Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. Venous ulcers are leg ulcers caused by problems with blood flow (circulation) in your leg veins. Inelastic. However, a recent Cochrane review of 22 RCTs of systemic and topical antibiotics and antiseptics for venous ulcer treatment found no evidence that routine use of oral antibiotics improves healing rates.1 Studies comparing topical antibiotics and antiseptics, such as povidone-iodine solution (Betadine), peroxide-based preparations, ethacridine lactate (not available in the United States), and mupirocin (Bactroban), have found some evidence to support the use of the topical antiseptic agent cadexomer iodine (not available in the United States; a pooled estimate from two trials suggests an increased healing rate at four to six weeks compared with placebo).1 More high-quality data are needed to better evaluate the effectiveness of topical preparations, however.1. Although numerous treatment methods are available, they have variable effectiveness and limited data to support their use. Effective treatments include topical silver sulfadiazine and oral antibiotics. Historically, trials comparing venous intervention plus compression with compression alone for venous ulcers showed that surgery reduced recurrence but did not improve healing.53 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.21 The most common complications of endovenous ablation were pain and deep venous thrombosis.21, The recurrence rate of venous ulcers has been reported as high as 70%.35 Venous intervention and long-term use of compression stockings are important for preventing recurrence, and leg elevation can be beneficial when used with compression stockings. Calf muscle contraction and intraluminal valves increase prograde flow while preventing blood reflux under normal circumstances. Compression therapy Treatment focuses on preventing new ulcers, controlling edema, and reducing venous hypertension through compression therapy. 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. Granulation tissue and fibrin are often present in the ulcer base. SAGE Knowledge. Dressings are beneficial for venous ulcer healing, but no dressing has been shown to be superior. 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. August 9, 2022 Modified date: August 21, 2022. 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. Contrast liquid is injected into the catheter to help the veins show up better in the pictures. 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. 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. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Chronic venous insufficiency (CVI) is a potentially debilitating disorder associated with serious complications such as lower extremity venous ulcers. 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). Even under perfect conditions, a pressure ulcer may take weeks or months to heal. 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. Conclusion Chronic venous insufficiency can develop from common conditions such as varicose veins. 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. Table 2 includes treatment options for venous ulcers.1622, Removal of necrotic tissue by debridement has been used to expedite wound healing. These ulcers are caused by poor circulation, diabetes and other conditions. 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. 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. This quiz will test your knowledge on both peripheral arterial disease (PAD) and peripheral venous . A simple non-sticky dressing will be used to dress your ulcer. 34. Unlike the Unna boot, elastic compression therapy methods conform to changes in leg size and sustain compression during both rest and activity. 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. Pentoxifylline (Trental) is an inhibitor of platelet aggregation, which reduces blood viscosity and, in turn, improves microcirculation. PVD can be related to an arterial or venous issue. St. Louis, MO: Elsevier. Otherwise, scroll down to view this completed care plan. They do not penetrate the deep fascia. If not treated, increased pressure and excess fluid in the affected area can cause an open sore to form. It can eventually lead to ulcerations or skin breakage on the skin making the person prone infections. We and our partners use cookies to Store and/or access information on a device. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). This will enable the client to apply new knowledge right away, improving retention. Some evidence supports the use of cadexomer iodine to improve healing of venous ulcers, but evidence for other agents is lacking.38. Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. 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. She moved into our skilled nursing home care facility 3 days ago. Debridement may be sharp, enzymatic, mechanical, larval, or autolytic. Most common type; women affected more than men; often occurs in older persons, Shallow, painful ulcer located over bony prominences, particularly the gaiter area (over medial malleolus); granulation tissue and fibrin present, Leg elevation, compression therapy, aspirin, pentoxifylline (Trental), surgical management, Associated findings include edema, venous dermatitis, varicosities, and lipodermatosclerosis, Associated with cardiac or cerebrovascular disease; patients may present with claudication, impotence, pain in distal foot; concomitant with venous disease in up to 25 percent of cases, Ulcers are commonly deep, located over bony prominences, round or punched out with sharply demarcated borders; yellow base or necrosis; exposure of tendons, Revascularization, antiplatelet medications, management of risk factors, Most common cause of foot ulcers, usually from diabetes mellitus, Usually occurs on plantar aspect of feet in patients with diabetes, neurologic disorders, or Hansen disease, Off-loading of pressure, topical growth factors; tissue-engineered skin, Usually occurs in patients with limited mobility, Tissue ischemia and necrosis secondary to prolonged pressure, Located over bony prominences; risk factors include excessive moisture and altered mental status, Off-loading of pressure; reduction of excessive moisture, sheer, and friction; adequate nutrition, Compression therapy (inelastic, elastic, intermittent pneumatic), Standard of care; proven benefit (benefit of intermittent pneumatic therapy is less clear); associated with decreased rate of ulcer recurrence, Standard of care when used with compression therapy; minimizes edema; recommended for 30 minutes, three or four times a day, Topical negative pressure (vacuum-assisted closure), No robust evidence regarding its use for venous ulcers, Effective when used with compression therapy; may be useful as monotherapy, Effective when used with compression therapy; dosage of 300 mg once per day, Intravenous administration (not available in the United States) may be beneficial, but data are insufficient to recommend its use; high cost limits use, Oral antibiotic treatment is warranted in cases of suspected cellulitis; routine use of systemic antibiotics provides no healing benefit; benefit of adding the topical antiseptic cadexomer iodine (not available in the United States) is unclear, May be beneficial when used with compression therapy; concern about infection transmission, May be beneficial for severe or refractory cases; associated with decreased rate of ulcer recurrence. Venous leg ulcers are open, often painful, sores in the skin that take more than 2 weeks to heal. The healing capacity of the pressure damage is maximized by providing the appropriate wound care following the stage of the decubitus ulcer. They also support healthy organ function and raise well-being in general. Four trials showed that pentoxifylline alone improved healing compared with placebo alone.19 Common adverse effects of pentoxifylline include nausea, gastrointestinal discomfort, headaches, dizziness, and prolonged bleeding time. Compared with compression plus a simple dressing, one study showed that advanced therapies can shorten healing time and improve healing rates.52, Skin Grafting. Venous ulcers are large and irregularly shaped with well-defined borders and a shallow, sloping edge. Venous ulcers are usually recurrent, and an open ulcer can persist for weeks to many years. 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. 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 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. This article has been double-blind peer reviewed Tell the healthcare provider if you have ever had an allergic reaction to contrast liquid. Severe complications include infection and malignant change. 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. Although intermittent pneumatic compression is more effective than no compression, its effectiveness compared with other forms of compression is unclear. The 10-point pain scale is a widely used, precise, and efficient pain rating measure. Abstract. 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. Nursing interventions in venous, arterial and mixed leg ulcers. 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. Patients experience poor quality of life as a result of pain and immobility, and they require advanced levels of wound care. A systematic review of hyperbaric oxygen therapy in patients with chronic wounds found only one trial that addressed venous ulcers. 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. Continue with Recommended Cookies, Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions. Ulcers heal from their edges toward their centers and their bases up. Compression therapy is beneficial for venous ulcer treatment and is the standard of care. Patients treated with debridement at each physician's office visit had significant reduction in wound size compared with those not treated with debridement.20. Your care team may include doctors who specialize in blood vessel (vascular . Clean, persistent wounds that are not healing may benefit from palliative wound care. Isolating the wound from the perineal region can occasionally be challenging. Its healing can take between four and six weeks, after their initial onset (1). The patient will continue to be free of systemic or local infections as shown by the lack of profuse, foul-smelling wound exudate. 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. Referral to a wound subspecialist should be considered for ulcers that are large, of prolonged duration, or refractory to conservative measures. We and our partners use data for Personalised ads and content, ad and content measurement, audience insights and product development. Aspirin. Color duplex ultrasonography is recommended in patients with venous ulcers to assess for venous reflux and obstruction. 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. Surgical options for treatment of venous insufficiency include ablation of the saphenous vein; interruption of the perforating veins with subfascial endoscopic surgery; treatment of iliac vein obstruction with stenting; and removal of incompetent superficial veins with phlebectomy, stripping, sclerotherapy, or laser therapy.19,35,40, In one study, ablative superficial venous surgery reduced the rate of venous ulcer recurrence at 12 months by more than one half, compared with compression therapy alone.42 In another study, surgical management led to an ulcer healing rate of 88 percent, with only a 13 percent recurrence rate over 10 months.43 There is no evidence demonstrating the superiority of surgery over medical management; however, evaluation for possible surgical intervention should occur early.44. 2 In some studies, 50% of patients had venous ulcers that persisted for more than 9 months, and 20% had ulcers that did not Immobile clients will need to be repositioned frequently to reduce the chance of breakdown in the intact parts. Poor prognostic factors include large ulcer size and prolonged duration. mostly non-infectious condition in association with venous insufficiency and atrophy of the skin of the lower leg during long . 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. No one dressing type has been shown to be superior when used with appropriate compression therapy. There are many cellular and tissue-based products approved for the treatment of refractory venous ulcers, including allografts, animal-derived extracellular matrix products, human-derived cellular products, and human amniotic membranederived products. 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. The primary risk factors for venous ulcer development are older age, obesity, previous leg injuries, deep venous thrombosis, and phlebitis. Patient information: See related handout on venous ulcers, written by the authors of this article. Oral antibiotics are preferred, and therapy should be limited to two weeks unless evidence of wound infection persists.1, Hyperbaric Oxygen Therapy. 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. Infection occurs when microorganisms invade tissues, leading to systemic and/or local responses such as changes in exudate, increased pain, delayed healing, leukocytosis, increased erythema, or fevers and chills.46 Venous ulcers with obvious signs of infection should be treated with antibiotics. 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. A wide range of dressings are available, including hydrocolloids (e.g., Duoderm), foams, hydrogels, pastes, and simple nonadherent dressings.14,28 A meta-analysis of 42 randomized controlled trials (RCTs) with a total of more than 1,000 patients showed no significant difference among dressing types.29 Furthermore, the more expensive hydrocolloid dressings were not shown to have a healing benefit over the lower-cost simple nonadherent dressings. 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 the most common lower extremity wounds in the United States. More analgesics should be given as needed or as directed. The term bedsores indicate the association of wounds with a stay in bed, which ignores the potential occurrence . Duplex Ultrasound 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. They typically occur around the medial malleolus, tend to be shallow and moist, and may be malodorous (especially when poorly cared for) or painful. Normally, when you get a cut or scrape, your body's healing process starts working to close the wound. Tiny valves in the veins can fail. Statins have vasoactive and anti-inflammatory effects.