Venous Ulcers

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Holly Hovan MSN, GERO-BC, APRN, CWOCN-A

Determining Wound Etiology:

Predominant pain pattern, ulcer location, ulcer appearance, type and amount of wound exudate, and vascular and sensorimotor assessment are some key factors used to determine the primary etiology of lower extremity ulcers.1

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By Holly Hovan MSN, GERO-BC, APRN, CWOCN-AP

Lower extremity wounds manifest in a multitude of ways, with numerous causative or trigger factors. These types of wounds are often costly to treat, are frequently refractory, and have a high risk for recurrence. A comprehensive assessment and an evidence-based treatment plan, along with ongoing patient education and routine follow-up, are essential components of an effective plan of care.

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Arteriography: Also called angiography, this technique is the medical imaging of blood vessels to look for aneurysm and stenosis.

Hemosiderin staining: Hemosiderin staining results in a red, ruddy appearance on the lower leg and ankle. This appearance is caused when red blood cells are broken down and not removed adequately as a result of venous insufficiency or another medical condition.

Phlebectomy: A minimally invasive procedure (usually outpatient) to remove varicose veins located near the surface of the skin.

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Approximately 2.5 million Americans are diagnosed with chronic venous insufficiency, and approximately 20% will go on to develop venous leg ulcerations. Chronic venous leg ulcers (VLUs) account for 90% of all chronic ulcers of the lower limb region. Wound chronicity takes place in wounds that are stalled and/or remain unhealed after four to six weeks. Although evidence-based care has been established, it has been reported that 30% of patients still experience delayed healing, with wounds often failing to heal within a 24-week time frame. Identifying risk factors for VLUs is imperative in best outcomes.

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Venous leg ulcers can be slow to heal; the longer a wound is present, the less likely it is to heal. To move a venous leg ulcer through the phases of wound healing may require more than just basic wound care.

Chronic venous leg ulcers can be prone to chronic inflammation. Changes in the microcirculation down to the capillary level can elevate levels of cytokines and proteases, thus leaving the wound stuck in the inflammatory cycle. Controlling, reducing, or eliminating inflammation is necessary to move the wound toward closure.

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Of all the types of chronic wounds in lower extremities, venous leg ulcers are the most common, and they account for up to 70% of lower leg ulcers. Infection is a common complication in these wounds, however, and may contribute to chronicity. Biofilm is another common complicating factor. Preventing infection, removing unhealthy tissue from the wound, providing dressings that manage exudate, and using advanced modalities can help heal these chronic wound types and prevent a recurrence.

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Hard-to-heal venous leg ulcers (VLUs) comprise the most common type of leg ulcer and impose a major economic burden on the health care system. These wounds can be difficult to heal, and they often experience recurrence within three months of closure, thus further complicating treatment. When managing VLUs, it is important to select strategies that are evidence based and cost-effective. Early diagnosis and implementation of interventions can encourage best outcomes.

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Chronic wounds of the lower extremities impose an increasing burden on health care providers and systems, and they can have a devastating impact on patients and their families. These wounds include diabetic ulcers, venous ulcers, arterial ulcers, and pressure injuries. The estimated socioeconomic cost of chronic wounds is 2% to 4% of the health budget in Western countries. Moreover, patient mortality in individuals with chronic wounds has been estimated at 28% over a two-year period, significantly higher than the 4% mortality rate reported for 75 to 79 year-olds without chronic wounds.

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Chronic and complex wounds of the lower extremity frequently recur. It is difficult to determine the precise recurrence rate across patients with different lower extremity wound types, including diabetic foot ulcers, arterial ulcers, pressure injuries, and venous ulcers. However, we know that recurrence rates are high; nearly 40% of patients with an ulcer will develop a recurrence within one year of healing. This percentage is 60% at three years after healing and 65% at the five-year mark.

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Compression therapy is a well-established treatment modality for a number of conditions, including venous disorders, thrombosis, lymphedema, and lipedema. It is also very effective in treating various kinds of edema.1 Based on patient diagnostic data, many patients with these conditions can benefit from targeted compression therapy.

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