Nursing assistance to the individual with venous ulcers

Resumo

Seventy per cent of leg ulcers are of venous origin, and of this total, 47% of the individuals have experienced two or more episodes of ulceration.

A venous ulcer causes several changes in people's lives such as walking difficulty, pain, exudate, and odor. In addition, the affected individuals are unable to perform their daily activities triggering negative feelings such as mood changes, changes in family relationships, social living, and leisure. All these changes affect sleep, quality of life, self-esteem, self-image, and cause anxiety and depression.^1-2  

The nurse who provides care to patients with venous ulcers must know the healing process, how to differentiate clinical diagnosis related to the types of leg ulcers, wound healing stages of the lesion, type of tissue, primary bandages on the market, and must know how to choose the type of compression therapy suitable for treatment.

The clinical diagnosis is based on the clinical history and physical exam of the patient. Pain is a frequent symptom and intensity varies, but it is not influenced by the size of the ulcer. When pain is present, it generally worsens at the end of the day due to the orthostatic position and improves when the limb is elevated. Deep ulcers located in the region of the malleolus and small ulcers with atrophie blanche are the most painful.³

In general, the venous ulcer is an uneven and superficial wound at first, but it can become deep with well defined edges and yellow exudate. Ulcers may be single or multiple with variable sizes and locations, but in general, they occur in the distal portion of the legs (gaiter region), particularly in the region of the medial malleolus. ³

In some circumstances, the venous ulcers may occur in the upper portion of the calf and foot. However, in these cases, other etiologies of chronic ulcers must be excluded before diagnosing them as venous ulcers. The skin around the ulcer may be purpura and hyperpigmented due to the extravasation of red blood cells in the dermis and hemosiderin deposits within macrophages.⁴

Eczema can occur around the ulcer, as evidenced by erythema, scaling, itching and occasionally exudate. Lipodermatosclerosis may also occur. The presence of varicose veins is a consequence of congestion of blood flow due to venous valve incompetence. Superficial veins, particularly those with thinner walls, become dilated and tortuous. The edema in the lower limbs is the result of venous hypertension, fed during muscle relaxation due to venous reflux, which prevents blood pressure within the vessel to reach a value below 60 mmHg15.

Hyperpigmentation of skin is characterized by the release of hemoglobin after the breakup of red blood cells due to the extravasation into the interstitium, which is degraded to hemosiderin, a pigment that gives the bluish-brown or grayish-brown color to the tissues.⁵

All the lower limb pulses should be palpated, especially the dorsalis pedis and posterior tibial pulses, though the latter can sometimes be difficult to detect due to the presence of lipodermatosclerosis or ulcers at the site.

The Doppler manual should be used to determine the systolic index between the ankle and the arm (ITB). The index is calculated using the highest value of ankle systolic blood pressure divided by the brachial artery systolic blood pressure. All patients with leg ulcers of venous origin must monitor the ankle/brachial pressure index (ITB) using the manual Doppler for compression therapy as part of the continuous monitoring of the pressure.^6-7

Compression therapy is a useful resource for patients with venous ulcers that originate from venous incompetence of the lower limbs. The aim of compression therapy is:^8-9

· To reduce venous hypertension inducing the increase in blood flow velocity, facilitating return of venous venous to the heart;

· To reduce exudate due to the decrease in capillary pressure differences;

· To facilitate the transport of metabolic products accumulated in the microcirculatory system promoting ulcer healing.