Venous ulcers can be debilitating, painful, and challenging to treat for healthcare professionals. It is reported that between 10 and 35% of the population has some form of venous disease and that 80 to 95% of leg ulcers are a result of chronic venous disease (Kline & Sieggreen, 2004).
What is chronic venous insufficiency? Chronic venous insufficiency can be defined as venous hypertension of the deep and superficial veins, and may be complicated by incompetent venous valves causing reflux, or backward flow of blood. The following steps are believed to occur in the development of venous ulcers:
- A blood clot (thrombosis) develops, which may occur months or years before the ulcer develops
- Valves become incompetent following the thrombosis, despite the vein recanalizing
- Valves in the distal segment of the vein become exposed to increasing pressure (venous hypertension); valve function in the proximal vein is compromised
- Pressure increases until perforating veins and capillaries are involved
- Once capillaries are involved, the skin follows suit, and the stage is set for the development of venous ulcers
Appearance of venous ulcers
Venous ulcers may vary in size from very small to extremely large. Borders may appear irregular and are not usually as well-defined as arterial ulcers. Venous ulcers often weep, and drainage may be moderate to heavy. The skin surrounding the ulcer may be edematous. The patient may have edema whether or not an ulcer is present, and this may cause weeping of fluid through the skin. This may cause itching of the skin, which the patient may not be able to resist scratching, leading to further damage to the skin. Venous ulcers may cause pain, especially upon weight-bearing.
Treatment of venous ulcers
The mainstay of treatment for venous insufficiency is external compression to improve blood flow and decrease edema.
Compression must be a lifelong treatment once venous insufficiency is diagnosed, not just for the duration of ulcer treatment. Compression stockings should be fitted properly to provide 30 to 40 mm Hg pressure. Knee-high stockings are sufficient, as it is the distal skin and subcutaneous tissues that are involved in venous insufficiency; some patients may prefer thigh-high stockings. Higher stockings are acceptable, but patients should ensure that they fit well and do not roll down, as this may compress tissue behind the knee.
Compression stockings should be worn during daytime hours when the patient is upright. At night, during sleep, the legs are elevated and stockings do not need to be worn.
Dressings to treat venous ulcers should have the capability of absorbing the large amount of drainage these ulcers may produce. If necrotic tissue is present, dressings that stimulate autolytic debridement can be used. Infection should be treated if present, but antibiotics should not be given empirically.
In the presence of these wounds, it should be mentioned that arterial insufficiency may also be present at the same time. Patients who have wounds that do not heal despite proper and aggressive treatment should be evaluated for underlying arterial insufficiency.
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