Venous stasis ulcers are chronic wounds that develop due to poor venous circulation in the lower extremities. This nursing diagnosis focuses on identifying risk factors, managing symptoms, and preventing complications associated with venous stasis ulcers.
Causes (Related to)
Venous stasis ulcers can develop due to various factors affecting venous circulation:
- Chronic venous insufficiency
- Deep vein thrombosis (DVT)
- Varicose veins
- Obesity
- Extended periods of immobility
- Previous leg injuries or surgeries
- Advanced age
- Family history of venous disease
- Pregnancy
- Occupations requiring prolonged standing
Signs and Symptoms (As evidenced by)
Subjective: (Patient reports)
- Pain and heaviness in legs
- Itching around the affected area
- Burning sensation
- Sleep disturbance due to discomfort
- Limited mobility
- Social isolation due to wound appearance
- Decreased quality of life
Objective: (Nurse assesses)
- Shallow ulcer with irregular borders
- Ruddy or purplish skin around the ulcer
- Edema in the affected limb
- Weeping or exudate from the wound
- Lipodermatosclerosis
- Varicose veins
- Hemosiderin staining
- Atrophie blanche
- Delayed wound healing
Expected Outcomes
- Wound healing progression within the expected timeframe
- Reduced edema in the affected limb
- Improved pain management
- Enhanced mobility
- Prevention of new ulcer formation
- Maintained skin integrity
- Improved quality of life
- Demonstrated understanding of preventive measures
Nursing Assessment
Wound Evaluation
- Measure wound dimensions
- Assess wound bed characteristics
- Document the exudate amount and type
- Check for signs of infection
- Evaluate periwound skin condition
Circulatory Assessment
- Check peripheral pulses
- Assess capillary refill
- Monitor edema levels
- Evaluate skin temperature
- Document varicose veins
Pain Assessment
- Rate pain intensity
- Identify pain triggers
- Document pain characteristics
- Assess the impact on daily activities
- Evaluate the effectiveness of pain management
Mobility Assessment
- Evaluate gait pattern
- Assess activity level
- Document mobility limitations
- Check for proper footwear
- Evaluate the use of assistive devices
Nutritional Status
- Monitor weight
- Assess dietary intake
- Check protein levels
- Document fluid intake
- Evaluate supplement needs
Nursing Care Plans
Nursing Care Plan 1: Impaired Skin Integrity
Nursing Diagnosis Statement:
Impaired skin integrity related to venous insufficiency as evidenced by open ulcer on lower extremity with irregular borders and moderate exudate.
Related Factors:
- Altered circulation
- Edema
- Impaired mobility
- Nutritional deficits
- Previous ulcer history
Nursing Interventions and Rationales:
- Perform regular wound assessment and documentation
Rationale: Monitors healing progress and identifies complications early - Apply appropriate wound dressings
Rationale: Maintains optimal wound healing environment - Implement compression therapy as ordered
Rationale: Reduces edema and improves venous return
Desired Outcomes:
- Progressive wound healing
- Decreased wound size
- Reduced exudate
- Improved periwound skin condition
Nursing Care Plan 2: Chronic Pain
Nursing Diagnosis Statement:
Chronic pain related to tissue damage and inflammation as evidenced by a reported pain score of 6/10 and disturbed sleep pattern.
Related Factors:
- Tissue inflammation
- Wound presence
- Edema
- Emotional distress
- Activity limitations
Nursing Interventions and Rationales:
- Administer prescribed pain medications
Rationale: Provides consistent pain management - Teach pain management techniques
Rationale: Empowers patient with self-management strategies - Position the affected limb appropriately
Rationale: Reduces edema and associated pain
Desired Outcomes:
- Improved pain control
- Enhanced sleep quality
- Increased activity tolerance
- Better quality of life
Nursing Care Plan 3: Impaired Physical Mobility
Nursing Diagnosis Statement:
Impaired physical mobility related to pain and fear of injury as evidenced by decreased activity level and altered gait pattern.
Related Factors:
- Pain
- Fear of injury
- Edema
- Wound location
- Muscle weakness
Nursing Interventions and Rationales:
- Develop an individualized exercise plan
Rationale: Maintains muscle strength and joint mobility - Teach proper leg elevation techniques
Rationale: Reduces edema and promotes circulation - Assist with mobility aids
Rationale: Ensures safe ambulation
Desired Outcomes:
- Increased activity level
- Improved gait pattern
- Enhanced independence
- Reduced fear of movement
Nursing Care Plan 4: Risk for Infection
Nursing Diagnosis Statement:
Risk for infection related to the presence of chronic wound and compromised tissue integrity.
Related Factors:
- Open wound
- Compromised circulation
- Poor nutrition
- Environmental exposure
- Decreased immunity
Nursing Interventions and Rationales:
- Maintain sterile technique during dressing changes
Rationale: Prevents wound contamination - Monitor for signs of infection
Rationale: Enables early intervention - Educate about wound care hygiene
Rationale: Promotes proper wound management
Desired Outcomes:
- Absence of infection
- Proper wound healing
- Demonstrated wound care technique
- Understanding of infection signs
Nursing Care Plan 5: Ineffective Health Management
Nursing Diagnosis Statement:
Ineffective health management related to knowledge deficit about venous stasis ulcer care as evidenced by incorrect wound care technique and poor compliance with treatment plan.
Related Factors:
- Limited understanding
- Complex treatment regimen
- Lack of resources
- Cultural beliefs
- Financial constraints
Nursing Interventions and Rationales:
- Provide comprehensive education
Rationale: Enhances understanding and compliance - Develop a simplified care routine
Rationale: Promotes adherence to treatment - Connect with support resources
Rationale: Ensures continued care management
Desired Outcomes:
- Improved treatment compliance
- Better self-management skills
- Enhanced wound care technique
- Reduced complications
References
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