2010. Ulcers are open skin sores. Pentoxifylline (400 mg three times per day) has been shown to be an effective adjunctive treatment for venous ulcers when added to compression therapy.31,40 Pentoxifylline may also be useful as monotherapy in patients who are unable to tolerate compression bandaging.31 The most common adverse effects are gastrointestinal (e.g., nausea, vomiting, diarrhea, heartburn, loss of appetite). The specialists of the Vascular Ulcer and Wound Healing Clinic diagnose and treat people with persistent wounds (ulcers) at the Gonda Vascular Center on Mayo Clinic's campus in Minnesota. It can also occur if something, such as a deep vein thrombosis or other clot, damages the valves inside the veins. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). This means they can't stop blood which should be headed upward to your heart from being pulled down by gravity. He or she also performs a physical exam to look for swelling, skin changes, varicose veins, or ulcers on the leg. -. Skin grafting should be considered as primary therapy only for large venous ulcers (larger than 25 cm2 [3.9 in2]), in which healing is unlikely without grafting. It is performed with autograft (skin or cells taken from another site on the same patient), allograft (skin or cells taken from another person), or artificial skin (human skin equivalent).41,42,49 However, skin grafting generally is not effective if there is persistent edema, which is common with venous insufficiency, and the underlying venous disease is not addressed.40 A recent Cochrane review found few high-quality studies to support the use of human skin grafting for the treatment of venous ulcers.41, The role of surgery is to reduce venous reflux, hasten healing, and prevent ulcer recurrence. Data Sources: We conducted searches in PubMed, Essential Evidence Plus, the Cochrane database, and Google Scholar using the key terms venous ulcers and venous stasis ulcers. More analgesics should be given as needed or as directed. The venous stasis ulcer is covered with a hydrocolloid dressing, . Continuous stress to the skins' integrity will eventually cause skin breakdowns. Traditional conservative management of venous ulcers usually entails compression therapy, leg elevation to reduce edema, and dressings on the wound. Venous ulcers commonly occur in the gaiter area of the lower leg. Dehydration makes blood more viscous and causes venous stasis, which makes thrombus development more likely. Buy on Amazon, Silvestri, L. A. Additionally, patients with pressure ulcers lose a lot of protein through their wound exudate and may need at least 4,000 calories per day to maintain their anabolic state. Affect 9% of patients admitted to hospital and 23% of those admitted to nursing homes. Venous ulcers are open skin lesions that occur in an area affected by venous hypertension.1 The prevalence of venous ulcers in the United States ranges from 1% to 3%.2,3 In the United States, 10% to 35% of adults have chronic venous insufficiency, and 4% of adults 65 years or older have venous ulcers.4 Risk factors for venous ulcers include age 55 years or older, family history of chronic venous insufficiency, higher body mass index, history of pulmonary embolism or superficial/deep venous thrombosis, lower extremity skeletal or joint disease, higher number of pregnancies, parental history of ankle ulcers, physical inactivity, history of ulcers, severe lipodermatosclerosis (panniculitis that leads to skin induration or hardening, increased pigmentation, swelling, and redness), and venous reflux in deep veins.5 Poor prognostic signs for healing include ulcer duration longer than three months, ulcer length of 10 cm (3.9 in) or more, presence of lower limb arterial disease, advanced age, and elevated body mass index.6, Complications of venous ulcers include infections and skin cancers such as squamous cell carcinoma.7,8 Venous ulcers are a major cause of morbidity and can lead to high medical costs.3 Economic and personal impacts include frequent visits to health care facilities, loss of productivity, increased disability, discomfort, need for dressing changes, and recurrent hospitalizations. Chronic Renal Failure CRF Nursing NCLEX Review and Nursing Care Plan, Newborn Hypoglycemia Nursing Diagnosis and Nursing Care Plan, Strep Throat Nursing Diagnosis and Care Plan. Patient who needs wound care for a chronic venous stasis ulcer on the lower leg. As soon as the client is allowed to leave the bed, assist with a progressive return to ambulation. Chronic venous insufficiency can develop from common conditions such as varicose veins. Oral antibiotics are preferred, and therapy should be limited to two weeks unless evidence of wound infection persists.1, Hyperbaric Oxygen Therapy. Venous ulcers (also known as venous stasis ulcers or nonhealing wounds) are open wounds around the ankle or lower leg. Examine the clients and the caregivers wound-care knowledge and skills in the area. The healing capacity of the pressure damage is maximized by providing the appropriate wound care following the stage of the decubitus ulcer. RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. Color duplex ultrasonography is recommended in patients with venous ulcers to assess for venous reflux and obstruction. The primary risk factors for venous ulcer development are older age, obesity, previous leg injuries, deep venous thrombosis, and phlebitis. Unna boots have limited capacity for fluid absorption in patients with highly exudative ulcers and are best used for early, small, dry ulcers and for venous dermatitis because of the skin soothing effects of zinc oxide.30, Stockings. Evidence has not shown that any one dressing is superior when used with appropriate compression therapy.18 Types of dressings are summarized in Table 3.37, Topical antiseptics, including cadexomer iodine (Iodosorb), povidone-iodine (Betadine), peroxide-based preparations, honey-based preparations, and silver, have been used to treat venous ulcers. Your doctor may also recommend certain diagnostic imaging tests. Wash the sores with the recommended cleanser to instruct the caregiver about good wound hygiene. The 10-point pain scale is a widely used, precise, and efficient pain rating measure. Further evaluation with biopsy or referral to a subspecialist is warranted if ulcer healing stalls or the ulcer has an atypical appearance. Despite a number of studies to support its effectiveness as adjunctive therapy, and possibly as monotherapy, the cost-effectiveness of pentoxifylline has not been established. RNspeak. Signs of venous disease, such as varicose veins, edema, or venous dermatitis, may be present. The patient will maintain their normal body temperature. Any of the lower leg veins can be affected. Risk Factors Trauma Thrombosis Inflammation Embolism Monitor for complications a. Thromboembolic complications due to hyperviscosity, including DVT; MI & CVA b. Hemorrhage tendency is caused by venous and capillary distention and abnormal platelet function. There is inconsistent evidence concerning the benefits and harms of oral aspirin in the treatment of venous ulcers.40,41, Statins. Care Plan/Nursing Diagnosis Template Potential Nursing Diagnosis (Priority) At risk for ineffective peripheral tissue perfusion related to DVT and evidenced by venous stasis ulcer on right medial malleolus (Wayne, 2022). Pressure Ulcer Nursing Care Plans Diagnosis and Interventions Pressure Ulcer NCLEX Review and Nursing Care Plans Pressure ulcers, sometimes called bedsores or Decubitus ulcers, are skin and tissue breakdown that arises from exertion of incessant pressure to the skin. Elastic bandages (e.g., Profore) are alternatives to compression stockings. A deep vein thrombosis nursing care plan includes assessment of the body parts, appropriate intervention, prevention, and patient education to prevent thromboembolism. Patients typically experience no pain to mild pain in the extremity, which is relieved with elevation. A group of nurse judges experienced in the treatment of venous ulcer validated 84 nursing diagnoses and outcomes, and 306 interventions. Tell the healthcare provider if you have ever had an allergic reaction to contrast liquid. Factors that may lead to venous incompetence include immobility; ineffective pumping of the calf muscle; and venous valve dysfunction from trauma, congenital absence, venous thrombosis, or phlebitis.14 Subsequently, chronic venous stasis causes pooling of blood in the venous circulatory system triggering further capillary damage and activation of inflammatory process. Medical-surgical nursing: Concepts for interprofessional collaborative care. Compression therapy Treatment focuses on preventing new ulcers, controlling edema, and reducing venous hypertension through compression therapy. On initial assessment, it is crucial to cover the history of health: associated co-morbidities, habitual therapy, psycho-emotional state, influence of odour on social life, nutritional state, presence and intensity of pain and individual treatment preference. To evaluate whether a treatment is effective. As an Amazon Associate I earn from qualifying purchases. You will undertake clinical handover and complete a nursing care plan. Encourage the patient to refrain from scratching the injured regions. Causes of Venous Leg Ulcers The speci c cause of venous ulcers is poor venous return. To prevent the infection from getting worse, it is best to discourage the youngster from scratching the sores, even if they are just mildly itchy. Date of admission: 11/07/ Current orders: . They do not heal for weeks or months and sometimes longer. Pentoxifylline (Trental) is an inhibitor of platelet aggregation, which reduces blood viscosity and, in turn, improves microcirculation. Compression stockings are removed at night, and should be replaced every six months because they lose pressure with regular washing.2. All Rights Reserved. Patient information: See related handout on venous ulcers, written by the authors of this article. Venous ulcers typically have an irregular shape and well-defined borders.3 Reported symptoms often include limb heaviness, pruritus, pain, and edema that worsens throughout the day and improves with elevation.5 During physical examination, signs of venous disease, such as varicose veins, edema, or venous dermatitis, may be present. Patients treated with debridement at each physician's office visit had significant reduction in wound size compared with those not treated with debridement.20. A wide range of dressings are available, including hydrocolloids (e.g., Duoderm), foams, hydrogels, pastes, and simple nonadherent dressings.14,28 A meta-analysis of 42 randomized controlled trials (RCTs) with a total of more than 1,000 patients showed no significant difference among dressing types.29 Furthermore, the more expensive hydrocolloid dressings were not shown to have a healing benefit over the lower-cost simple nonadherent dressings. All Rights Reserved. Venous Leg Ulcers are the most common type of lower extremity wound, afflicting approximately 1% of the western population during their lifetime. VLUs also represent a significant burden for patients and healthcare systems.. Remind the client not to cross their legs or hyperextend their knees in positions where they are seated with their legs hanging or lying jackknife. B) Apply a clean occlusive dressing once daily and whenever soiled. For wound closure to be effective, leg edema must be reduced. This is often used alongside compression therapy to reduce swelling. What is the most appropriate intervention for this diagnosis? To view the purposes they believe they have legitimate interest for, or to object to this data processing use the vendor list link below. Infection occurs when microorganisms invade tissues, leading to systemic and/or local responses such as changes in exudate, increased pain, delayed healing, leukocytosis, increased erythema, or fevers and chills.46 Venous ulcers with obvious signs of infection should be treated with antibiotics. It has been estimated that active VU have This hemorheologic agent affects microcirculation and oxygenation, and can be used effectively as monotherapy or with compression therapy for venous ulcers.1,39 In seven randomized controlled trials, pentoxifylline plus compression improved healing of venous ulcers compared with placebo plus compression. Examine for fecal and urinary incontinence. Pentoxifylline. Venous leg ulcers are open, often painful, sores in the skin that take more than 2 weeks to heal. To encourage numbing of the pain and patient comfort without the danger of an overdose. Treatment options for venous ulcers include conservative management, mechanical treatment, medications, and surgical options (Table 2).1,2,7,10,19,2244 In general, the goals of treatment are to reduce edema, improve ulcer healing, and prevent recurrence. Please follow your facilities guidelines, policies, and procedures. She has worked in Medical-Surgical, Telemetry, ICU and the ER. Impaired Skin Integrity ADVERTISEMENTS Impaired Skin Integrity Nursing Diagnosis Impaired Skin Integrity May be related to Chronic disease state. It might be necessary to apply the prescription antibiotic cream or ointment directly to the affected area. This process is thought to be the primary underlying mechanism for ulcer formation.10 Valve dysfunction, outflow obstruction, arteriovenous malformation, and calf muscle pump failure contribute to the pathogenesis of venous hypertension.8 Factors associated with venous incompetence are age, sex, family history of varicose veins, obesity, phlebitis, previous leg injury, and prolonged standing or sitting posture.11 Venous ulcers result from a complex process secondary to increased pressure (venous hypertension) and inflammation within the venous circulation, vein wall, and valve leaflet with extravasation of inflammatory cells and molecules into the interstitium.12, Clinical history, presentation, and physical examination findings help differentiate venous ulcers from other lower extremity ulcers (Table 15 ). Nursing Diagnosis: Acute Pain related to pressure ulcers as evidenced by a pain level of 10/10, restlessness, and irritability, especially during wound care secondary to venous stasis ulcers. It can eventually lead to ulcerations or skin breakage on the skin making the person prone infections. Poor venous return is due to damage of the valves in leg veins that facilitate the return of the blood to the heart. A simple non-sticky dressing will be used to dress your ulcer. Self-care such as exercise, raising the legs when sitting or lying down, or wearing compression stockings can help ease the pain of varicose veins and might prevent them from getting worse. The ultimate aim is to promote evidence-based nursing care among patients with venous leg ulcer. To compile a patients baseline set of observations. As the patient is experiencing pain, have him or her score it on a scale of 0 to 10 and describe it. Other findings include lower extremity varicosities; edema; venous dermatitis associated with hyperpigmentation and hemosiderosis or hemoglobin deposition in the skin; and lipodermatosclerosis associated with thickening and fibrosis of normal adipose tissue under skin. It also is expensive and requires immobilization of the patient; therefore, intermittent pneumatic compression is generally reserved for bedridden patients who cannot tolerate continuous compression therapy.24,40. Venous stasis ulcers are often on the ankle or calf and are painful and red. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. Debridement may be sharp, enzymatic, mechanical, larval, or autolytic. 2 In some studies, 50% of patients had venous ulcers that persisted for more than 9 months, and 20% had ulcers that did not Shallow, exudative ulcer with granulating base and presence of fibrin; commonly located over bony prominences such as the gaiter area (over the medial malleolus; Associated findings include edema, telangiectasias, corona phlebectatica, atrophie blanche (atrophic, white scarring; Typically, a deep ulcer located on the anterior leg, distal dorsal foot, or toes; dry, fibrous base with poor granulation tissue and eschar; exposure of tendons, Associated findings include abnormal distal pulses, cold extremities, and prolonged venous filling time, Most commonly a result of diabetes mellitus or neurologic disorder, Peripheral neuropathy and concomitant peripheral arterial disease; associated foot deformities and abnormal gait with uneven distribution of foot pressure; repetitive mechanical trauma, Deep ulcer, usually on the plantar surface over a bony prominence and surrounded by callus, Usually occurs in people with limited mobility, Prolonged areas of high pressure and shear forces, Area of erythema, erosion, or ulceration; usually located over bony prominences such as the sacrum, coccyx, heels, and hips, Standard care; recommended for at least one hour per day at least six days per week to prevent recurrence, Recommended to cover ulcers and promote moist wound healing, Oral antibiotic treatment is warranted if infection is suspected, Improves healing with or without compression therapy, Early endovenous ablation to correct superficial venous reflux may increase healing rates and prevent recurrence, Primary therapy for large ulcers (larger than 25 cm, Calcium alginate with or without silver, hydrofiber with or without silver, super absorbent dressing, surgical pad, Releases free iodine when exposed to wound exudate, Hydrophilic fibers between low-adherent contact layers, Gel-forming agents in an adhesive compound laminated onto a flexible, water-resistant outer film or foam, Alginate to increase fluid absorption, with or without an adhesive border, multiple shapes and sizes, Starch polymer and water that can absorb or rehydrate, Variable absorption, silicone or nonsilicone coating, With or without an adhesive border, with or without a silicone contact layer, multiple shapes and sizes, Oil emulsion gauze, petrolatum gauze, petrolatum with bismuth gauze, Possible antimicrobial and anti-inflammatory properties; absorption based on associated dressing material or gel, Gel, paste, hydrocolloid, alginate, or adhesive foam, Chlorhexidine (Peridex), antimicrobial dyes, or hydrophobic layer, Antimicrobial dyes in a flexible or solid foam pad; hydrophobic layer available as a ribbon, pad, swab, or gel, Permeable to water vapor and oxygen but not to water or microorganisms, With or without an absorbent center or adhesive border, Collagen matrix dressing with or without silver, Silver ions (thought to be antimicrobial), Silver hydrocolloid, silver mesh, nonadhesive, calcium alginate, other forms, Silicone polymer in a nonadherent layer, moderately absorbent. This causes blood to collect and pool in the vein, leading to swelling in the lower leg. Without clear evidence to support the use of one dressing over another, the choice of dressings for venous ulcers can be guided by cost, ease of application, and patient and physician preference.29. Patient information: See related handout on venous ulcers. These ulcers are caused by poor circulation, diabetes and other conditions. Inelastic compression wraps, most commonly zinc oxideimpregnated Unna boots, provide high compression only during ambulation and muscle contraction. Assist client with position changes to reduce risk of orthostatic BP changes. Ulcers heal from their edges toward their centers and their bases up. Ackley, Nursing Diagnosis Handbook, Page 153 Nursing CLINICAL WORKSHEET Dat e: 10/2/2022 Student Name: Michele Tokar Assigned vSim: Vernon Russell Initia ls: VR Diagnosis: Right sided ischemic These are most common in your legs and feet as you age and happen because the valves in your leg veins can't do their job properly. In diabetic patients, distal symmetric neuropathy and peripheral . It can be used as secondary therapy for ulcers that do not heal with standard care.22, Like conservative therapies, the goal of operative and endovascular management of venous ulcers (i.e., endovenous ablation, ligation, subfascial endoscopic perforator surgery, and sclerotherapy) is to improve healing and prevent ulcer recurrence. Any delay in care increases the risk of infection, sepsis, amputation, skin cancers, and death. Aspirin (300 mg per day) is effective when used with compression therapy for venous ulcers. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. At-home wound healing can be accelerated by providing proper wound care and bandaging the damaged regions to stop pressure injury from getting worse. The patient will verbalize an ability to adapt sufficiently to the existing condition. Patients who are severely malnourished (serum albumin 2.5 mg/dl) are more likely to acquire an infection from a pressure ulcer. Severe complications include cellulitis, osteomyelitis, and malignant change. Compression therapy is a standard treatment modality for initial and long-term treatment of venous ulcers in patients without concomitant arterial disease.1,28 Goals of compression therapy include reduced edema and pain, improved venous reflux, and enhanced healing.16 Compression therapy is useful for ulcer healing and prevention of recurrence. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Dressings are recommended to cover venous ulcers and promote moist wound healing. These actions are intended to improve overall muscle tone and strength, as well as boost venous return from the lower extremities and decrease venous stasis. arterial pulse examination, and measurement of ankle-brachial index is recommended for all patients with suspected venous ulcers. Clean, persistent wounds that are not healing may benefit from palliative wound care. To encourage ideal patient comfort and lessen agitation/anxiety. The synthetic prostacyclin iloprost is a vasodilator that inhibits platelet aggregation. nous insufficiency and ambulatory venous hypertension. Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. Continue with Recommended Cookies, Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions. Dressings are often used under compression bandages to promote faster healing and prevent adherence of the bandage to the ulcer. Compression stockings can be used for ulcer healing and prevention of recurrence (recommended strength is at least 20 to 30 mm Hg, but 30 to 40 mm Hg is preferred).31,32 Donning stockings over dressings can be challenging. Although intermittent pneumatic compression is more effective than no compression, its effectiveness compared with other forms of compression is unclear. No one dressing type has been shown to be superior when used with appropriate compression therapy. Compression therapy is beneficial for venous ulcer treatment and is the standard of care. Eventually non-healing or slow-healing wounds may form, often on the . Venous ulcers, or stasis ulcers, account for 80 percent of lower extremity ulcerations.1 Less common etiologies for lower extremity ulcerations include arterial insufficiency; prolonged pressure; diabetic neuropathy; and systemic illness such as rheumatoid arthritis, vasculitis, osteomyelitis, and skin malignancy.2 The overall prevalence of venous ulcers in the United States is approximately 1 percent.1 Venous ulcers are more common in women and older persons.36 The primary risk factors are older age, obesity, previous leg injuries, deep venous thrombosis, and phlebitis.7, Venous ulcers are often recurrent, and open ulcers can persist from weeks to many years.810 Severe complications include cellulitis, osteomyelitis, and malignant change.3 Although the overall prevalence is relatively low, the refractory nature of these ulcers increase the risk of morbidity and mortality, and have a significant impact on patient quality of life.11,12 The financial burden of venous ulcers is estimated to be $2 billion per year in the United States.13,14, The pathophysiology of venous ulcers is not entirely clear. Examine the clients and the caregivers comprehension of the long-term nature of wound healing. Effective treatments include topical silver sulfadiazine and oral antibiotics. Compared with compression plus a simple dressing, one study showed that advanced therapies can shorten healing time and improve healing rates.52, Skin Grafting. They do not penetrate the deep fascia. Author: Leanne Atkin lecturer practitioner/vascular nurse consultant, School of Human and Health Sciences, University of Huddersfield and Mid Yorkshire Trust. This article reviews the incidence and pathophysiology of CVI, nursing assessment, diagnosis and interventions, and patient education needed to manage the disease and prevent complications. Granulation tissue and fibrin are typically present in the ulcer base. Preamble. Calf muscle contraction and intraluminal valves increase prograde flow while preventing blood reflux under normal circumstances. Inelastic compression therapy provides high working pressure during ambulation and muscle contraction, but no resting pressure. To diagnose chronic venous insufficiency, your NYU Langone doctor asks about your health history to determine the extent of your symptoms. Nursing diagnoses handbook: An evidence-based guide to planning care. Venous ulcers are believed to account for approximately 70% to 90% of chronic leg ulcers. Venous Ulcers. Nursing Care of the Patient with Venous Disease - Fort HealthCare They typically occur in people with vein issues. Venous incompetence and associated venous hypertension are thought to be the primary mechanisms for ulcer formation. Peripheral vascular disease is the impediment of blood flow within the peripheral vascular system due to vessel damage, which mainly affects the lower extremities. Venous ulcer, also known as stasis ulcer, is the most common etiology of lower extremity ulceration, affecting approximately 1 percent of the U.S. population. Current evidence supports treatment of venous ulcers with compression therapy, exercise, dressings, pentoxifylline, and tissue products. This article has been double-blind peer reviewed Poor prognostic factors include large ulcer size and prolonged duration. The patient verbalized 2 exercise regimens to improve venous return to help promote wound healing within 12-hour shift by elevated her legs and had antiembolism stockings on all day, continue to reevaluate or educate patient. SAGE Knowledge. The Unna boot improves healing rates compared with placebo or hydroactive dressings.22,26 However, a 2009 Cochrane review found that adding a component of elastic compression therapy is more effective than inelastic compression therapy alone.45 Also, because of its inelasticity, the Unna boot does not conform to changes in leg size and may be uncomfortable to wear. Situation: Mrs. Morrow is an obese, 80-year-old white female who developed a venous stasis ulcer on her right medial malleolus while still living at home. Associated findings include lower extremity varicosities, edema, venous dermatitis, and lipodermatosclerosis. Gently remove dry skin scales from the legs, particularly around the ulcer edges to allow new growth of epithelium. Leg elevation minimizes edema in patients with venous insufficiency and is recommended as adjunctive therapy for venous ulcers. Intermittent pneumatic compression therapy comprises a pump that delivers air to inflatable and deflatable sleeves that embrace extremities, providing intermittent compression.7,23 The benefits of intermittent pneumatic compression are less clear than that of standard continuous compression. Your care team may include doctors who specialize in blood vessel (vascular . Nursing Care Plan for: Impaired Skin Integrity, Risk for Skin Breakdown, Altered Skin Integrity, and Risk for Pressure Ulcers. 2 Irrigate in the shower or bathe in buckets or bowls lined with a clean plastic bag to reduce the risk of cross-infection. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). Copyright 2023 American Academy of Family Physicians. Unlike the Unna boot, elastic compression therapy methods conform to changes in leg size and sustain compression during both rest and activity. St. Louis, MO: Elsevier. Encouraging the patient through physical therapy to get out of bed and sit down and carry out the necessary exercises. She found a passion in the ER and has stayed in this department for 30 years. Encourage performing simple exercises and getting out of bed to sit on a chair. She received her RN license in 1997. Nonhealing ulcers also raise your risk of amputation. Provide analgesics or other painkillers as directed, at least 30 minutes before caring for a wound. Examine the patients vital statistics. The treatment goal for venous ulcers is to reduce the edema, promote ulcer healing, and prevent a recurrence of the ulcer. Employed individuals with venous ulcers missed four more days of work per year than those without venous ulcers (29% increase in work-loss costs).9, Venous hypertension is defined as increased venous pressure resulting from venous reflux or obstruction. Venous stasis ulcers may be treated with gauze impregnated with a zinc oxide tincture (Unna boot). Patients are no longer held in hospitals until their pressure ulcers have healed; they may still require home wound care for several weeks or months. Examine the patients skin all over his or her body. They typically occur around the medial malleolus, tend to be shallow and moist, and may be malodorous (especially when poorly cared for) or painful. Venous ulcers are believed to account for approximately 70% to 90% of chronic leg ulcers. 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