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Compression Bandages

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Putting the squeeze on venous ulcers

Compression is still the cornerstone of treatment for these common wounds. Learn how to choose the right product for your patient.

Despite all the advances in health care we enjoy today, venous ulcers continue to exact a high toll in the United States. Consider these facts:

* In the general population, about 1% of people have venous ulcers. Among people over age 65, the figure rises to 3.5%.

* Nearly 70% of venous ulcers recur.

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

* The estimated per-episode cost of care can exceed $40,000.

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

* An estimated 2 million workdays per calendar year are lost due to chronic venous ulcers.

Venous ulcers related to chronic venous insufficiency persist and recur unless all caregivers consistently follow an effective treatment protocol. In this article, I'll explain how to set up and implement a practical working protocol that can lower the cost-in time, money, and suffering-of venous ulcers.

Multidisciplinary affair

Ideally, a wound care protocol is a multidisciplinary affair that enlists the expertise of a wound care specialist, primary care nurses, the primary care physician, and the vascular surgeon; a case manager also may be involved. To develop a protocol tailored to the patient, the team focuses on the ulcer's type and characteristics, the length of time it's been present, results of any diagnostic studies or tests, and treatment options suited to the patient's condition.

Bandages

Remembering the basics of venous blood flow will help you assess and manage your patient's condition. Adequate blood flow in the leg depends on:

* deep veins (the femoral, popliteal, and tibial veins)

* superficial veins (the greater and lesser saphenous veins)

* communicating veins, which connect the superficial veins to the deep veins

* calf muscles, which assist blood flow throughout the venous system when they contract.

Absorbers

Normally, blood flow through the superficial veins to the deep veins is unidirectional, and blood returns from the capillary system to the heart without difficulty. However, damage to the vein valves or calf muscles impedes venous blood flow and causes high venous pressures (venous hypertension) in the deep veins. This damage can be caused by heart failure, muscle weakness secondary to paralysis, obesity, pregnancy, trauma, diabetes, thrombosis formation in deep veins, and valve incompetence.

History lessons

To assess a patient with a venous ulcer, first obtain a detailed history and conduct a physical assessment. Ask him these questions:

* Have you had a venous ulcer before? If yes, when did it occur? How long did it last? How was it treated?

* Does much fluid drain from the wound? Do you notice any odor from the wound? Is your skin itchy? Is the skin around the wound wet? Is the wound painful?

* Have you had any trauma to your lower leg in the past? If yes, how and when did the trauma occur?

* Do you have a history of deep vein thrombosis? If yes, when did this first occur? Where and how were you treated?

* Have you undergone coronary artery bypass surgery? If yes, when did this occur? Where were you treated?

Next, perform thorough systems and lower extremity assessments and a wound evaluation. During the lower extremity assessment, you may uncover characteristic markers of venous ulceration, such as ankle flare, dermatitis, hemosiderosis, lipodermatosclerosis, and varicosities (see Understanding Key Terms). Also assess for the following typical wound characteristics:

* 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 appearance

* wound size, shape, and margins-large with irregular margins

* drainage/exudate-moderate to heavy

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

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

Dressing

Thoroughly document all your findings and relay the information to other team members to ensure continuity of care and prevent duplication of tests and services.

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