venous leg ulcers
DESCRIPTION
A guide to venous leg ulcers: their pathophysiology, current treatments, nursing implications.TRANSCRIPT
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Venous Leg UlcersVenous Leg UlcersAn Evidence-Based Approach
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Researched and Compiled byResearched and Compiled by
Valarie, Sandy, Leann, Ruth
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Venous Leg UlcersVenous Leg Ulcers
What interventions work best?
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An Introduction:An Introduction:
Venous Leg UlcersVenous Leg Ulcers
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• A non-healing open wound
• Often near the ankle
• With or without visible varicose veins
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Signs and SymptomsSigns and Symptoms
• red, open, draining
• non-healing
• painful
• swollen leg
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What Lies What Lies Beneath:Beneath:IncompetentIncompetentPerforatorsPerforators• Perforators should
only allow inward flow from super-
ficial to deep
• Valve competencein perforators is critical to protectingsuperficial tissues from elevated deep venous pressure
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• Maternal history of venous insufficiency
• History of DVT, DM, chronic heart failure or recent edema
• Obesity
• Severe trauma to the leg
• Vigorous exercise
• Number of pregnancies
Risk FactorsRisk Factors
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Venous Insufficiency:Venous Insufficiency:
it’s in the it’s in the circulationcirculation
edema varicoseveins
changes in color, skin
ulceration
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• >80% of ulcers treated are venous
• 1-2% of the population affected
Venous Leg Ulcer FactsVenous Leg Ulcer Facts
• Rarely occurs < 45years of age
• Average time to heal 12-30 weeks
• Annual burden: >$1B
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Poor circulation decreases delivery of oxygen and nutrients, prevents removal of metabolic waste products such as carbon dioxide, and ultimately delays healing.
Blood Flow:Blood Flow:The key to The key to Wound Wound HealingHealing
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InterventionsInterventions
• Modify activity to promoteblood flow
• Apply compression therapy
• Provide local wound andskin care
• Treat and control infection, inflammation
• Improve nutrition
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First Step: Assess for PADFirst Step: Assess for PAD(Peripheral Arterial Disease)(Peripheral Arterial Disease)
Check pedal pulses before compression
Use Doppler to check ABPI >0.8 (ankle/brachial press. index)
If ABI is <0.5 NO compression needs referral to vascular surgeon
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Keep the pressure on: Keep the pressure on: Unna Boot Unna Boot
• A paste bandage withzinc oxide, glycerin, etc.
• Applied without tensiondistal to proximal to below knee
• Primary dressing applied first
• Boot dries to a semirigid cast
• Changed 1-2x q week, depends on drainage
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Pneumatic Compression Pneumatic Compression Pump Pump
• Inflatable boot and pump
rhythmically fills with air
• Long-term use for ptsnoncompliant with
othermethods
• For pts who have failedtreatment with other compression devices
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Lifelong: Lifelong: Compression Compression TherapyTherapy
• After healing of ulcer,fit for custom stockings
• Remove and bathe each evening, apply moisturizer• Each morning put on
to prevent edema• Metal frame used to assist• Pt should purchase in pairs of two, replace every 6 months
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Advanced Cases:Advanced Cases:Surgical TreatmentSurgical Treatment
• Subfascial endoscopic perforator surgery (SEPS)
• Improves healing rates, and reoccurence
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Advanced Cases:Advanced Cases:Maggot TherapyMaggot Therapy
• Maggots are currently one of the mosteffective means of treating ulcers with MRSA
• Specially bred fly larvae secrete enzymes to
break down dead tissue into a liquid they will ingest
• The FDA approved thistherapy in Jan, 2004.
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Venous Leg UlcersVenous Leg UlcersRandom Control TrialsRandom Control Trials
Study 1-Review Question:• What are the effects of systemic
antibiotics and topical antibiotics and antiseptic on healing?– 22 RCTs included
– High bacterial colonization
– Currently no strong evidence
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Venous Leg UlcersVenous Leg UlcersRandom Control TrialsRandom Control Trials
Study 2 –Efficacy and safety of CHRONOSEAL cream• Evaluates if CHRONOSEAL
– Is safe…
– Is tolerated …
– Reduces size
• The study is currently recruiting participants – Sponsors and collaborators: Tripep AB, Kringle Pharma,
Inc.
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Venous Leg UlcersVenous Leg UlcersRandom Control TrialsRandom Control Trials
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Best Nursing PracticeBest Nursing PracticeIdentify and treat the causeIdentify and treat the cause
• Obtain history
• Perform physical assessment
• Determine cause
• Implement appropriate therapy
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Best Nursing PracticeBest Nursing PracticeAddress Patient ConcernsAddress Patient Concerns
• Communicate
• Establish realistic goals
• Provide information
• Assess support system
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Best Nursing PracticeBest Nursing PracticeProvide Wound Care & Provide Wound Care &
SupportSupport
• Assess
• Optimize healing environment
• Consider additional therapies
• Refer as needed
• Consider all factors that affect healing
• Teach patient measures of prevention
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REFERENCES
http://www.medscape.com
http://www.mayoclinic.org/vascularcenter
http://www.ncbi.nlm.nih.gov
http://veinforum.org
http://www.cawc.net/
http://www.VeinClinics.com
http://www.icvein.com/
http://clinicaltrials.gov/identifier:nct00797706
Journal of Advanced Nursing, prepared by Joana
Briggs Institute, Cochrane Library; 2008