Unit 5 - Venous Insufficiency Wounds

Venous System — Normal Pathology

• Venous flow

  • Valves prevent retrograde flow

  • Return of blood flow is facilitated by muscle pump

• Interstitial Spaces —> Venous Capillaries —> Superficial Veins —> Deep Veins

Venous Hypertension — Pathophysiology

• Weak, “leaky” valves

• Varicose veins

• Hemosiderin staining/deposits

• Edema

Edema below the lower leg =

venous insufficiency

Edema extending to the thigh =

lymphedema

Theories of venous Insufficiency Ulceration

• Fibrin Cuff Theory

• White Blood Cell Trapping Theory

Fibrin Cuff Theory

White Blood Cell Trapping Theory

Risk Factors for Venous Wound Development

• Vein Dysfunction

• Muscle pump failure

• Trauma

• Previous wound

• Advanced age

• Obesity

• Diabetes

Venous Insufficiency — Examination

Non-Invasive

• Supine and standing

• Ankle Brachial Index as needed

• Trendelenburg test

• Venous Duplex ultrasound

• Photoplethysmography

• Venous filling time

Venous Insufficiency — Examination

Invasive

Phlebography/venography, ambulatory venous pressure, intravenous ultrasound

Clinical Signs and Symptoms

Pain

• No Pain/General Aching

• Elevated = Good

  • *NOTE: Contraindication with Active CHF

Position

Gaiter Region (medial lower leg)

Presentation

• Insidious onset

• Shallow/Superficial

• Little to no Eschar

• Irregular shape

Periwound

Hemosiderin Staining

Pulses

Palpable without deficits

Temperature

Mild increases

Better Prognosis

• smaller

• acute / subacute

• fast healing

• low comorbid factors

• adherence

Worse Prognosis

• larger

• chronic

• slow healing

• older age

• higher BMI

• concurrent arterial deficits

General Interventions

• Patient Education

  • Wound etiology

  • Lifestyle modifications

  • Adherence to interventions

• Compression (Gold Standard)

• Absorptive dressings

• General skin care

Precautions/Contraindications to Treatment

• Arterial Disease

  • Compression should NOT be used with ABI < 0.5

  • Consultation required with ABI between 0.5-0.7

• Allergic Reactions

• Whirlpool

General Intervention Guidelines

1. control edema

2. protection

3. healthy living

4. follow up with physician

Gold Standard Treatment - Compression

• Non-elastic vs Elastic bandages

• Enhances calf muscle pump

  • Graded distal to proximal

  • Mild-Moderate: 30-40 mm hg (ankle)

  • Severe: 40-50 mmhg (ankle)

• Shifts blood from superficial à deep veins

• Decreases pain

Compression Contraindications

• ABI < 0.7

• Acute Infection

• Pulmonary edema

• Active CHF

• Active DVT

Compression Types

• Unna boot

• short stretch wraps

• long stretch / elastic wraps

• multilayer systems

• compression stockings

Unna Boot

• Zinc Oxide that hardens after application

• Worn for ~ 1 week

• May shape the limb into a “wineglass” after use

Short stretch wraps

• Ideal

• Avoid tourniquet effect

• Consistent distal à proximal pressure

• Increasing width =

Long stretch / elastic wraps

Not safe for coexisting arterial disease

Multilayer Systems

• Decreased slippage

• Increased compression

• Bulky

Manual wrapping techniques

• short/long stretch procedure

• multilayer procedure

Short/Long Stretch Procedure

1. Prepare Wound/limb

2. Protect skin/Add padding as needed

3. Apply wrap

   1. Pt in supine

   2. Foot in DF

   3. Anchor with Fig 8

4. Continue with spiral or Fig 8 at 50% overlap

   1. No more than 50% stretch

5. End at popliteal space

   1. Secure with tape

Multi-layer Procedure

1. Prepare Wound/limb

2. Protect skin

3. Apply wrap

   1. Pt in supine

   2. Foot in DF

   3. Apply initial padding layer (no tension/spiral)

   4. Apply light layer

   5. Apply light compression layer – FIG 8

   6. Apply flexible bandage - No more than 50% stretch

   7. End at popliteal space

      1. Secure with tape

Double check the wrapping

• No gaps

• No wrinkles

• Coban

  • Metatarsal heads

  • Top of lower limb at popliteal space

• Capillary refill!!

Types of wrapping

• spiral

• figure 8