Potential Nursing Interventions: (3 minimum) 1. Valves in the veins prevent backflow, but failure of the valves results in increased pressure in the veins. Anna Curran. Your doctor may also recommend certain diagnostic imaging tests. Position the patient back in his or her comfortable or desired posture. St. Louis, MO: Elsevier. Nursing Times [online issue]; 115: 6, 24-28. such as venous ulcers and lymphoedema, concomitant bacterial and fungal colonisation or infection may be present. Any delay in care increases the risk of infection, sepsis, amputation, skin cancers, and death. In diabetic patients, distal symmetric neuropathy and peripheral . It is performed with autograft (skin or cells taken from another site on the same patient), allograft (skin or cells taken from another person), or artificial skin (human skin equivalent).41,42,49 However, skin grafting generally is not effective if there is persistent edema, which is common with venous insufficiency, and the underlying venous disease is not addressed.40 A recent Cochrane review found few high-quality studies to support the use of human skin grafting for the treatment of venous ulcers.41, The role of surgery is to reduce venous reflux, hasten healing, and prevent ulcer recurrence. Encouraging the patient through physical therapy to get out of bed and sit down and carry out the necessary exercises. 2010. Elderly people are more frequently affected. The patient will demonstrate improved tissue perfusion as evidenced by adequate peripheral pulses, absence of edema, and normal skin color and temperature. SUSAN BONKEMEYER MILLAN, MD, RUN GAN, MD, AND PETRA E. TOWNSEND, MD. The first step is to remove any debris or dead tissue from the ulcer, wash and dry it, and apply an appropriate dressing. In a small study, patients receiving simvastatin (Zocor), 40 mg once daily, had a higher rate of ulcer healing than matched patients given placebo.42, Phlebotonics. RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. Removal of necrotic tissue and bacterial burden through debridement has long been used in wound care to enhance healing. Possible causes of venous ulcers include inflammatory processes resulting in leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema. Signs of chronic venous insufficiency, such as: The patient will verbalize an understanding of the aspects of home care for venous stasis ulcers such as pressure relief and wound management. Two prospective randomized controlled trials reviewed the effect of sharp debridement on the healing of venous ulcers. Venous stasis ulcers are often on the ankle or calf and are painful and red. The patient will demonstrate increased tolerance to activity. Venous stasis ulcers may develop spontaneously or after affected skin is scratched or injured. Venous ulcers (open sores) can occur when the veins in your legs do not push blood back up to your heart as well as they should. Nursing Care of the Patient with Venous Disease - Fort HealthCare Calf muscle contraction and intraluminal valves increase prograde flow while preventing blood reflux under normal circumstances. Nursing Diagnosis: Risk for Infection related to poor circulation and oxygen delivery and ischemia secondary to venous pressure ulcers. Current evidence supports treatment of venous ulcers with compression therapy, exercise, dressings, pentoxifylline, and tissue products. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. Patient information: See related handout on venous ulcers, written by the authors of this article. Chronic venous insufficiency can pose a more serious result if not given proper medical attention. In one study, patients with venous ulcers used more medical resources than those without, and their annual per-patient health expenditures were increased by $6,391 for those with Medicare and $7,030 for those with private health insurance. If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Teach the caretaker how to properly care for the afflicted regions of the wounds if the patient is to be discharged. This content is owned by the AAFP. Ackley, Nursing Diagnosis Handbook, Page 153 Nursing CLINICAL WORKSHEET Dat e: 10/2/2022 Student Name: Michele Tokar Assigned vSim: Vernon Russell Initia ls: VR Diagnosis: Right sided ischemic 1 The incidence of venous ulceration increases with age, and women are three times more likely than men to develop venous leg ulcers. To diagnose chronic venous insufficiency, your NYU Langone doctor asks about your health history to determine the extent of your symptoms. The patient will continue to be free of systemic or local infections as shown by the lack of profuse, foul-smelling wound exudate. Venous ulcers are the most common lower extremity wounds in the United States. This causes blood to collect and pool in the vein, leading to swelling in the lower leg. However, a recent Cochrane review of 22 RCTs of systemic and topical antibiotics and antiseptics for venous ulcer treatment found no evidence that routine use of oral antibiotics improves healing rates.1 Studies comparing topical antibiotics and antiseptics, such as povidone-iodine solution (Betadine), peroxide-based preparations, ethacridine lactate (not available in the United States), and mupirocin (Bactroban), have found some evidence to support the use of the topical antiseptic agent cadexomer iodine (not available in the United States; a pooled estimate from two trials suggests an increased healing rate at four to six weeks compared with placebo).1 More high-quality data are needed to better evaluate the effectiveness of topical preparations, however.1. St. Louis, MO: Elsevier. Based on a clinical practice guideline on disease-oriented outcome, Based on a clinical practice guideline and clinical review on disease-oriented outcome, Based on a clinical practice guideline on disease-oriented outcome and systematic review of moderate-quality evidence, Based on a clinical practice guideline on disease-oriented outcome and review article, Based on a clinical practice guideline on disease-oriented outcome, commentary, and Cochrane review of randomized controlled trials, Based on one randomized controlled trial of more than 400 patients, Most common type of chronic lower extremity ulcer, Venous hypertension due to chronic venous insufficiency. Surgical management may be considered for ulcers. 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. Traditional conservative management of venous ulcers usually entails compression therapy, leg elevation to reduce edema, and dressings on the wound. Venous ulcers are believed to account for approximately 70% to 90% of chronic leg ulcers. However, in a recent meta-analysis of six small studies, oral zinc had no beneficial effect in the treatment of venous ulcers.34, Bacterial colonization and superimposed bacterial infections are common in venous ulcers and contribute to poor wound healing. Enzymatic debridement using collagenase has been shown to effectively remove nonviable tissue. Gently remove dry skin scales from the legs, particularly around the ulcer edges to allow new growth of epithelium. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. Venous ulcers are leg ulcers caused by problems with blood flow (circulation) in your leg veins. Venous ulcers are usually recurrent, and an open ulcer can persist for weeks to many years. Chronic venous insufficiency can develop from common conditions such as varicose veins. Author: Leanne Atkin lecturer practitioner/vascular nurse consultant, School of Human and Health Sciences, University of Huddersfield and Mid Yorkshire Trust. In comparison to a single long walk, short, regular walks are healthier for the extremities and the prevention of pulmonary problems. Intermittent pneumatic compression therapy comprises a pump that delivers air to inflatable and deflatable sleeves that embrace extremities, providing intermittent compression.7,23 The benefits of intermittent pneumatic compression are less clear than that of standard continuous compression. No one dressing type has been shown to be superior when used with appropriate compression therapy. Risk factors for the development of venous ulcers include age 55 years or older, family history of chronic venous insufficiency, higher body mass index, history of pulmonary embolism or superficial/deep venous thrombosis, lower extremity skeletal or joint disease, higher number of pregnancies, parental history of ankle ulcers, physical inactivity, history of ulcers, severe lipodermatosclerosis, and venous reflux in deep veins. 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. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). They typically occur around the medial malleolus, tend to be shallow and moist, and may be malodorous (especially when poorly cared for) or painful. The Unna boot improves healing rates compared with placebo or hydroactive dressings.22,26 However, a 2009 Cochrane review found that adding a component of elastic compression therapy is more effective than inelastic compression therapy alone.45 Also, because of its inelasticity, the Unna boot does not conform to changes in leg size and may be uncomfortable to wear. 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. St. Louis, MO: Elsevier. Although the main goal of treatment is ulcer healing, secondary goals include reduction of edema and prevention of recurrence. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. It can eventually lead to ulcerations or skin breakage on the skin making the person prone infections. Inelastic compression therapy provides high working pressure during ambulation and muscle contraction, but no resting pressure. Here are three (3) nursing care plans (NCP) and nursing diagnosis for pressure ulcers (bedsores): ADVERTISEMENTS Impaired Skin Integrity Risk For Infection Risk For Ineffective Health Maintenance 1. The current plan of care is focused on promoting wound healing, improving venous return, and preventing skin breakdown. Peripheral vascular disease (PVD) NCLEX review questions for nursing students! Examine the clients and the caregivers comprehension of pressure ulcer development prevention. There is currently insufficient high-quality data to support the use of topical negative pressure for venous ulcers.30 In addition, the therapy generally has not been used in clinical practice because of the challenge in administering both topical negative pressure and a compression dressing on the affected leg. Immobile clients will need to be repositioned frequently to reduce the chance of breakdown in the intact parts. Oral zinc therapy has been shown to decrease healing time in patients with pilonidal sinus. Abstract. There is no evidence that collagenase is superior to sharp debridement.23 Larval therapy using maggots is an effective method of debridement with added potential for disinfection, stimulation of healing, and biofilm inhibition and eradication.24,25 Potential barriers to larval debridement include patient acceptability and pain.26,27 Autolytic debridement uses moisture-retentive dressings and may be used in addition to other forms of debridement. Compression therapy reduces edema, improves venous reflux, enhances healing of ulcers, and reduces pain.23 Success rates range from 30 to 60 percent at 24 weeks, and 70 to 85 percent after one year.22 After an ulcer has healed, lifelong maintenance of compression therapy may reduce the risk of recurrence.12,24,25 However, adherence to the therapy may be limited by pain; drainage; application difficulty; and physical limitations, including obesity and contact dermatitis.19 Contraindications to compression therapy include clinically significant arterial disease and uncompensated heart failure. Unna boots have limited capacity for fluid absorption in patients with highly exudative ulcers and are best used for early, small, dry ulcers and for venous dermatitis because of the skin soothing effects of zinc oxide.30, Stockings. Specific written plans are necessary for long-term management to improve treatment adherence. Print. Color duplex ultrasonography is recommended to assess for deep and superficial venous reflux and obstruction. Copyright 2023 American Academy of Family Physicians. Because of limited evidence and no long-term benefit, hyperbaric oxygen therapy is not recommended for treatment of venous ulcers.47, Negative Pressure Wound Therapy. Without clear evidence to support the use of one dressing over another, the choice of dressings for venous ulcers can be guided by cost, ease of application, and patient and physician preference.29. She found a passion in the ER and has stayed in this department for 30 years. The cornerstone of treatment for venous leg ulcers is compression therapy, but dressings can aid with symptom control and optimise the local wound environment, promoting healing There is no evidence to support the superiority of one dressing type over another when applied under appropriate multilayer compression bandaging What is the most appropriate intervention for this diagnosis? Poor prognostic signs for healing include ulcer duration longer than three months, initial ulcer length of 10 cm or more, presence of lower limb arterial disease, advanced age, and elevated body mass index. All Rights Reserved. Venous stasis ulcers may be treated with gauze impregnated with a zinc oxide tincture (Unna boot). Chronic venous ulcers significantly impact quality of life. But they most often occur on the legs. The patient verbalized 2 exercise regimens to improve venous return to help promote wound healing within 12-hour shift by elevated her legs and had antiembolism stockings on all day, continue to reevaluate or educate patient. Venous ulcers are the most common type of chronic lower extremity ulcers, affecting 1% to 3% of the U.S. population. Examine the clients and the caregivers wound-care knowledge and skills in the area. A yellow, fibrous tissue may cover the ulcer and have an irregular border. Factors that may lead to venous incompetence include immobility; ineffective pumping of the calf muscle; and venous valve dysfunction from trauma, congenital absence, venous thrombosis, or phlebitis.14 Subsequently, chronic venous stasis causes pooling of blood in the venous circulatory system triggering further capillary damage and activation of inflammatory process. Although numerous treatment methods are available, they have variable effectiveness and limited data to support their use. Timely specialized care is necessary to prevent complications, like infections that can become life-threatening. Over time, the breakdown of tissues combined with the lack of oxygen . The primary risk factors for venous ulcer development are older age, obesity, previous leg injuries, deep venous thrombosis, and phlebitis. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. Venous ulcers, or stasis ulcers, account for 80 percent of lower extremity ulcerations.1 Less common etiologies for lower extremity ulcerations include arterial insufficiency; prolonged pressure; diabetic neuropathy; and systemic illness such as rheumatoid arthritis, vasculitis, osteomyelitis, and skin malignancy.2 The overall prevalence of venous ulcers in the United States is approximately 1 percent.1 Venous ulcers are more common in women and older persons.36 The primary risk factors are older age, obesity, previous leg injuries, deep venous thrombosis, and phlebitis.7, Venous ulcers are often recurrent, and open ulcers can persist from weeks to many years.810 Severe complications include cellulitis, osteomyelitis, and malignant change.3 Although the overall prevalence is relatively low, the refractory nature of these ulcers increase the risk of morbidity and mortality, and have a significant impact on patient quality of life.11,12 The financial burden of venous ulcers is estimated to be $2 billion per year in the United States.13,14, The pathophysiology of venous ulcers is not entirely clear. Copyright 2019 by the American Academy of Family Physicians. Preamble. After administering the analgesic, give the patient 30 to 60 minutes to rate their acute pain again. There are many cellular and tissue-based products approved for the treatment of refractory venous ulcers, including allografts, animal-derived extracellular matrix products, human-derived cellular products, and human amniotic membranederived products. Ulcers are open skin sores. Tell the healthcare provider if you have ever had an allergic reaction to contrast liquid. Causes of Venous Leg Ulcers The speci c cause of venous ulcers is poor venous return. Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. Compression stockings Wearing compression stockings all day is often the first approach to try. Historically, trials comparing venous intervention plus compression with compression alone for venous ulcers showed that surgery reduced recurrence but did not improve healing.53 Recent trials show faster healing of venous ulcers when early endovenous ablation to correct superficial venous reflux is performed in conjunction with compression therapy, compared with compression alone or with delayed intervention if the ulcer did not heal after six months.21 The most common complications of endovenous ablation were pain and deep venous thrombosis.21, The recurrence rate of venous ulcers has been reported as high as 70%.35 Venous intervention and long-term use of compression stockings are important for preventing recurrence, and leg elevation can be beneficial when used with compression stockings. Compression therapy is the standard of care for venous ulcers and chronic venous insufficiency.23,45 A recent Cochrane review found that venous ulcers heal more quickly with compression therapy than without.45 Methods include inelastic, elastic, and intermittent pneumatic compression. The nurse is caring for a patient with a large venous leg ulcer. Even under perfect conditions, a pressure ulcer may take weeks or months to heal. Compression therapy is a standard treatment modality for initial and long-term treatment of venous ulcers in patients without concomitant arterial disease.1,28 Goals of compression therapy include reduced edema and pain, improved venous reflux, and enhanced healing.16 Compression therapy is useful for ulcer healing and prevention of recurrence. The healing capacity of the pressure damage is maximized by providing the appropriate wound care following the stage of the decubitus ulcer. They should not be used in nonambulatory patients or in those with arterial compromise. Abstract: Chronic venous insufficiency (CVI) is a potentially debilitating disorder associated with serious complications such as lower extremity venous ulcers. Inelastic. How to Cure Venous Leg Ulcers Mark Whiteley. Choice of knee-high, thigh-high, toes-in, or toes-out compression stockings depends on patient preference. Self-care such as exercise, raising the legs when sitting or lying down, or wearing compression stockings can help ease the pain of varicose veins and might prevent them from getting worse. This quiz will test your knowledge on both peripheral arterial disease (PAD) and peripheral venous . This hemorheologic agent affects microcirculation and oxygenation, and can be used effectively as monotherapy or with compression therapy for venous ulcers.1,39 In seven randomized controlled trials, pentoxifylline plus compression improved healing of venous ulcers compared with placebo plus compression. She has brown hyperpigmentation on both lower legs with +2 oedema. Buy on Amazon. These ulcers are caused by poor circulation, diabetes and other conditions. A catheter is guided into the vein. The patient will verbalize an ability to adapt sufficiently to the existing condition. Care Plan/Nursing Diagnosis Template Potential Nursing Diagnosis (Priority) At risk for ineffective peripheral tissue perfusion related to DVT and evidenced by venous stasis ulcer on right medial malleolus (Wayne, 2022). Manage Settings Clean, persistent wounds that are not healing may benefit from palliative wound care. He or she also performs a physical exam to look for swelling, skin changes, varicose veins, or ulcers on the leg. Intermittent pneumatic compression may improve ulcer healing when added to layered compression.30,34, Although leg elevation can increase deep venous flow and reduce venous pressure, leg elevation added to compression may not improve ulcer healing.17 However, one prospective study found that leg elevation for at least one hour per day at least six days per week can reduce venous ulcer recurrence when used with compression.17,35, A systematic review evaluating progressive resistance exercise, resistance exercise plus prescribed physical activity, only walking, and only ankle exercises found that progressive resistance exercise with prescribed physical activity may result in an additional nine to 45 venous ulcers healed per 100 patients.36, Dressings are recommended to cover ulcers and promote moist wound healing.1,18 Dressings should be chosen based on wound location, size, depth, moisture balance, presence of infection, allergies, comfort, odor management, ease and frequency of dressing changes, cost, and availability. 3M can help manage challenges related to VLUs and help improve patient outcomes so that people can fully engage and participate in normal everyday activities. Treatment options for venous ulcers include conservative management, mechanical treatment, medications, and surgical options (Table 2).1,2,7,10,19,2244 In general, the goals of treatment are to reduce edema, improve ulcer healing, and prevent recurrence. Its essential to keep the impacted areas clean by washing them with the recommended cleanser. Interventions for Venous Insufficiency Encourage the patient to elevate the legs above the level of the heart several times per day. Venous Ulcers. At-home wound healing can be accelerated by providing proper wound care and bandaging the damaged regions to stop pressure injury from getting worse. The Peristomal Skin Assessment Guide for Clinicians is a mobile tool that provides basic guidance to clinicians on identifying and treating peristomal skin complications, including instructions for patient care and conditions that warrant referral to a WOC/NSWOC (Nurse Specialized in Wound, Ostomy and Continence). Wound, Ostomy, and Continence . Intermittent Pneumatic Compression. Figure A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. 1 The incidence of venous ulceration increases with age, and women are three times more likely than men to develop venous leg ulcers. 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. Poor venous return is due to damage of the valves in leg veins that facilitate the return of the blood to the heart. Wash the sores with the recommended cleanser to instruct the caregiver about good wound hygiene. Although intermittent pneumatic compression is more effective than no compression, its effectiveness compared with other forms of compression is unclear. Pentoxifylline (Trental) is an inhibitor of platelet aggregation, which reduces blood viscosity and, in turn, improves microcirculation. Search dates: November 12, 2018; December 27, 2018; January 8, 2019; and March 21, 2019. Compression therapy is beneficial for venous ulcer treatment and is the standard of care. The essential requirements of management are to debride the ulcer with appropriate precautions, choose dressings that maintain adequate moisture balance, apply graduated compression bandage after evaluation of the arterial circulation and address the patient's concerns, such as pain and offensive wound discharge. This means they can't stop blood which should be headed upward to your heart from being pulled down by gravity. All Rights Reserved. Of the diagnoses developed, 62 are included in ICNP and 23 are new diagnoses, not included. It also is expensive and requires immobilization of the patient; therefore, intermittent pneumatic compression is generally reserved for bedridden patients who cannot tolerate continuous compression therapy.24,40. Assist client with position changes to reduce risk of orthostatic BP changes. Intermittent pneumatic compression may be considered when there is generalized, refractory edema from venous insufficiency; lymphatic obstruction; and significant ulceration of the lower extremity. Human skin grafting may be used for patients with large or refractory venous ulcers. The 10-point pain scale is a widely used, precise, and efficient pain rating measure. Leg elevation. Elastic compression bandages conform to the size and shape of the leg, accommodate to changes in leg circumference, provide sustained compression during rest and walking, have absorptive capacity, and require infrequent changes (about once a week).5 There is strong evidence for the use of multiple elastic layers vs. single layers to increase ulcer healing.30, Inelastic. Caused by vein problems, these make up the majority of vascular ulcers. Compared with compression plus a simple dressing, one study showed that advanced therapies can shorten healing time and improve healing rates.52, Skin Grafting. Shallow, exudative ulcer with granulating base and presence of fibrin; commonly located over bony prominences such as the gaiter area (over the medial malleolus; Associated findings include edema, telangiectasias, corona phlebectatica, atrophie blanche (atrophic, white scarring; Typically, a deep ulcer located on the anterior leg, distal dorsal foot, or toes; dry, fibrous base with poor granulation tissue and eschar; exposure of tendons, Associated findings include abnormal distal pulses, cold extremities, and prolonged venous filling time, Most commonly a result of diabetes mellitus or neurologic disorder, Peripheral neuropathy and concomitant peripheral arterial disease; associated foot deformities and abnormal gait with uneven distribution of foot pressure; repetitive mechanical trauma, Deep ulcer, usually on the plantar surface over a bony prominence and surrounded by callus, Usually occurs in people with limited mobility, Prolonged areas of high pressure and shear forces, Area of erythema, erosion, or ulceration; usually located over bony prominences such as the sacrum, coccyx, heels, and hips, Standard care; recommended for at least one hour per day at least six days per week to prevent recurrence, Recommended to cover ulcers and promote moist wound healing, Oral antibiotic treatment is warranted if infection is suspected, Improves healing with or without compression therapy, Early endovenous ablation to correct superficial venous reflux may increase healing rates and prevent recurrence, Primary therapy for large ulcers (larger than 25 cm, Calcium alginate with or without silver, hydrofiber with or without silver, super absorbent dressing, surgical pad, Releases free iodine when exposed to wound exudate, Hydrophilic fibers between low-adherent contact layers, Gel-forming agents in an adhesive compound laminated onto a flexible, water-resistant outer film or foam, Alginate to increase fluid absorption, with or without an adhesive border, multiple shapes and sizes, Starch polymer and water that can absorb or rehydrate, Variable absorption, silicone or nonsilicone coating, With or without an adhesive border, with or without a silicone contact layer, multiple shapes and sizes, Oil emulsion gauze, petrolatum gauze, petrolatum with bismuth gauze, Possible antimicrobial and anti-inflammatory properties; absorption based on associated dressing material or gel, Gel, paste, hydrocolloid, alginate, or adhesive foam, Chlorhexidine (Peridex), antimicrobial dyes, or hydrophobic layer, Antimicrobial dyes in a flexible or solid foam pad; hydrophobic layer available as a ribbon, pad, swab, or gel, Permeable to water vapor and oxygen but not to water or microorganisms, With or without an absorbent center or adhesive border, Collagen matrix dressing with or without silver, Silver ions (thought to be antimicrobial), Silver hydrocolloid, silver mesh, nonadhesive, calcium alginate, other forms, Silicone polymer in a nonadherent layer, moderately absorbent. 2 In some studies, 50% of patients had venous ulcers that persisted for more than 9 months, and 20% had ulcers that did . Most common type; women affected more than men; often occurs in older persons, Shallow, painful ulcer located over bony prominences, particularly the gaiter area (over medial malleolus); granulation tissue and fibrin present, Leg elevation, compression therapy, aspirin, pentoxifylline (Trental), surgical management, Associated findings include edema, venous dermatitis, varicosities, and lipodermatosclerosis, Associated with cardiac or cerebrovascular disease; patients may present with claudication, impotence, pain in distal foot; concomitant with venous disease in up to 25 percent of cases, Ulcers are commonly deep, located over bony prominences, round or punched out with sharply demarcated borders; yellow base or necrosis; exposure of tendons, Revascularization, antiplatelet medications, management of risk factors, Most common cause of foot ulcers, usually from diabetes mellitus, Usually occurs on plantar aspect of feet in patients with diabetes, neurologic disorders, or Hansen disease, Off-loading of pressure, topical growth factors; tissue-engineered skin, Usually occurs in patients with limited mobility, Tissue ischemia and necrosis secondary to prolonged pressure, Located over bony prominences; risk factors include excessive moisture and altered mental status, Off-loading of pressure; reduction of excessive moisture, sheer, and friction; adequate nutrition, Compression therapy (inelastic, elastic, intermittent pneumatic), Standard of care; proven benefit (benefit of intermittent pneumatic therapy is less clear); associated with decreased rate of ulcer recurrence, Standard of care when used with compression therapy; minimizes edema; recommended for 30 minutes, three or four times a day, Topical negative pressure (vacuum-assisted closure), No robust evidence regarding its use for venous ulcers, Effective when used with compression therapy; may be useful as monotherapy, Effective when used with compression therapy; dosage of 300 mg once per day, Intravenous administration (not available in the United States) may be beneficial, but data are insufficient to recommend its use; high cost limits use, Oral antibiotic treatment is warranted in cases of suspected cellulitis; routine use of systemic antibiotics provides no healing benefit; benefit of adding the topical antiseptic cadexomer iodine (not available in the United States) is unclear, May be beneficial when used with compression therapy; concern about infection transmission, May be beneficial for severe or refractory cases; associated with decreased rate of ulcer recurrence.

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