Management of the patient with a venous ulcer

Advances in Skin & Wound Care, Mar/Apr 2000 by Hess, Cathy Thomas

Management of a patient with a chronic condition is often challenging for both the patient and the health care professional, exacting a physical, emotional, and financial toll. Management of a patient with an ulcer related to chronic venous insufficiency is no exception.

The statistics offer a sobering look at the big picture of the problem of venous ulcers in the United States:

* Approximately 1% of the general population and 3.5% of people over age 65 have venous ulcers. The number is rising as the population ages.1

* The recurrence rate of venous ulcers approaches 70%.2

* Women are 3 times more likely than men to have a venous ulcer.2

* The estimated per-episode cost of care can exceed $40,000.1

* If it is assumed that 2.5 million people have venous ulcers, the total cost of treatment is estimated at $2.5 to $3.5 billion.3

* It is estimated that 2 million workdays per calendar year are lost due to chronic venous ulcers.1

One reason for the high physical and financial cost of venous ulcers may be the lack of a definitive treatment protocol. The proactive wound care professional will make it a priority, therefore, to develop a protocol for managing these patients, beginning with a multidisciplinary team approach. The team members may include a variety of health care professionals, such as the primary care physician, vascular surgeon, wound care specialist, and bedside caregivers; the case manager may also be involved. The focus of the discussion should center on (1) the etiology, or cause, of the ulcer; (2) the length of time the ulcer has been present; (3) diagnostic studies or tests performed related to the ulcer; and (4) the ongoing management/treatment modalities used in the care of the patient.

Pathophysiology of the Venous Ulcer

An in-depth understanding of the anatomy and physiology of the venous system provides a basis for proper diagnosis and management of the patient with a venous ulcer. The venous system is comprised of:

* the deep vein system-the femoral, popliteal, and tibial veins

* the superficial veins-the greater and lesser saphenous veins

* the communicating veins-the veins that connect the superficial veins to the deep veins

* the calf muscles-the muscles that assist the return of blood flow throughout the venous system when contracted. Blood flow through the superficial veins to the deep veins is unidirectional in patients without venous disease. Thus, blood returns from the capillary system to the heart without difficulty. In patients with venous insufficiency damage occurs to the veins or calf muscle pump, resulting in high venous pressures in the deep veins. This high venous pressure is termed venous hypertension. Precursors to venous hypertension include those clinical conditions that trigger a sequence of events promoting edema and, perhaps, dermal ulceration, such as heart failure, muscle weakness secondary to paralysis, obesity, pregnancy; thrombosis formation in the deep vein system, and valve incompetence.

Assessment and Diagnostic Tests

A detailed history and physical examination of the patient with a venous ulcer should be obtained. Specific questions should be asked relative to the history of the patient's venous disease (Figure 1). If the patient responds "yes" to any of the questions, the clinician should carefully detail the answers in the patient's chart in order to provide an accurate picture of the patient's past and present clinical condition. The information should also be relayed to other team members to ensure continuity of appropriate care. The patient's answers may reveal additional information or trigger a better understanding of the longevity of the problem and other treatments and tests that may have been ordered and performed. This can help to reduce duplication of services.

A thorough systems assessment should be performed in conjunction with the lower extremity assessment and/or wound evaluation. A lower extremity assessment may uncover characteristic markers of venous ulceration, such as ankle flare, dermatitis, hemosiderosis, lipodermatosclerosis, and varicosities (see Key Terms). In evaluating a patient with a suspected venous ulcer (Figure 2), the clinician should take into consideration these characteristics of venous ulcers:

* wound location-typically on the medial lower leg; superior to the medial malleolus (where the saphenous vein is located)

* wound bed and appearance-referred to as "ruddy" or "beefy red"; granular in appearance

* wound shape and wound margins-- large wounds with irregular wound margins

* drainage/exudate--moderate to heavy

* surrounding skin-hemosiderin stain (brownish discoloration), edematous, macerated, hyperpigmented, lipodermatosclerosis

* pain-pain may be present; small but deep ulcers around malleoli are the most painful.

Performing the appropriate diagnostic tests is paramount when evaluating the patient with a suspected venous ulcer. The results of the tests will provide the basis for proper interventions and patient management. Tests typically ordered include: