Venous Stasis Ulcers

  1. General information
    1. Usually a complication of thrombophlebitis and varicose veins.
    2. Ulcers result from incompetent valves in the veins, causing high pressure with rupture of small skin veins and venules.
  2. Medical management
    1. Antibiotic therapy (specific to organism cultured); topical bacteriocidal solutions
    2. Skin grafting
    3. Enzymatic or surgical debridement
  3. Assessment findings
    1. Pain in the limb in dependent position or during ambulation
    2. Skin of leathery texture, brownish pigment around ankles; positive pulses but edema makes palpation difficult.
  4. Nursing interventions
    1. Provide bed rest, elevating extremity.
    2. Provide a balanced diet with added protein and vitamin supplements.
    3. Administer antibiotics as ordered to control infection.
    4. Promote healing by cleansing ulcer with prescribed agents.
    5. Provide client teaching and discharge planning concerning
      1. Importance of avoiding trauma to affected limb
      2. Skin care regimen
      3. Use of elastic support stockings (after ulcer is healed)
      4. Need for planned rest periods with elevation of the extremities
    6. Adherence to balanced diet with vitamin supplements.

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