension of pressure ulcer development prevention. Referral to a wound subspecialist should be considered for ulcers that are large, of prolonged duration, or refractory to conservative measures. RNspeak. Patient information: See related handout on venous ulcers, written by the authors of this article. These venoactive drugs theoretically work by improving venous tone and decreasing capillary permeability. Dressings are often used under compression bandages to promote faster healing and prevent adherence of the bandage to the ulcer. She found a passion in the ER and has stayed in this department for 30 years. 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. Buy on Amazon. VLUs are the result of chronic venous insufficiency (CVI) in the legs. There is currently insufficient high-quality data to support the use of topical negative pressure for venous ulcers.30 In addition, the therapy generally has not been used in clinical practice because of the challenge in administering both topical negative pressure and a compression dressing on the affected leg. They usually develop on the inside of the leg, between the and the ankle. 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. Duplex Ultrasound All Rights Reserved. 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. They typically occur around the medial malleolus, tend to be shallow and moist, and may be malodorous (especially when poorly cared for) or painful. 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). Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. Author: Leanne Atkin lecturer practitioner/vascular nurse consultant, School of Human and Health Sciences, University of Huddersfield and Mid Yorkshire Trust. 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. Of the diagnoses developed, 62 are included in ICNP and 23 are new diagnoses, not included. Surgical management may be considered for ulcers that are large in size, of prolonged duration, or refractory to conservative measures. 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. arterial pulse examination, and measurement of ankle-brachial index is recommended for all patients with suspected venous ulcers. To compile a patients baseline set of observations. All Rights Reserved. St. Louis, MO: Elsevier. Pentoxifylline is effective when used as monotherapy or with compression therapy for venous ulcers. mostly non-infectious condition in association with venous insufficiency and atrophy of the skin of the lower leg during long . 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. Venous stasis ulcers may be treated with gauze impregnated with a zinc oxide tincture (Unna boot). 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. Oral antibiotics are recommended to treat venous ulcers only in cases of suspected cellulitis. Contraindications to compression therapy include significant arterial insufficiency and uncompensated congestive heart failure.29, Elastic. Patient who needs wound care for a chronic venous stasis ulcer on the lower leg. 3M can help manage challenges related to VLUs and help improve patient outcomes so that people can fully engage and participate in normal everyday activities. Suspected osteomyelitis warrants an evaluation for arterial disease and consideration of intravenous antibiotics to treat the underlying infection. -. Early endovenous ablation to correct superficial venous reflux improves ulcer healing rates. When seated in a chair or bed, raise the patients legs as needed. Any delay in care increases the risk of infection, sepsis, amputation, skin cancers, and death. (2020). 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. Over time, as the veins become increasingly weak, they have more trouble sending blood to the heart. Valves in the veins prevent backflow, but failure of the valves results in increased pressure in the veins. The synthetic prostacyclin iloprost is a vasodilator that inhibits platelet aggregation. ANTICIPATED NURSING INTERVENTIONS Venous Stasis Ulcer = malfunctioning venous valves causing pressure in the veins to increase o Pathophysiology: Venous (or stasis) ulceration is initiated by venous hypertension that develops because of inadequate calf muscle pump action o Risk factors: Diabetes mellitus Congestive heart failure Peripheral . Care Plan Provider: Jessie Nguyen Date: 10/05/2020 Although numerous treatment methods are available, they have variable effectiveness and limited data to support their use. such as venous ulcers and lymphoedema, concomitant bacterial and fungal colonisation or infection may be present. Nursing Diagnosis: Risk for Infection related to poor circulation and oxygen delivery and ischemia secondary to venous pressure ulcers. Further evaluation with biopsy or referral to a subspecialist is warranted for venous ulcers if healing stalls or the ulcer has an atypical appearance. Pentoxifylline. Stockings or bandages can be used; however, elastic wraps (e.g., Ace wraps) are not recommended because they do not provide enough pressure.45 Compression stockings are graded, with the greatest pressure at the ankle and gradually decreasing pressure toward the knee and thigh (pressure should be at least 20 to 30 mm Hg, and preferably 30 to 44 mm Hg). 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. Abstract. St. Louis, MO: Elsevier. Venous ulcers are leg ulcers caused by problems with blood flow (circulation) in your leg veins. Leg elevation when used in combination with compression therapy is also considered standard of care. Less often, patients have arterial leg ulcer resulting from peripheral arterial occlusive disease, the most common cause of which is arteriosclerosis. . 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. The patient will demonstrate increased tolerance to activity. Chronic venous insufficiency can develop from common conditions such as varicose veins. Peripheral vascular disease is the impediment of blood flow within the peripheral vascular system due to vessel damage, which mainly affects the lower extremities. Desired Outcome: The patients skin integrity will be at its best by adhering to the decubitus ulcer treatment plan, Nursing Diagnosis: Risk for Ineffective Health Maintenance related to impaired functional status, need for long-term pressure management, and the possible need for special equipment secondary to venous stasis ulcers. Conclusion It can eventually lead to ulcerations or skin breakage on the skin making the person prone infections. Most venous ulcers occur on the leg, above the ankle. Severe complications include cellulitis, osteomyelitis, and malignant change. document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. Aspirin (300 mg per day) is effective when used with compression therapy for venous ulcers. Compression therapy is a standard treatment modality for initial and long-term treatment of venous ulcers in patients without concomitant arterial disease. As the patient is experiencing pain, have him or her score it on a scale of 0 to 10 and describe it. Nursing diagnoses handbook: An evidence-based guide to planning care. Venous ulcers are believed to account for approximately 70% to 90% of chronic leg ulcers. The current plan of care is focused on promoting wound healing, improving venous return, and preventing skin breakdown. The student can make adjustments as soon as they receive feedback, as opposed to practicing the skill incorrectly. They typically occur in people with vein issues. nous insufficiency and ambulatory venous hypertension. 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. As long as the heart can handle it, up the patients daily fluid intake to at least 1500 to 2000 mL. In diabetic patients, distal symmetric neuropathy and peripheral . Symptoms of venous stasis ulcers include: Risk factors for venous stasis ulcers include the following: Diagnostic tests for venous stasis ulcers usually include: Compression therapy and direct wound management are the standard of care for VLUs. Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). Patients typically experience no pain to mild pain in the extremity, which is relieved with elevation. Ulcers are open skin sores. Inelastic. Impaired Skin Integrity ADVERTISEMENTS Impaired Skin Integrity Nursing Diagnosis Impaired Skin Integrity May be related to Chronic disease state. The disease has shown a worldwide rising incidence as the worlds population ages. It might be necessary to apply the prescription antibiotic cream or ointment directly to the affected area. 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. Debridement may be sharp (e.g., using curette or scissors), enzymatic, mechanical, biologic (i.e., using larvae), or autolytic. Ackley, Nursing Diagnosis Handbook, Page 153 Nursing CLINICAL WORKSHEET Dat e: 10/2/2022 Student Name: Michele Tokar Assigned vSim: Vernon Russell Initia ls: VR Diagnosis: Right sided ischemic