1. The client/caregiver can define venous stasis ulcers.
   1. It is the breakdown of the skin caused by incompetent valves in the veins.
   2. Incompetent valves cause excessive venous pressure that causes small skin veins and venules to rupture.
   3. Venous ulcers frequently occur on the front of lower legs or around the ankle.
   4. They are slow to heal, prone to trauma, and may lead to secondary infections.
2. The client/caregiver can list factors that increase risk of venous stasis ulcers.
   1. Thrombophlebitis
   2. Varicose veins
   3. Poor hygiene
   4. Poor nutritional status
   5. General debilitation
3. The client/caregiver can recognize signs and symptoms of venous insufficiency
   1. Thickened leathery skin
   2. Reddish brown skin discoloration
   3. Swelling of extremity
   4. Pain (relieved with elevation of foot)
4. The client/caregiver can list measures to prevent or treat venous stasis ulcers.
   1. Use elastic compression stockings. Have more than one pair of stockings so that one pair can be worn while the other pair is laundered.
   2. Apply stockings each morning before legs are lowered to floor.
   3. Promote weight loss if necessary.
   4. Eat a well-balanced diet high in protein, vitamin C, zinc, and iron.
   5. Avoid heating pads, hot water bottles, and so forth.
   6. Elevate legs at regular periods for 15 to 20 minutes.
   7. Walk or do isometric calf muscle pumps frequently.
   8. Raise the foot of the bed to promote venous drainage during sleep.
   9. Wear shoes with laces to reduce pooling of blood in the feet.
   10. Avoid poorly fitting shoes and sandals to avoid injury.
   11. Avoid morning showers or sitting in front of a fire because the heat dilates the blood vessels and may add to congestion and swelling.
   12. Avoid extreme temperatures. M. Avoid nicotine and caffeine.
5. The client/caregiver can provide treatment as ordered by physician.
   1. Provide dressing changes of wound as ordered by physician using aseptic technique. Avoid tape directly on skin.
   2. Application of Unna boots.
   3. Chronic nonhealing ulcers may be treated with topical hyperbaric oxygen therapy.
   4. Vascular surgery for repair or debridement of wound.
   5. Pain medication as directed.
6. The client/caregiver is aware of possible complications.
   1. Infection
   2. Reoccurrence of venous stasis ulcer
   3. Amputation of extremity
   4. Cellulitis

Resources

Registered dietician
Certified nurse wound specialist
Podiatrist

References

Ackley, B. J., & Ladwig, G. B. (2006). Nursing diagnosis handbook: A guide to planning care.
Philadelphia: Mosby Inc.
Cohen, B. J., & Wood, D. L. (2000). Memmler’s the Human Body in Health and Disease (9th ed.). Philadelphia: Lippincott Williams & Wilkins.
Nutrition made incredibly easy. (2003). Springhouse: Lippincott, Williams & Wilkins.
Portable RN: The all-in-one nursing reference. (2002). Springhouse: Lippincott, Williams & Wilkins.
Taylor, C., Lillis, D., & LeMone, P. (2005). Fundamentals of nursing. Philadelphia: Lippincott Williams & Wilkins. Timby, B. K., & Smith, N. C. (2003). Introductory medical-surgical nursing (8th ed.). Philadelphia: J. B. Lippincott Williams & Wilkins.

Credits

Client Teaching Guides for Home Health Care, 2nd ed.
© 2008 Jones and Bartlett Publishers, Inc.
www.jbpub.com