Venous Stasis Ulcer Nursing Diagnosis and Nursing Care Plan

Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions

Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions

Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). Calf muscle contraction and intraluminal valves increase prograde flow while preventing blood reflux under normal circumstances.

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.

Elderly people are more frequently affected. The disease has shown a worldwide rising incidence as the world’s population ages. Males experience a lower overall incidence than females do. 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.

Signs and Symptoms of Venous Stasis Ulcer

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. Symptoms of venous stasis ulcers include:

  • dull pain (improves with the elevation of the affected extremity)
  • foul smell
  • itching (pruritus)
  • oozing pus or another fluid from the lesion
  • swelling (edema) that worsens throughout the day
  • Signs of chronic venous insufficiency, such as:
    • Early signs
      • telangiectasia
      • reticular veins
    • Late signs
      • varicose veins
      • brown-orange hyperpigmentation
      • chronic leg edema
      • stasis dermatitis
      • atrophie blanche
      • lipodermatosclerosis

Cause of Venous Stasis Ulcer

  • Valve damage in leg veins. Typically, damage to the valves inside the leg veins leads to venous ulcers. These valves regulate the veins’ internal blood pressure. When one walks, they let it fall. Sustained venous hypertension is the name for the problem that occurs when the blood pressure in the leg veins doesn’t decrease when one moves. The ankles develop ulcers as a result of the rise in blood pressure. Mast cell degranulation, leukocyte recruitment, elevated levels of prostacyclin and matrix metalloproteinase inhibitors, the development of smooth muscle cells with a non-contractile secretory phenotype, and fibroblast differentiation into myofibroblasts are cellular processes that contribute to vein wall remodeling and varix formation.
  • Chronic venous insufficiency (CVI). Blood reflux, obstruction, or a combination of both mechanisms may result in CVI and lead to macro- and microcirculatory dysfunction. An inflammatory reaction is triggered by elevated intraluminal pressure, which also induces protein extravasation and fibrin cuff development. These mechanisms then obstruct the diffusion of oxygen and growth factors across tissues. Persistent inflammation and poor blood flow favor thrombus development, advancing fibrosis, and valvular damage. Together, these inflammatory reactions hinder the healing process, which leads to the development of ulcers after trauma.
  • Varicose veins. Venous ulcers are more likely to occur in people with varicose veins. Blood collects in the legs when veins in this area are unable to circulate blood effectively. This can result in venous insufficiency ulcers.
  • Venous hypertension. Increased pressure in the leg’s distal veins and venous hypertension are the results of deep vein thrombosis, perforator insufficiency, superficial and deep vein insufficiencies, arteriovenous fistulas, and calf muscle pump insufficiencies.
  • Cytokine dysregulation. Tumor necrosis factor (TNF), transforming growth factor (TGF), and matrix metalloproteinases are a few examples of growth factors whose dysregulation results in the chronicity of ulcers.

Risk Factors to Venous Stasis Ulcer

Risk factors for venous stasis ulcers include the following:

  • A family history of CVI
  • Advancing age
  • Female sex
  • Prior thrombosis or pulmonary embolism
  • Multiparity
  • Lipodermatosclerosis
  • Musculoskeletal and joint illness
  • Obesity
  • Sedentarism

Complications of Venous Stasis Ulcer

  • Cellulitis. The most frequent complication of venous stasis ulcers, like those of any chronic wound, is infection. This should be managed promptly to enhance healing and patient adherence. Cellulitis is a soft tissue infection that affects the skin, connective tissues, and tissues nearby. Swelling, erythema, and warmth in the affected area are its defining features.
  • Skin cancer. Less frequently, skin cancer may appear in wounds that take a long time to heal. Squamous cell cancer may arise from a type of chronic, non-healing wound called a Marjolin’s ulcer.
  • Osteomyelitis. Osteomyelitis, often known as a bone infection, is a serious infection that has damaged the body’s bones by penetrating them deeper. The harm this illness causes will restrict the damaged bones’ movement and abilities.
  • Sepsis. Severe decubitus ulcer complication brought on by widespread wound infection that jeopardizes the body’s hemodynamic stability.
  • Risk of amputation. Amputation risk is also increased by non-healing sores.
  • Recurrence. After therapy, venous ulcers may recur, which is why preventive medicines are frequently used in treatment.

Diagnosis of Venous Stasis Ulcer

Diagnostic tests for venous stasis ulcers usually include:

  • Comprehensive history taking. Identification of risk factors through history-taking aids in separating venous stasis ulcers from other causes of lower extremity non-healing wounds. Pruritus with or without a rash, agonizing discomfort in the gaiter area, evening pedal edema, and nocturnal cramps are common referrals from patients with CVI and venous stasis ulcers.
  • Physical examination. The ulcer’s area, depth, margins, wound base, infection symptoms, and peripheral skin changes should all be described in the clinical assessment. On examination, early CVI physical symptoms must be recognized. Telangiectasia and reticular veins are the early signs of venous insufficiency. Late signs include varicose veins, brown-orange hyperpigmentation, chronic leg edema, stasis dermatitis, atrophie blanche, and lipodermatosclerosis.
  • Palpation of pulses and measurement of ankle-brachial pressure index (ABPI). Since about 20% of VLU patients have concurrent arterial disease, sufficient arterial blood flow is assessed by the palpation of distal pulses and the ABPI. By dividing the systolic arm pressure measured while lying flat by the systolic ankle pressure, the ABPI is calculated. An ABPI between 1.00 and 1.3 is regarded as normal.
  • Color-flow duplex. ultrasound. Another affordable, non-invasive, and extremely informative diagnostic technique is color-flow duplex ultrasound, which is particularly helpful for assessing superficial veins. It is possible to look into the blood flow through arteries and veins to find any obstructions. It can map both superficial and deep veins, identify flow through valves, and allow for the direct sight of veins.
  • CT scan and MRI. Deeper vessels are best evaluated with computed tomography or magnetic resonance imaging because they are frequently difficult or impossible to evaluate with ultrasound.
  • Photoplethysmography. This non-invasive test calculates how quickly the veins refill. The detection is done using a probe that is applied to the skin’s surface right above the ankle. The patient is told to do short bursts of calf muscle pump exercises, then take a break. The probe gauges the decline in cutaneous blood flow after exercise. The effectiveness of the calf muscle pump and the presence of any aberrant venous reflux are determined by this. Patients who have issues with their superficial or deep veins typically have inadequate vein emptying and unusually quick refilling (25 s).
  • Pulse oximetry. This noninvasive test analyzes the amount of oxygenated and deoxygenated hemoglobin in a digit by absorbing red and infrared light. More infrared light is absorbed by oxygenated hemoglobin, but more red light can flow through a digit. More red light is absorbed by deoxygenated hemoglobin, but more infrared light can pass through the digit. However, there is not enough data to support the use of this research as the main diagnostic tool.
  • Nylon monofilament. To rule out sensory neuropathy, a straightforward screening test with nylon monofilament can be utilized.

Treatment for Venous Stasis Ulcer

Compression therapy and direct wound management are the standard of care for VLUs. For wound closure to be effective, leg edema must be reduced. Treatment for venous stasis ulcer should usually include:

  • Compression therapy. The most practical, efficient, and economical intervention for the treatment of VLUs is compression therapy. This calls for the use of various hosiery or bandages, which may be single- or multi-layered, elastic or inelastic, etc.
  • Wound management. Cleaning, debridement, infection control, dressing application, and topical medication are all direct ulcer interventions. To minimize harm to the live tissue, cleaning should be done with a non-toxic substance. Debridement is possible and highly advised by surgically removing non-viable tissue. To lessen discomfort, the anesthetic may be applied topically or intravenously. Enzymatic drugs, larval therapy, and autolytic dressings are non-invasive debridement alternatives, albeit recovery times may be prolonged.
    • Debridement. For new tissue to the surface, dead and necrotic tissues must be surgically removed. For larger wounds, reconstructive surgery may also be necessary, and flaps will be used to cover the wounds.
    • Wound dressing. Dressings promote granulation and re-epithelialization, maintain a sufficient moisture level, and provide physical protection. To treat dry, exudative, and infected wounds, respectively, a variety of absorbent (such as alginates), and moisture-retaining (such as hydrocolloids).
    • Topical treatment.  Topical medications are frequently used as debriding agents, antimicrobials, and antiseptics.
  • Pharmacologic therapy. Treatment with micronized pure flavonoids is an efficient supplementary approach to compression therapy.
  • Systemic antibiotic therapy. Systemic antibiotic therapy should be taken into consideration if an infection is suspected in a newly developing painful ulcer accompanied by erythema, tenderness, warmth, and systemic symptoms (such as fever and chills).
  • Tissue culture. To direct antibiotic therapy, tissue culture (rather than a swab) must be carried out in fetid, purulent, or not-healing.
  • Pain medications. Anti-inflammatory and analgesic medications will be used to alleviate pain, particularly during dressing changes and wound care.
  • Physical therapy. Encourage the patient to get out of bed and sit down by performing the necessary exercises during physical therapy.

Prevention of Venous Stasis Ulcer

The following lifestyle changes must be implemented to increase circulation and lower the risk of developing venous stasis ulcers: 

  • Antihypertensive medications. Maintain the course of treatment for persistent ailments like high blood pressure that have an impact on vein health.
  • Maintain a healthy weight. High pressure in the leg veins brought on by being overweight might harm the skin.
  • Quit smoking. Smoke-damaged veins result in chronic venous insufficiency, a condition marked by continuously inadequate blood flow. The legs may swell, cramp, and develop skin ulcers as a result.
  • Anticoagulants. If prescribed, take anticoagulants (blood thinners) to prevent blood clots.
  • Be physically active by doing regular exercise. Regular exercise and a healthy, balanced diet are advised to aid with weight loss.
  • Wear compression stockings. Because of their unique design, these stockings will compress the legs, increasing circulation.
  • Elevate the legs. An extended time standing or sitting should also be avoided. Every time this happens, elevate the patient’s legs unless contraindicated.

Venous Stasis Ulcer Nursing Diagnosis

Nursing Care Plan for Venous Stasis Ulcer 1

Impaired Skin Integrity

Nursing Diagnosis: Impaired Skin Integrity related to skin breakdown secondary to pressure ulcer as indicated by a pressure sore on the sacrum, a few days of sore discharge, pain, and soreness

Desired Outcome:  The patient’s skin integrity will be at its best by adhering to the decubitus ulcer treatment plan,

Venous Stasis Ulcer Nursing InterventionsRationale
Encourage the patient to refrain from scratching the injured regions. Wash the sores with the recommended cleanser to instruct the caregiver about good wound hygiene.It’s essential to keep the impacted areas clean by washing them with the recommended cleanser. 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.
Start providing wound care according to the decubitus ulcer’s development. It might be necessary to apply the prescription antibiotic cream or ointment directly to the affected area.The healing capacity of the pressure damage is maximized by providing the appropriate wound care following the stage of the decubitus ulcer.
Encourage performing simple exercises and getting out of bed to sit on a chair. If necessary, recommend the physical therapy team.Encouraging the patient through physical therapy to get out of bed and sit down and carry out the necessary exercises
Teach the caretaker how to properly care for the afflicted regions of the wounds if the patient is to be discharged.At-home wound healing can be accelerated by providing proper wound care and bandaging the damaged regions to stop pressure injury from getting worse.
Examine the patient’s skin all over his or her body. Make a chart for wound care.To assess the size and extent of decubitus ulcers, as well as any affected areas that need specific care or wound treatment.

Nursing Care Plan for Venous Stasis Ulcer 2

Risk for Ineffective Health Maintenance

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

Desired Outcomes: 

  • The patient will verbalize an understanding of the aspects of home care for venous stasis ulcers such as pressure relief and wound management.
  • The patient will verbalize an ability to adapt sufficiently to the existing condition.
Venous Stasis Ulcer Nursing InterventionsRationale
Examine the client’s and the caregiver’s wound-care knowledge and skills in the area.Patients are no longer held in hospitals until their pressure ulcers have healed; they may still require home wound care for several weeks or months.  
Examine the client’s and the caregiver’s comprehension of pressure ulcer development prevention.Immobile clients will need to be repositioned frequently to reduce the chance of breakdown in the intact parts.  
Examine the client’s and the caregiver’s comprehension of the long-term nature of wound healing.Even under perfect conditions, a pressure ulcer may take weeks or months to heal. Ulcers heal from their edges toward their centers and their bases up. Clean, persistent wounds that are not healing may benefit from palliative wound care.  
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.Early discovery calls for rapid action.  
Provide information about local wound care to the patient and the caregiver, and then let them watch a demonstration.This will enable the client to apply new knowledge right away, improving retention. The student can make adjustments as soon as they receive feedback, as opposed to practicing the skill incorrectly.  
Along with the materials given, provide written instructions.Specific written plans are necessary for long-term management to improve treatment adherence. There are numerous online resources for lay education.  

Nursing Care Plan for Venous Stasis Ulcer 3

Acute Pain

Nursing Diagnosis: Acute Pain related to pressure ulcers as evidenced by a pain level of 10/10, restlessness, and irritability, especially during wound care secondary to venous stasis ulcers.

Desired Outcome:  The patient will verbally report their level of pain as 0 out of 10.

Venous Stasis Ulcer Nursing InterventionsRationale
Examine the patient’s vital statistics. As the patient is experiencing pain, have him or her score it on a scale of 0 to 10 and describe it.To compile a patient’s baseline set of observations. The 10-point pain scale is a widely used, precise, and efficient pain rating measure.
Provide analgesics or other painkillers as directed, at least 30 minutes before caring for a wound.To relieve the patient’s agony.
After administering the analgesic, give the patient 30 to 60 minutes to rate their acute pain again.To evaluate whether a treatment is effective.
More analgesics should be given as needed or as directed.To encourage numbing of the pain and patient comfort without the danger of an overdose.
Position the patient back in his or her comfortable or desired posture. Encourage deep breathing exercises and pursed lip breathing.To encourage ideal patient comfort and lessen agitation/anxiety.

Nursing Care Plan for Venous Stasis Ulcer 4

Risk for Infection

Nursing Diagnosis: Risk for Infection related to poor circulation and oxygen delivery and ischemia secondary to venous pressure ulcers

Desired Outcomes:

  • The patient will maintain their normal body temperature.
  • The patient will continue to be free of systemic or local infections as shown by the lack of profuse, foul-smelling wound exudate.
Venous Stasis Ulcer Nursing InterventionsRationale
Analyze the client’s nutrient intake.Patients who are severely malnourished (serum albumin 2.5 mg/dl) are more likely to acquire an infection from a pressure ulcer. 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.
Determine whether the client has unexplained sepsis.The pressure ulcer needs to be taken into consideration as a potential cause during the septic workup.
Monitor the client’s body temperature.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.
Examine for fecal and urinary incontinence.Sacral wounds are most susceptible to infection from urine or feces contamination due to their closeness to the perineum. Isolating the wound from the perineal region can occasionally be challenging.
Give antibiotics as directed.Cellulitis or sepsis may develop in complicated wounds, necessitating antibiotic therapy. Effective treatments include topical silver sulfadiazine and oral antibiotics.

Nursing Care Plan for Venous Stasis Ulcer 5

Impaired Peripheral Tissue Perfusion

Nursing Diagnosis: Impaired Peripheral Tissue Perfusion related to deficient knowledge of risk factors secondary to venous stasis ulcers as evidenced by edema, decreased peripheral pulses, capillary refill time > 3 seconds, and altered skin characteristics.

Desired Outcomes: 

  • The patient will demonstrate improved tissue perfusion as evidenced by adequate peripheral pulses, absence of edema, and normal skin color and temperature.
  • The patient will employ behaviors that will enhance tissue perfusion.
  • The patient will demonstrate increased tolerance to activity.
Venous Stasis Ulcer Nursing InterventionsRationale
Encourage early ambulation.In comparison to a single long walk, short, regular walks are healthier for the extremities and the prevention of pulmonary problems. Make careful to perform range-of-motion exercises if the client is bedridden.
When seated in a chair or bed, raise the patient’s legs as needed.This prevents overdistention and quickly empties the superficial and tibial veins, which reduces tissue swelling and boosts venous return. Note: According to certain medical professionals, elevation may enhance thrombus release, raising the risk of embolization and reducing blood flow to the extremity’s most distal part.
Start performing active or passive exercises while in bed, including occasionally rotating, flexing, and extending the feet. As soon as the client is allowed to leave the bed, assist with a progressive return to ambulation.These actions are intended to improve overall muscle tone and strength, as well as boost venous return from the lower extremities and decrease venous stasis. They also support healthy organ function and raise well-being in general.
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.Physically restricting circulation reduces blood flow and heightens venous stasis in the pelvic, popliteal, and leg veins, causing swelling and discomfort to worsen.
As long as the heart can handle it, up the patient’s daily fluid intake to at least 1500 to 2000 mL.Dehydration makes blood more viscous and causes venous stasis, which makes thrombus development more likely.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

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.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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Author
Anna Curran. RN, BSN, PHN

Anna Curran. RN, BSN, PHN
Clinical Nurse Instructor

Emergency Room Registered Nurse
Critical Care Transport Nurse
Clinical Nurse Instructor for LVN and BSN students

Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process and help nursing students pass the NCLEX exams.

Her experience spans almost 30 years in nursing, starting as an LVN in 1993. She received her RN license in 1997. She has worked in Medical-Surgical, Telemetry, ICU and the ER. She found a passion in the ER and has stayed in this department for 30 years.

She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse.

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