Lower extremity venous disease affects millions of Americans and may ultimately lead to open, draining wounds that adversely affect quality of life. However, there are exciting developments in early diagnosis, prevention and treatment of venous leg ulcers (VLUs). On the treatment side, there are more choices now than ever before in compression products, which is greatly improving the patient experience. But proper treatment also comes from a better understanding of venous leg ulcers, and better understanding comes from more education. Luckily, we’re here to help provide education and support for you and your team, so here are six things to know when treating VLUs.
1. Know the pathology of VLUs.
Venous hypertension and varicosities may lead to VLUs. When blood isn’t getting properly pumped to the heart, it stagnates and pools in venous blood vessels. Eventually the engorged blood vessels leak, leading to dermatitis. For patients, that means itchiness, discoloration in the ankle-to-calf area, leg swelling, and often throbbing and achiness.
The entire leg may be affected by dermatitis and can swell to the point of oozing fluids. Once fluids start to drain, skin breakdown occurs because the drainage itself is caustic to skin. Venous hypertension is a high pressure of blood within the veins, causing the vein to stretch and weaken. The vein walls eventually leak fluid and proteins. The protein fibrin, a normal part of the clotting process, starts to decrease the flow of oxygen and nutrients to the tissue and leads to tissue death and ulceration.
2. Recognize the challenges of venous disease.
Venous disease is a chronic, lifelong disease. So it’s important to encourage patients to practice proper compression therapy and to elevate their legs on a daily basis. Even after a wound heals, patients still need to wear compression garments to avoid a recurrence of swelling and another venous leg ulcer. When patients don’t comply with treatment, it’s important to understand why.
Keep their personal circumstances in mind: They may be unable to afford compression stockings. They may be frail or obese, they may lack mobility or live alone and physically unable to apply their own compression or change their wound dressings. The compression may also be uncomfortable to wear at all times, particularly in hot, humid weather. Venous ulcers and drainage can be quite malodorous and can lead to poor quality of life. Compression wraps and stockings can be challenging to put on — even for caregivers.
3. Help patients manage their own care.
Compression is key to healing venous ulcers and keeping legs healthy. Compression works best when patients stay active by walking or doing calf pumps and toe-up exercises. It’s also a good idea to collaborate with occupational therapists, who can teach patients and caregivers the best ways to apply compression. Physical therapists can teach them techniques to keep active. Patients with venous disease should be taught to inspect their feet and legs for any changes. Avoid sitting or standing for extended periods of time. If they smoke, they should seriously stop doing so because nicotine has direct adverse effects on oxygenation. Patients should strive to keep a healthy weight and limit salt intake. It’s also wise to help patients take accountability for their own care. When devising a care plan, help them set reasonable care goals based on their lifestyle choices, such as determining when they will elevate their legs, do exercises, or start a smoking cessation plan.
4. Treat leg ulcers on a case-to-case basis.
Many new and exciting compression wraps and pull-on socks have come onto the market in recent years. There’s now a wide assortment, including long-stretch and short stretch, two-, three- and four-layer, Velcro, foam impregnated with zinc or calamine and pneumatic compression devices. Before treatment, patients should be tested to ensure that compression is safe for them. Then choose the proper treatment for each patient. You should take into consideration the right style of compression to use, as well as conditions such as edema (soft or non-pitting vs. woody and hard) or the amount of drainage.
5. Properly prep skin & apply appropriate compression.
- It’s extremely important to apply the compression correctly.
After removing a wrap, wash the leg thoroughly with soap and water, rinse, dry the legs thoroughly and inspect. This will help prevent topical infection or cellulitis. Do not skip or minimize this step. It’s very important to cleanse the patient’s legs and feet thoroughly and dry completely.
- Moisturize intact skin with an emollient product. If there is drainage, use a moisture-barrier product. If there is dermatitis or fungal infection, the patient may need topical medications.
- Treat open areas according to the wound care provider’s orders, including from an ARNP.
- Apply the compression from the base of toes all the way up to just below the knee. Explain to patients why this is necessary, even if they object. Most manufacturers suggest a 50 percent overlap.
- Frequency of dressing changes depends on drainage and the patient’s compliance. If there is no open wound, change once or twice a week. With an open, draining wound, change two to three times a week to manage drainage and assess and treat the wound.
6. Consider these things when selecting products.
- Use proper garments and wraps designed for compression.
- Never use a 4-inch-long stretch elastic bandage for compression. These bandages may slip out of place and constrict areas of the leg and cause harm. Long-stretch elastic should only be used to hold a dressing in place.
- Thromboembolic disease (TED) stockings are elastic stockings used to prevent thrombophlebitis. They are not designed for edema management associated with venous hypertension. Indeed, the band at the top of the TED stocking is constrictive and has been known to cause injury to the patient’s skin.
- There are different levels (high, medium, low) and styles of compression, but you also need to consider a patient’s type of edema, skin condition and tolerance to compression.
- If there is drainage, choose an absorbent product. For example, for a patient with highly exudating wounds, you may want to start with a four-layer compression because it provides both absorption and compression.