Care of patients with venous ulcers
Maria T. Szewczyk, Ph. D.
Department of Surgical Nursing, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń
„In the treatment of ulcers, especially of their advanced form, omnidirectional and interdisciplinary care of the patient is required. Venous ulcers are chronic wounds, where the healing process is difficult and lengthy, and requires the effort of many measures. (…)”
Chronic venous insufficiency and venous ulcers
In about 80% of cases the cause of leg ulcers is chronic venous insufficiency. Venous ulcers are the final and most serious complication. In the treatment of ulcers, especially of their advanced form, omnidirectional and interdisciplinary care of the patient is required. Venous ulcers are chronic wounds, where the healing process is difficult and lengthy, and requires the effort of many measures. Extensive and ongoing for years wounds often lead to movement limitation in the ankle joint, foot deformation and permanent disability (Photo 1, 2, 3, 4).
The first step is the diagnostic and ultrasound examination of venous vessels, and then topical and causal treatment. Etiopathogenesis, in which the main role plays venous hypertension, requires at first elimination or reduction of causative factors. The cause of ulcers are in fact circulatory disorder leading to the venous hypertension in the lower limbs. These relate to pathological anatomical and physiological changes occurring in several successive stages. It begins with overload and baggy or fusiform enlargement of the vascular system in the form of varicose veins. Accompanying changes include: a decrease of flexibility and patency of blood vessel walls, and valvular regurgitation, venous blood reflex and (or) occlusion of the deep venous system (by e.g. deep vein thrombosis). Long-lasting high hydrostatic pressure eventually leads to an increase in vascular patency and transition – first of exudate and also of cellular components. In the so-called gaiter area of the leg (the lower half of the leg above the ankle and around the ankle) trophic changes occur, initially only in the form of over-pigmentation and discolouration, and later also in the form of inflammation, fibrosis and thinning of the skin tissue. On the surface of these changes ulceration can be developed. The immediate cause of the injury can be not only the changes in the skin nutrition, but also spontaneous rupture of varicose veins, or even a slight mechanical shock.
The gold standard of conservative treatment of venous ulcers is compression therapy followed by wound cleansing and active moist or biological dressings.
In the conservative treatment a vital role plays compression therapy, which deals with individually chosen compression dressings. It can be bandages (band) with compatible compression degree as well as ready products in the form of knee-length, short and long stockings and tights. The compression therapy using the bandages depends inter alia on the material from which they are made and the method of bandaging the limb. The use of the compression greatly reduces venous hypertension in the superficial system, improves the efficiency of the muscle pump, reduces venous stasis and restores proper hydrostatic conditions for the outflow of blood from the vessels. The compression will be effective if the degree of compression will be applied depending on the severity of chronic venous insufficiency i.e. it will depend on the superficial, perforator and deep vein system. To measure the interfacial pressure of the compression a Kikuhime device is used. With the help of this apparatus we can provide the required pressure. (Photo 5)
Similar effects can be brought by a massage – both sequential pneumatic massage (Photo 6) and manual massage reducing the oedema and improving the return of venous blood towards the heart.
Before the use of compression the state of the peripheral circulation must be checked. The use of compression therapy in a patient with impaired blood flow can result in severity of ischemia, skin necrosis, and even limb amputation. Therefore, before applying the compression therapy is necessary to perform Doppler imaging and marking the Ankle Brachial Index (Photo 7).
The topical proceedings parallel with the compression therapy includes: necrosis removal, wound debridement, moist wound healing, care of the skin around the wound.
Contaminations, superficial necrosis reaching the dermis can be removed in a conservative way, e.g. mechanical, enzymatic, autolytic, and in a surgical way. However, necrotic tissues, including subcutaneous layers require a surgical intervention by removal of the changed tissues with a scalpel and scissors. You can also include the VAC system (vacuum-assisted wound closure) as a non-invasive active therapy to promote healing in difficult wounds that fail to respond to established treatment modalities. The method of necrosis removal is determined by the location and depth of the ulcer, the exudate amount in the wound and the patient’s general condition. Of great importance in the selection of the treatment method is the nature and extent of necrosis structures. The mechanical wound debridement, as well as the surgical debridement of wound edges give immediate effect to remove necrotic elements. The autolytic debridement is a natural process that occurs spontaneously in a properly healing wound. It is the effect of proteolytic enzyme and phagocyte activity , which can be both initiated and supported by the maintenance of moist environment at the bottom of the wound. Low severity of these processes in the debridement phase might require to use ready proteolytic enzymes and to introduce enzymatic debridement. Wound cleaning and removal of the necrosis reduces the risk of infection and the development of a local infection. The purpose of this treatment is to prepare the wound to further proliferative processes and stimulation of these processes to maintain optimal healing conditions. Please note that venous ulcers are heavily exposed to the risk of infection. It can be caused by different types of microorganisms (viruses, bacteria and fungi), but the most common etiological agent are bacteria, including staphylococci, streptococci, Escherichia coli and Pseudomonas. Proliferating in the wound, the bacteria secrete its own metabolites and toxins, destroying migrating fibroblasts and budding vessels, and limiting the healing progress. An uncontrolled infection can spread deep inside the wound, infiltrate adjacent tissues, and even lead to the development of sepsis.
The risk of infection and the development of infection can be additionally reduced by flushing the wound bed with antiseptic solution. Its concentration should not only have a bactericidal or bacteriostatic effect, but also should be safe for healthy tissue and does not cause cytotoxic effects or inhibit the healing. Only the preparation meeting the above criteria can be safely applied directly on the wound surface (e.g. Octenisept containing a mixture of octenidyne dihydrochloride and phenoxyethanol safe for skin and mucous membranes). In justified cases general antibiotics are used, which should not be used topically. To support the natural debridement and recovery processes, on a clean wound a special active dressing maintaining moist wound healing environment should be applied.
Moist wound healing
Features of the „ideal” dressing, developed on the basis of Winter analysis (1962) and his successors are satisfied by so-called new generation dressing. They maintain adequate moisture wound environment, which prevents the scab formation and drying out of the ulcer surface. A moist wound heals twice as fast and in a more structured way, because the moist environment stimulates both cell proliferation and the migration of new cells, ensuring their optimal differentiation and neovascularisation.
Features of a dressing supporting the natural healing processes were defined in 1991 by Turner et al:
- maintains a moist environment in the wound bed,
- has high absorption capacity, regulates the excess of exudate,
- does not adhere to the wound surface, enables painless and atraumatic change,
- protects the wound against bacteria and contamination,
- is non-toxic and non-allergenic,
- maintains the correct wound temperature similar to the body temperature,
- facilitates the healing process at all wound healing stages.
The new generation dressings fulfilling the listed criteria are produced in several groups, differing in the design and application. They are designed for different types of wounds, depending on their etiology, the healing phase, the depth of tissue damage, the nature of the exudate and the presence of an infection.
The dressings have different properties to keep the exudate, whose secretion varies during the particular wound healing phases. Apart from the outer protection and moisture content control the dressing has to fulfil other important task at every stage of venous ulcers healing.
The management of chronic venous insufficiency in states with weak skin barrier function requires particularly attentive care and concentration of efforts aimed at conditioning and regeneration of the natural protective barrier of the epidermis. One of the major care actions taken in concern of the integrity of the skin is to maintain the cleanliness of the body, including the limbs. Cleaning agents used for personal hygiene should be properly chosen and correctly applied, especially when it comes to this group of patients. Detergents are designed to remove and reduce the number of contaminations and microorganisms residing on the surface of the body, if possible without damaging the skin protective barrier. Since the lipid coat has the properties of „binding” impurities, and water alone is not able to overcome them, the washing agent needs to contain surfactants. It is recommended to use agents that are delicate, have a pH of 5.5 or liquid agents containing a substance modifying the acidity of the product (for example: phosphoric acid, citric acid, sodium hydroxide, triethanolamine), and enriched with physiological lipids, ceramides, and moisturising agents, which at least partially allow to compensate for the lipid loss caused by the action of the detergent.
After thorough cleaning of the skin it is advised to apply agents supporting the regeneration and increasing the moisture level of the skin. This can be obtained thanks to biologically inert substances supporting the treatment and skin care of the, so-called emollients. Due to moisturising properties, they increase the water content of the stratum corneum and improve the biophysical properties of the epidermis (Photo 8). The emollients are available in form of creams, lotions, ointments and emulsions of different consistency, serving the same purpose – moisturising and / or oiling the dry skin. Creams and ointments usually need to be applied thicker. Agents of lighter consistency, such as lotions, make it possible apply thin film. Agents applied on sensitive skin should not contain alcohol, metals, fragrances, or talc. In specific situations they should contain only water-based hydrophilic ingredients. Distributed on the skin they are easily absorbed, and after washing do not leave unwanted residues.
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