INTRODUCTION
The estimated worldwide prevalence of chronic venous disease is 5% to 8%; approximately 1% of these individuals will have a venous leg ulcer.1,2 The certified WOC or wound care nurse must be able to demonstrate a thorough understanding of these wounds and their treatment based on current evidence-based research. In addition, they should be prepared to answer questions related to this information on the WOCNCB certification examination.
Chronic venous disorders (CVDs) or lower extremity venous disorders (LEVDs) involve a spectrum of abnormalities of the venous system that range in severity from mild, including spider veins, to complex, which can include deep vein thrombosis.3 Venous ulcers are included in this spectrum, affect approximately 1% of the US population, and come with a significant burden to health-related quality of life.2 Venous leg ulcers comprise 75% to 90% of all lower extremity ulcers, with an annual cost of up to $3.5 billion.1 Those living with CVD wounds face reoccurrence rates as high as 97%. Chronic venous disease and venous leg ulcers negatively impact health-related quality of life, increase emotional distress, cause pain, impair mobility, increase the frequency of visits to health care professionals, and days lost from work.2,3
When preparing for the WOCNCB wound care examination, a review of the pathophysiology of the disease assists the candidate to identify appropriate assessments, diagnostic testing, preventative strategies, and effective treatment. A normal functioning lower extremity venous system drains blood from the skin and subcutaneous tissues through the low-pressure superficial vessels and high-pressure deep veins.3 Venous insufficiency develops when this system is impaired resulting in abnormally high pressures of the deep venous system and pathological changes such as varicosities, capillary bed congestion, and the deposit of intravascular blood molecules in surrounding tissues.1,3 The progression to venous ulceration is not as obvious as the disease, but the cause is due to inflammatory damage of the endothelial lining of the vessel wall combined with platelet congestion, white blood cell activation, high levels of inflammatory cytokines, and fibrotic changes associated with long-standing proliferation of intravascular molecules rendering the extremity at risk for ulceration in response to even slight trauma.1,3
Accurate assessment of patients with CVD is an essential starting point for management of these patients; knowledge of assessment is expected content on the WOCNCB wound care examination.4 Patients often recall the starting point of their venous leg ulcer. The development of a wound is typically referred to as the trigger, and 74% of individuals with venous ulcers can recall this event on their history and physical explanation.3,4 On the initial visit the patient may complain of pain typically described as heaviness or aching legs, swelling, changes in the skin that includes drying, tightening, irritation, and/or itching.3,4 Physical examination typically reveals dilated veins, edema, skin changes, and ulcerations, along with palpable pulses and skin that is warm to touch.3,4
If an ulcer is present additional assessment is required. The wound care nurse must consider the location, dimensions, appearance of wound bed, edges, drainage, and periwound skin.4 Venous ulcers can occur on any location of the lower extremity including the dorsal foot and posterior calf but are found most commonly above the medial malleolus.3 The typical venous ulcer appearance is shallow with a red-ruddy wound base; an adherent yellow film may be present. Venous leg ulcers typically have asymmetrical wound borders and they produce moderate to heavy exudate that may or may not be bloody. The periwound skin may be macerated with crusting and scaling, sometimes accompanied by hyperpigmentation.3 Vascular studies are used to assist in the diagnosis of CVD with or without ulcer, and venous duplex ultrasonography is the most reliable noninvasive test to diagnose CVD, reflux, or obstruction.3,4
Management of the individual with CVD involves compression, elevation, medications, and surgical intervention in selected patients.3,4 Compression therapy applies mechanical pressure to the distended superficial veins, decreasing their size to a more normal anatomical diameter. In addition, it improves competence of the valve system by supporting the muscle pump provided by the calf muscle during activity that improves venous return.3 Diuretics may be used to manage the symptoms of LEVD, but they do nothing to improve or reverse the pathophysiology of the disease process.3 Multiple pharmacologic agents may be used for management of CVD and venous leg ulcers such as horse chestnut seed extract or pentoxifyllie; although; evidence related to the efficacy of multiple pharmacological agents is limited and outcomes are mixed.3 Open surgical or endovascular treatment of LEVD typically focuses on removal or ablation of the damaged vessel.3 Effectiveness of treatment results and wound healing is mixed; however, existing evidence suggests these interventions may reduce the likelihood of wound reoccurrence and decrease venous pressures.3,4
1. de Carvalho MR. Comparison in patients with venous leg ulcers treated with compression therapy alone versus combination of surgery and compression therapy: a systematic review. J Wound Ostomy Continence Nurs. 2015;42(1):42-46. [Context Link]
2. Shannon MM, Hawk J, Nacaroli L, Serena T. Factors affecting patient adherence to recommended measures for prevention of recurrent venous ulcers. J Wound Ostomy Continence Nurs. 2013;40(3):268-274. [Context Link]
3. Johnson J, Yates SS, Burgess JJ. Venous insufficiency, venous ulcers, and lymphedema. In: Doughty DB, McNichol LL, eds. Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:384-419. [Context Link]
4. Kelechi TJ, Johnson JJ. Guidelines for the management of wounds in patients with lower-extremity venous disease. J Wound Ostomy Continence Nurs. 2012;39:598-606. [Context Link]
PRACTICE QUESTIONS
1. The wound care nurse must demonstrate knowledge of the pathophysiology of lower extremity venous disease (LEVD). Which statement best indicates comprehension of this process? The disease process begins with:
a. plaques narrowing the lining of the vessels to the lower extremities.
b. failure of the lower extremity 1-way bicuspid valves.
c. an impaired low-pressure venous system of the lower extremities.
d. sensory impairment of the lower extremities.
Content Outline: Wound Task 4; Skill: 010402
Cognitive Level: Application
Rationale:
Correct answer-B
CVD occurs when the valves in the superficial and/or deep venous system no longer work correctly, which results in an increase in the hydrostatic pressure of the venous system. The 1-way venous return is impaired with the valve damage and venous congestion and pooling of blood and fluid in the extremity increases the venous pressure. Atherosclerotic plaque occurs in arterial disease narrowing the lining of the arterial system. Sensory impairment of the lower extremities commonly occurs with neuropathic disease caused by diabetes.
1. de Carvalho MR. Comparison in patients with venous leg ulcers treated with compression therapy alone versus combination of surgery and compression therapy: a systematic review. J Wound Ostomy Continence Nurs. 2015;42(1):42-46.
2. Johnson J, Yates SS, Burgess JJ. Venous insufficiency, venous ulcers, and lymphedema. In: Doughty DB, McNichol LL, eds. Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:384-419.
2. A wound care nurse is asked to evaluate on an obese 58-year-old woman who was lost to medical follow-up with a lower extremity leg ulcer. Her lower leg is warm, with areas of patchy dark skin, varicosities, and with brisk capillary refill. The wound is diffuse, moderate in size, borders irregular, pink wound base. What evaluation is needed to best determine the etiology of her disease?
a. Ultrasound duplex scan
b. Ability to take part in an exercise program
c. Ankle brachial index
d. Sensory testing with monofilament
Content Outline: Wound Task 4; Skill: 010404
Cognitive Level: Application
Rationale:
Correct answer-A
This patient is presenting with signs and symptoms of venous disease. The most reliable noninvasive test to diagnose venous disease is the ultrasound duplex scan. A secondary assessment, after the wound is healing, would be to assess this patient's ability to participate in physical activity, which will strengthen the calf muscle and improve ankle mobility decreasing the rate of reoccurrence of the venous ulcer. The assessment shows normal capillary refill and warm extremities, which decreases likelihood of arterial disease. Assessing for impaired oxygenation or perfusion with the ankle brachial index would be important if arterial disease was suspected. Sensory testing would be appropriate if the wound is suspicious for neuropathy. In this case there is no mention in the question stem of a history of neurological history such as diabetic neuropathy or that the location of the wound suggests neuropathy-based etiology.
1. Johnson J, Yates SS, Burgess JJ. Venous insufficiency, venous ulcers, and lymphedema. In: Doughty DB, McNichol LL, eds. Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:384-419.
2. Kelechi TJ, Johnson JJ. Guidelines for the management of wounds in patients with lower-extremity venous disease. J Wound Ostomy Continence Nurs. 2012;39:598-606.
3. Beitz JM. Wound healing. In: Doughty DB, McNichol LL, eds. Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:24-37.
3. What should be included in a discussion with a patient with a recently healed ulcer from lower extremity venous disease about long-term prevention?
a. Use of compression stockings
b. Hyperbaric oxygenation therapy
c. Use of therapeutic foot ware
d. Long term diuretic therapy
Content Outline: Wound; Task 7; Skill: 010407
Cognitive Level: Application
Rationale:
Correct answer-A
Compression therapy is considered the gold standard for management of venous insufficiency and to prevent wound recurrence. Compression stockings must be worn every day to prevent edema and the reoccurrence of venous leg ulcers. Hyperbaric oxygenation therapy is indicated with disease related to impaired ventilation or perfusion of the body with oxygen and is not required for this patient. Specialty foot ware is critical as an off-loading therapy in neuropathic disease. Diuretic therapy is sometimes used to treat edema from other causes, such as heart failure, but is not effective alone in treating the edema associated with venous disease.
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