Venous stasis ulcers: causes, pathophysiology, and clinical management

Nursing: WOC ET Approach to Venous Stasis Ulcers

Chronic venous insufficiency is a complicated problem leading to multiple health concerns including venous stasis ulcers. WOC/ET nurses are often challenged with providing the best care for patients with venous stasis ulcers while working with researchers and medical practitioners to identify at risk populations.

This paper will review the role of WOC/ET Nursing in treatment and patient outcomes for individuals diagnosed with venous stasis leg ulcers. Specifically the paper will review the prevalence, etiology, prevention, assessment, care and treatment by WOC/ET nurses in various settings including acute care and home care settings. The article will include details about recent studies reflecting modern treatment approaches and guidelines provided to help nurses provide adequate care for patients with venous stasis ulcers, CVI and related conditions. The paper will conclude with areas for future research.

Prevalence/Etiology/Assessment

Venous insufficiency ulcers or stasis ulcers typically form as side effects of complications with blood flow through the veins (Rastinehad, 2006). Leaky valves and obstructions are partly to blame for stagnated or incorrect blood flow especially to the lower extremities. Typically as blood from the lower extremities begins to college in the leg, tissues surrounding the veins and leg are damaged, and ulcers commonly result (Tyco, 2006). It is important when reviewing venous ulcers to understand the cause and the characteristics so a proper diagnosis may be made. Typically venous stasis ulcers are characterized by distinct symptoms including: ruddy color, shallow depth, irregular margins surrounding wound, infection causing pain or discomfort, capillary refill and advanced skin temperature (Rastinehad, 2006; Tyco, 2006). Patients may also experience brown or reddened skin surrounding the ulcer and may experience edema in the lower calf especially near the ankles (Tyco, 2006). Hiser et al. (2006) note some patients are more at risk than others for developing venous insufficiency and resulting ulcers. These include patients with edema or chronic swelling, venous insufficiency, varicose veins and those who are housebound or do not have access to regular physical fitness to promote blood circulation throughout the lower limbs (Hiser et al. 2006). Most venous ulcers are characterized with irregular boarders and associated with patients with a long history of varicose veins or blood clots, or other vein problems (Tyco, 2006). Typically venous ulcers account for as much as 80% or more of all ulcers in the lower extremities and calves (Hiser et al. 2006).

Rastinehad (2006) describes and attempts to interpret the "complexities of the pain experienced by persons subject to venous ulcers" (p. 252). The author assesses ten participants hospitalized for acute care with pressure ulcers. The results suggest a strong need for increasing attention among nurses to pain assessment and management in patients and in WOC nursing education, practice and research (Rastinehad, 2006). The researcher also suggests commonly used definitions for pain are not adequate for describing the discomfort experienced by patients, and it is important nurses understand this to be able to administer helpful treatments to patients. This sentiment is echoed by other researchers (Doughty, et al. 2006) who note wound assessment is a key element of effective wound care, thus must be undertaken correctly.

WOC nurses should work to assess causative and contributing factors related to various lower-extremity ulcers and recommend treatment modalities according, according to WOCN (2005) guidelines. Among assessment procedures to adhere to include health history compilation and review of specific risk factors which may include presence of LEVD (lower-extremity venous disease) and wound history (WOCN, 2005). WOCN protocols also recommend reviewing labs with information on patient hematocrit and prothrombin time and review of erythrocyt sedimentation rate in patients taking anticoagulant agents (WOCN, 2005). Lower extremity examination is also recommended by (1) assessing skin temperature and color changes (2) reviewing skin for prevalence of paresthesias (3) assessing presence or absence of pedal pulses by palpating dorsalis pedis and posterios tibial pulses and (4) assessing the characteristics of ulcers present (WOCN, 2005). Nurses should also measure the ankle brachial index using Doppler and in some cases consider using Duplex imaging to rule out hemodynamic abnormalities (WOCN, 2005). Certain patients may require referral for examination or to rule out complications including deep vein thrombosis or variceal bleeds (WOCN, 2005).

Prevention

Prevention recommendations may depend on the patient's risk factors for veinous ulcers and the severity of their illness or any conditions precipitating the appearance of ulcers. Many recommend encouraging routine exercise and healthy living, combined with early treatment for veinous insufficiency to help reduce the likelihood venous ulcers will form and cause patient complications (Baronoski & Thimsen, 2003).

Studies often investigate the causes of problems including venous ulcers in search of prevention techniques. Incompetent perforator veins are a key factor in formation and chronic prevalence of venous ulcers in patients (Baron, et al. 2004). The WOCN (2005) guidelines note studies suggest individuals with LEVD and CVI may demonstrate impaired calf muscle function compared with healthier counterparts. Prevention of severe cases may include compression to prevent recurrence of LEVD; higher compression is recommended especially for patients who are not able to afford compression garments (WOCN, 2005). Other recommendations include health promotion by working to reduce edema through compression, though compression is not recommended for patients with ABI (WOCN, 2005). The WOCN (2005) suggests there is not adequate evidence supporting vein surgery to prevent ulcer recurrence, though does support use of compression devices to prevent venous ulcer recurrence in patients and for prevention of venous edema (WOCN, 2005).

Treatment

Acute treatment choices recommended by WOCN (2005) include cleansing wounds at every dressing change and minimizing trauma to the wound; additionally the WOCN recommends avoidance of chemicals that may prove irritating or allergenic especially when working with patients with dermatitis (WOCN, 2005). In certain instances, EMLA cream may be applied to reduce pain or hydrocolloid dressings may be applied under compression bandages (WOCN, 2005). Other helpful strategies for acute cases include use of cadexomer iodine to remove "slough and thus reduce bacterial bioburden" (WOCN, 2005). This method is recommended over wet-to-dry dressings and other measures to "promote faster healing in patients" (WOCN, 2005). The WOCN (2005) guidelines suggest other beneficial treatments may include use of flavonoids or Rutoside in "dosing up to 300 mg twice daily" to stimulate improved healing combined with "short-stretch compression bandages" which may help reduce the pain and discomfort associated with leg ulcers (WOCN, 2006). Compression therapy in general is provides greater benefits than no compression and high compression is better than lower compression (WOCN, 2005). Adjunct therapies that may prove beneficial include ultrasound to help heal ulcers and use of home-based exercise programs on release, which may improve poor muscle tone and "pump function," thereby decreasing the incidence of ulceration in patients (WOCN, 2005).

Baranoski & Thimsen (2003) note that home care nurses and clinical case nurses working in acute care settings have to educate themselves about the Wound, Ostomy, and Continence Nurses Guidance Document on OASIS Skin and Wound Status to understand the best methods for caring for patients with CVI and related conditions.

Care/Treatment by WOC/ET Nurse in Different Settings

The type of care and treatment offered patients with venous ulcers would depend on many factors including whether their condition is chronic or long standing and whether their condition is severe or moderate. Most studies explore treatment of chronic venous insufficiency rather than discuss treatment for acute symptoms, though the WOCN does provide numerous guidelines for treating acute cases in various settings.

Russell & Logsdon (2002) note the responsibilities of WOC nurses include possessing intimate and expert knowledge about treating and managing chronic venous insufficiency (CVI). Nurses must above all else, educate themselves and engage in continuous education programs so they are trained to use new techniques in managing acute and chronic cases. New techniques helpful for treating venous insufficiency important for WOC nurses to learn about include subfascial endoscopic perforator surgery or SEPS (Russell & Logsdon, 2002). For chronic patients or those with repeated ulceration requiring home treatment, long-term compression therapy may be advised in conjunction with other basic care routines (such as good skin care) (Russell & Logsdon, 2002).

Patients receiving home care or long-term care for repeated problems may be good candidates for the SEPS procedure, which doctors are using to "ligate the perforator veins in the lower extremities" to bypass faulty valves allowing backflow in the veinous system, resulting in CVI (Russell & Logsdon, 2002:34). SEPS research is among the leading methods holding strong promise for better recovery among patients with chronic CVI, and may be beneficial for long-term healing for patients, especially those "plagued" with recurrent ulcers (Russell & Logsdon, 2002).

Using SEPS as other researchers who suggest chronic patients confirm a primary treatment for patients with CVI will benefit (Baron, et al. 2004). Prior to 1985 according to Baron, et al. 2004, surgery on patients with CVI was referred to as the "Linton operation" and typically resulted in poor healing and increased risk for infection or complication (Baron, et al. 2004: 442). The SEPS procedures is now however, easily incorporated into overall treatment plans for patients with CVI and generally results in "excellent healing" with "minimal postoperative complications: (Baron, et al. 2004: 45).

Recommendations

Many recommend use of minimally invasive techniques including SEPS to treat and address problems related to chronic venous insufficiency (Kalra & Glovisczki, 2002). Multiple studies confirm the safety and efficacy of SEPS when used early, especially resulting from its low complication rates compared with other procedures including the formerly popular Linton procedures (Kalra & Gloiscki, 2002; Lee, et al. 2003; Tenbrook, et al., 2004; Bianchi, et al. 2003).

More randomized clinical trials are necessary however to answer additional questions related to the efficacy of new procedures including SEPS, though this procedures remains important for patients with advanced CVI secondary to PVI or with patients who do not demonstrate other complications including DVT (Kalra & Gloiscki, 2002; Bianchi, et al. 2003).

Wagner-Cox (2005) also notes that it is important for nurses to be considerate, knowledgeable and compassionate toward patients with acute and chronic illnesses, especially when caring for patients in the home. This sentiment emphasizes research suggesting nurse case managers and other critical staff takes into consideration patient's assessment of their pain and discomfort (Hiser, et al. 2006). Pieper et al. (2006) note that WOCN nurses also have a responsibility to patients to adequately address their self-care concerns prior to preparing patients for discharge after surgery, SEPS or treatment for venous ulcers. This education should include discussion of wound care, incision care, symptom management and pain management and also education regarding the patient's quality of life and prevention of new problems (Pieper, et al. 2006). Education is vital to the long-term success and positive patient outcomes, as unmet discharge needs may contribute "to poor patient outcomes and readmission" (Pieper, et al. 2006: 290).

Summary of Literature

The best treatment for any disease whether acute or chronic is prevention. The literature points to the importance of identifying at risk populations. WOC nurses have a responsibility to screen all patients at risk for developing venous stasis ulcers early and recommending appropriate treatment plans taking into consideration their future risk for developing acute or chronic conditions. While it is impossible to prevent all cases of ulcers, much can be done in the way of prevention.

It is vital nurses receive education in new treatments and techniques for diagnosing, assessing and caring for ulcers. The latest research suggests new surgical interventions including use of the SEPS is ideal for treating patients especially those with long-term or long-standing venous ulcers. Thus far all research related to this area of treatment proves promising. The goals of treatment should include not only treating the immediate problem or ulcers but also working with the patient to identify their specific risk factors and educating patients about ways they can prevent future complications.