Despite all the advances in health care we enjoy today, venous ulcers continue to exact a high toll in the United States. Consider these facts:
* In the general population, about 1% of people have venous ulcers. Among people over age 65, the figure rises to 3.5%.
* Nearly 70% of venous ulcers recur.
* Women are three times more likely than men to have a venous ulcer.
* The estimated per-episode cost of care can exceed $40,000.
* Assuming that 2.5 million people have venous ulcers, the total cost of treatment is estimated at $2.5 billion to $3.5 billion.
* An estimated 2 million workdays per calendar year are lost due to chronic venous ulcers.
Venous ulcers related to chronic venous insufficiency can persist and recur unless all caregivers consistently follow an effective treatment protocol. In this article, I'll explain how to set up and implement a practical working protocol that can lower the cost—in time, money, and suffering—of venous ulcers.
Ideally, a wound care protocol is a multidisciplinary affair that enlists the expertise of a wound care specialist, primary care nurses, the primary care physician, and the vascular surgeon; a case manager also may be involved. To develop a protocol tailored to the patient, the team focuses on the ulcer's type and characteristics, the length of time it's been present, results of any diagnostic studies or tests, and treatment options suited to the patient's condition.
Remembering the basics of venous blood flow will help you assess and manage your patient's condition. Adequate blood flow in the leg depends on:
* deep veins (the femoral, popliteal, and tibial veins)
* superficial veins (the greater and lesser saphenous veins)
* communicating veins, which connect the superficial veins to the deep veins
* calf muscles, which assist blood flow throughout the venous system when they contract.
Normally, blood flow through the superficial veins to the deep veins is unidirectional, and blood returns from the capillary system to the heart without difficulty. However, damage to the vein valves or calf muscles impedes venous blood flow and causes high venous pressures (venous hypertension) in the deep veins. This damage can be caused by heart failure, muscle weakness secondary to paralysis, obesity, pregnancy, trauma, diabetes, thrombosis formation in deep veins, and valve incompetence.
To assess a patient with a venous ulcer, first obtain a detailed history and conduct a physical assessment. Ask him these questions:
* Have you had a venous ulcer before? If yes, when did it occur? How long did it last? How was it treated?
* Does much fluid drain from the wound? Do you notice any odor from the wound? Is your skin itchy? Is the skin around the wound wet? Is the wound painful?
* Have you had any trauma to your lower leg in the past? If yes, how and when did the trauma occur?
* Do you have a history of deep vein thrombosis? If yes, when did this first occur? Where and how were you treated?
* Have you undergone coronary artery bypass surgery? If yes, when did this occur? Where were you treated?
Next, perform thorough systems and lower extremity assessments and a wound evaluation. During the lower extremity assessment, you may uncover characteristic markers of venous ulceration, such as ankle flare, dermatitis, hemosiderosis, lipodermatosclerosis, and varicosities (see Understanding Key Terms). Also assess for the following typical wound characteristics:
* location—typically on the medial lower leg superior to the medial malleolus (where the saphenous vein is located)
* wound bed and appearance—referred to as “ruddy” or “beefy red”; granular appearance
* wound size, shape, and margins—large with irregular margins
* drainage/exudate—moderate to heavy
* surrounding skin—hemosiderin stain (brownish discoloration), edematous, macerated, hyperpigmented, or showing lipodermatosclerosis
* pain—pain may be present; small but deep ulcers around malleoli are the most painful.
Thoroughly document all your findings and relay the information to other team members to ensure continuity of care and prevent duplication of tests and services.
Depending on your patient's condition, his health care provider may order one or more of these diagnostic tests.
* contrast venogram—provides a radiographic picture of the venous system through use of radiopaque dye injected into a pedal dorsal vein (nonionic dye should be used in patients with renal insufficiency who can't handle the dye load)
* Doppler ultrasonography—establishes the absence or presence of venous reflux and obstruction; the accuracy of the test depends on the operator's expertise
* duplex scan—locates venous reflux in the popliteal, superficial femoral, common femoral, and iliac veins, but is less accurate with calf veins
* impedance plethysmography—assesses the venous outflow of the legs by measuring variations in electrical impedance that may occur with blood volume changes
* photoplethysmography—measures vascular volume and vascular competence via a transducer with infrared light
* radionuclide venography—assesses the venous system using the radiopharmaceutical technetium 99.
Elevation and compression
Reducing edema and improving blood return to the heart reduce venous hypertension and help the wound heal. To reduce edema, teach the patient to elevate his legs 18 cm (7 inches) above his heart for 2 to 4 hours during the day and at night.
Also initiate compression therapy. Applying sustained external pressure to the affected leg helps reduce edema and improves venous blood return to the heart. Teach the patient and his caregiver to use the compression system; verify their understanding through return demonstrations.
In the past, the Unna's boot—inelastic gauze impregnated with zinc oxide—set the standard for compression therapy. Today, however, clinicians have many choices for treating the patient with a venous ulcer, from inelastic wraps to technologically advanced multilayer elastic compression therapy systems (see A Sampling of Com-pression Therapy Products). Here's how they compare.
* Inelastic system (Unna's boot). A zinc oxide–impregnated inelastic bandaging system is applied to the affected leg. As it dries, it becomes a rigid compression system. When the calf muscles press against the inelastic bandage, they pump more effectively, improving blood flow and reducing edema. This system can be used for mobile or immobile patients, but the rigidity of the system doesn't allow for changes in leg circumference. As edema clears, the leg gets smaller. Because the Unna's boot can't adjust to the reduced leg circumference, it's less effective over time. And it can't absorb large amounts of drainage, so it may become soiled and malodorous, and the periwound skin may become macerated.Compression stockings, elastic wraps, and compression pumps. Except for the compression pumps, these systems are suitable for mobile or immobile patients. Compression stockings are available with different grades of pressure and can be taken on and off, even though they may be difficult to apply properly. These stockings may need to be replaced every 6 months.Elastic wraps are an inexpensive product that maintain pressure at about 20 mm Hg when they're new. After being washed, however, they lose some of their compression capability.Compression pumps assist in venous return, decreasing edema. They provide pumping action by inflation and deflation of select chambers. Although this may be effective for some patients, it may be impractical and too costly for others.
* Sustained graduated compression (elastic, multilayer bandage systems) Achieved with a multilayered system, this system can decrease edema throughout the day regardless of leg size. It's been clinically proven to achieve pressures of 30 to 40 mm Hg at the ankle, graduating to 12 to 17 mm Hg below the knee. (Optimal pressures are 24 to 55 mm Hg at the ankle and 16 mm Hg just below the knee.)
Padding, applied as the initial layer, redistributes pressure around bony prominences and absorbs wound exudate. The remaining layers are elastic and cohesive bandages that achieve sustained graduated compression.
The multilayer system is appropriate for ambulatory and nonambulatory patients. Flexible and comfortable, it can control heavy drainage. Therapeutic pressures are sustained for at least 7 days, as opposed to other bandage systems in which the pressure decreases rapidly after application.
Other wound care principles
Many concurrent physical conditions, such as obesity, cardiovascular disease, deep vein thrombosis, and a family history of varicose veins, can impair healing and contribute to recurrence. Drawing on the expertise of other team members, assess and treat underlying problems as part of the wound management protocol.
Clean the wound regularly and prepare the patient for aggressive debridement, if indicated. When choosing a dressing, consider the wound's characteristics, including amount of exudate or drainage, size of the wound, the presence or absence of infection, and the characteristics of the surrounding skin.
Remember that wounds heal best in a moist environment. Use a moisture-retentive dressing (such as a hydrocolloid, transparent film, and certain foams) for wounds with light to moderate drainage. Use an absorbent dressing (such as foams, alginates, and specialty absorptive dressings) for wounds with moderate to heavy exudate. For a patient with a chronic venous ulcer, new technologies, such as skin substitutes and biologics, growth factors, and gene therapy, give you an even greater choice of products.
Cutting the high physical, emotional, and financial cost of venous ulcers requires a team approach. Draw on your colleagues' expertise to develop a care plan tailored to your patient's needs.
Understanding key terms
Ankle flare: distension of the small veins on the medial aspect of the foot caused by chronic venous hypertension
Dermatitis: chronic dryness of the skin with epithelial scaling
Hemosiderosis: pigmentation changes on the surface of the skin that generally appear as a brown discoloration affecting the medial portion of the leg
Lipodermatosclerosis: woody induration of the leg; when fibrous tissue replaces the fatty layer, edema remains above this area, making the leg look like an inverted champagne bottle
Varicosities: dilated veins
This article was updated and adapted from “Putting the squeeze on Venous Ulcers,” by Cathy Thomas Hess, Nursing2001. 31(9):58–64, September 2001.
The author has disclosed that she had no significant relationships or financial interest in any commercial companies that pertain to this educational activity.
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Goldman, R.J.: “5 Things You Should Know about Compression Therapy,” Advances in Skin & Wound Care
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Sieggreen, M.Y. and Kline, R.A.: “Recognizing and Managing Venous Leg Ulcers,” Advances in Skin & Wound Care
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Thomas Hess, C.: “Skin & Wound Care: Managing a Patient with a Venous Ulcer,” Nursing2003
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Thomas Hess, C.: Clinical Guide: Wound Care, 5th edition, Lippincott Williams & Wilkins, 2004.
van Rijswijk, L.: “Moist Dressings: Bridging the Gap between Research and Practice,” Advances in Skin & Wound Care
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