Tiny valves in the veins can fail. Treatment for venous stasis ulcer should usually include: The following lifestyle changes must be implemented to increase circulation and lower the risk of developing venous stasis ulcers: Nursing Diagnosis: Impaired Skin Integrity related to skin breakdown secondary to pressure ulcer as indicated by a pressure sore on the sacrum, a few days of sore discharge, pain, and soreness. Compression therapy is a standard treatment modality for initial and long-term treatment of venous ulcers in patients without concomitant arterial disease. dull pain (improves with the elevation of the affected extremity), oozing pus or another fluid from the lesion, swelling (edema) that worsens throughout the day. disorders peggy hoff rn mn university of north florida department of nursing review liver most versatile cells in the body, ncp esophageal varices pleural effusion free download as word doc doc or read online for free esophageal varices nursing care plan pallor etc symptoms may reflect color continued bleeding varices rupture b hb level of 12 18 g dl, hi im writing a careplan on a patient who had Any of the lower leg veins can be affected. Less often, patients have arterial leg ulcer resulting from peripheral arterial occlusive disease, the most common cause of which is arteriosclerosis. If necessary, recommend the physical therapy team. Print. Because bacterial colonization and infection may contribute to poor healing, systemic antibiotics are often used to treat venous ulcers. The student can make adjustments as soon as they receive feedback, as opposed to practicing the skill incorrectly. This provides the best conditions for the ulcer to heal. Elastic compression bandages conform to the size and shape of the leg, accommodate to changes in leg circumference, provide sustained compression during rest and walking, have absorptive capacity, and require infrequent changes (about once a week).5 There is strong evidence for the use of multiple elastic layers vs. single layers to increase ulcer healing.30, Inelastic. A) Provide a high-calorie, high-protein diet. Other associated findings include telangiectasias, corona phlebectatica, atrophie blanche, lipodermatosclerosis, and inverted champagne-bottle deformity of the lower leg. Copyright 2023 American Academy of Family Physicians. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process and help nursing students pass the NCLEX exams. He or she also performs a physical exam to look for swelling, skin changes, varicose veins, or ulcers on the leg. Chronic venous insufficiency can pose a more serious result if not given proper medical attention. Patients who are severely malnourished (serum albumin 2.5 mg/dl) are more likely to acquire an infection from a pressure ulcer. Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). The healing capacity of the pressure damage is maximized by providing the appropriate wound care following the stage of the decubitus ulcer. Slough with granulation tissue comprises the base of the wound, with moderate to heavy exudate. 2 In some studies, 50% of patients had venous ulcers that persisted for more than 9 months, and 20% had ulcers that did not If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. The patient will continue to be free of systemic or local infections as shown by the lack of profuse, foul-smelling wound exudate. 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. The patient will demonstrate increased tolerance to activity. Signs of chronic venous insufficiency, such as: The patient will verbalize an understanding of the aspects of home care for venous stasis ulcers such as pressure relief and wound management. Leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema contribute to venous ulcer development and impaired wound healing.2,14, Determining etiology is a critical step in the management of venous ulcers. Inelastic. Physically restricting circulation reduces blood flow and heightens venous stasis in the pelvic, popliteal, and leg veins, causing swelling and discomfort to worsen. At-home wound healing can be accelerated by providing proper wound care and bandaging the damaged regions to stop pressure injury from getting worse. Signs of venous disease, such as varicose veins, edema, or venous dermatitis, may be present. Table 2 includes treatment options for venous ulcers.1622, Removal of necrotic tissue by debridement has been used to expedite wound healing. . St. Louis, MO: Elsevier. She found a passion in the ER and has stayed in this department for 30 years. On physical examination, venous ulcers are generally irregular, shallow, and located over bony prominences. The current plan of care is focused on promoting wound healing, improving venous return, and preventing skin breakdown. For patients who have difficulty donning the stockings, use of layered (additive) compression stockings; stockings with a Velcro or zippered closure; or donning aids, such as a donning butler (Figure 4), may be helpful.33, Intermittent Pneumatic Compression. Choice of knee-high, thigh-high, toes-in, or toes-out compression stockings depends on patient preference. 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. 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. She received her RN license in 1997. To compile a patients baseline set of observations. Duplex Ultrasound In one study, intravenous iloprost (not available in the United States) used with elastic compression therapy significantly reduced healing time of venous ulcers compared with placebo.33 However, the medication is very costly and there are insufficient data to recommend its use.40, Zinc is a trace metal with potential anti-inflammatory effects. August 9, 2022 Modified date: August 21, 2022. Nonhealing ulcers also raise your risk of amputation. Causes of Venous Leg Ulcers The speci c cause of venous ulcers is poor venous return. Continue with Recommended Cookies, Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions. This means they can't stop blood which should be headed upward to your heart from being pulled down by gravity. Compression therapy has been proven beneficial for venous ulcer treatment and is the standard of care. Topical negative pressure, also called vacuum-assisted closure, has been shown to help reduce wound depth and volume compared with a hydrocolloid gel and gauze regimen for wounds of any etiology.30 However, clinically meaningful outcomes, such as healing time, have not yet been adequately studied. Enzymatic debridement using collagenase has been shown to effectively remove nonviable tissue. Nursing interventions in venous, arterial and mixed leg ulcers. Venous ulcers are believed to account for approximately 70% to 90% of chronic leg ulcers. 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 ulcers (also known as venous stasis ulcers or nonhealing wounds) are open wounds around the ankle or lower leg. Granulation tissue and fibrin are often present in the ulcer base. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Ulcers are open skin sores. 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. Venous stasis ulcers may develop spontaneously or after affected skin is scratched or injured. Of the diagnoses developed, 62 are included in ICNP and 23 are new diagnoses, not included. List of orders: 1.Enalapril 10 mg 1 tab daily 2.Furosemide 40 mg 1 tab daily in the morning 3.K-lor 20 meq 1 tab daily in the morning 4.TED hose on in AM and off in PM 5.Regular diet, NAS 6.Refer to Wound care Services 7.I & O every shift 8.Vital signs every shift 9.Refer to Social Services for safe discharge planning QUESTIONS BELOW ARE NOT FOR These venoactive drugs theoretically work by improving venous tone and decreasing capillary permeability. 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. Compression therapy is a standard treatment modality for initial and long-term treatment of venous ulcers in patients without concomitant arterial disease. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. Nursing Care Plan Description Peripheral artery disease ( PAD ), also known as peripheral vascular disease ( PVD ), peripheral artery occlusive disease, and peripheral obliterative arteriopathy, is a form of arteriosclerosis involving occlusion of arteries, most commonly in the lower extremities. 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. Two prospective randomized controlled trials reviewed the effect of sharp debridement on the healing of venous ulcers. Pentoxifylline. B) Apply a clean occlusive dressing once daily and whenever soiled. Compression therapy is the standard of care for venous ulcers and chronic venous insufficiency.23,45 A recent Cochrane review found that venous ulcers heal more quickly with compression therapy than without.45 Methods include inelastic, elastic, and intermittent pneumatic compression. Stockings or bandages can be used; however, elastic wraps (e.g., Ace wraps) are not recommended because they do not provide enough pressure.45 Compression stockings are graded, with the greatest pressure at the ankle and gradually decreasing pressure toward the knee and thigh (pressure should be at least 20 to 30 mm Hg, and preferably 30 to 44 mm Hg). 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. 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. Surgical management may be considered for ulcers. Suspected osteomyelitis warrants an evaluation for arterial disease and consideration of intravenous antibiotics to treat the underlying infection. This article reviews the incidence and pathophysiology of CVI, nursing assessment, diagnosis and interventions, and patient education needed to manage the disease and prevent . Author disclosure: No relevant financial affiliations. Leg elevation. Nursing Diagnosis: Impaired Peripheral Tissue Perfusion related to deficient knowledge of risk factors secondary to venous stasis ulcers as evidenced by edema, decreased peripheral pulses, capillary refill time > 3 seconds, and altered skin characteristics. 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. As soon as the client is allowed to leave the bed, assist with a progressive return to ambulation. 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. Contrast venography is a procedure used to show the veins on x-ray pictures. However, in a recent meta-analysis of six small studies, oral zinc had no beneficial effect in the treatment of venous ulcers.34, Bacterial colonization and superimposed bacterial infections are common in venous ulcers and contribute to poor wound healing. Further evaluation with biopsy or referral to a subspecialist is warranted for venous ulcers if healing stalls or the ulcer has an atypical appearance. When seated in a chair or bed, raise the patients legs as needed. Venous ulcers are the most common lower extremity wounds in the United States. 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. Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). The first step is to remove any debris or dead tissue from the ulcer, wash and dry it, and apply an appropriate dressing. For wound closure to be effective, leg edema must be reduced. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. We and our partners use data for Personalised ads and content, ad and content measurement, audience insights and product development. Once the ulcer has healed, continued use of compression stockings is recommended indefinitely. What is the most appropriate intervention for this diagnosis? We and our partners use cookies to Store and/or access information on a device. Wash the sores with the recommended cleanser to instruct the caregiver about good wound hygiene. These ulcers are caused by poor circulation, diabetes and other conditions. nous insufficiency and ambulatory venous hypertension. Treat venous stasis ulcers per order. Dressings are beneficial for venous ulcer healing, but no dressing has been shown to be superior. Venous stasis commonly presents as a dull ache or pain in the lower extremities, swelling that subsides with elevation, eczematous changes of the surrounding skin, and varicose veins.2 Venous ulcers often occur over bony prominences, particularly the gaiter area (over the medial malleolus). Compression therapy reduces swelling and encourages healthy blood circulation. Arterial pulse examination and measurement of ankle-brachial index are recommended for all patients with suspected venous ulcers. Start providing wound care according to the decubitus ulcers development. Like pentoxifylline therapy, aspirin (300 mg per day) combined with compression therapy has been shown to increase ulcer healing time and reduce ulcer size, compared with compression therapy alone.32 In general, adding aspirin therapy to compression bandages is recommended in the treatment of venous ulcers as long as there are no contraindications to its use. Nursing care planning and management for ineffective tissue perfusion is directed at removing vasoconstricting factors, improving peripheral blood flow, reducing metabolic demands on the body, patient's participation, and understanding the disease process and its treatment, and preventing complications. o LPN education and scope of practice includes wound care. There is currently insufficient high-quality data to support the use of topical negative pressure for venous ulcers.30 In addition, the therapy generally has not been used in clinical practice because of the challenge in administering both topical negative pressure and a compression dressing on the affected leg. Examine the patients vital statistics. This usually needs to be changed 1 to 3 times a week. The patient will employ behaviors that will enhance tissue perfusion. Symptoms of venous stasis ulcers include: Risk factors for venous stasis ulcers include the following: Diagnostic tests for venous stasis ulcers usually include: Compression therapy and direct wound management are the standard of care for VLUs. -. A recent meta-analysis showed that elastic compression therapy is more effective than inelastic therapy.46 In addition, high compression has been proven more effective than low compression, and multilayer bandages are more effective than single layer.23,45,47 The disadvantage of multilayer compression bandages is that they require skilled application in the physician's office one or two times per week, depending on drainage. On physical examination, venous ulcers are generally irregular and shallow with well-defined borders and are often located over bony prominences. Mechanical debridement (wet-to-dry dressings, pulsed lavage, whirlpool) has fallen out of favor. Examine the clients and the caregivers wound-care knowledge and skills in the area. Compression therapy reduces edema, improves venous reflux, enhances healing of ulcers, and reduces pain.23 Success rates range from 30 to 60 percent at 24 weeks, and 70 to 85 percent after one year.22 After an ulcer has healed, lifelong maintenance of compression therapy may reduce the risk of recurrence.12,24,25 However, adherence to the therapy may be limited by pain; drainage; application difficulty; and physical limitations, including obesity and contact dermatitis.19 Contraindications to compression therapy include clinically significant arterial disease and uncompensated heart failure. Author: Leanne Atkin lecturer practitioner/vascular nurse consultant, School of Human and Health Sciences, University of Huddersfield and Mid Yorkshire Trust. Abstract. St. Louis, MO: Elsevier. This, again, helps in the movement of venous blood to the heart.This also prevents the build-up of liquid in the legs that leads to swelling. 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. Based on a clinical practice guideline on disease-oriented outcome, Based on a clinical practice guideline and clinical review on disease-oriented outcome, Based on a clinical practice guideline on disease-oriented outcome and systematic review of moderate-quality evidence, Based on a clinical practice guideline on disease-oriented outcome and review article, Based on a clinical practice guideline on disease-oriented outcome, commentary, and Cochrane review of randomized controlled trials, Based on one randomized controlled trial of more than 400 patients, Most common type of chronic lower extremity ulcer, Venous hypertension due to chronic venous insufficiency. 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. Your doctor may also recommend certain diagnostic imaging tests. document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. A deep vein thrombosis nursing care plan includes assessment of the body parts, appropriate intervention, prevention, and patient education to prevent thromboembolism. 17 The rationale for cleaning leg ulcers is the removal of any dry skin due to the wearing of bandages, it also removes any build-up of emollients that are being used. This will enable the client to apply new knowledge right away, improving retention. Chronic venous insufficiency (CVI) is a potentially debilitating disorder associated with serious complications such as lower extremity venous ulcers. The primary risk factors for venous ulcer development are older age, obesity, previous leg injuries, deep venous thrombosis, and phlebitis. This prevents overdistention and quickly empties the superficial and tibial veins, which reduces tissue swelling and boosts venous return. As fluid leaking from dysfunctional veins accumulates into surrounding tissues, the flesh surrounding the area becomes irritated, inflamed, and begins to break down. Normally, when you get a cut or scrape, your body's healing process starts working to close the wound. 2010. Intermittent Pneumatic Compression. Sacral wounds are most susceptible to infection from urine or feces contamination due to their closeness to the perineum. To view the purposes they believe they have legitimate interest for, or to object to this data processing use the vendor list link below. 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. 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. Teach the caretaker how to properly care for the afflicted regions of the wounds if the patient is to be discharged. This is a common treatment for venous ulcers and can decrease the chance that a healed ulcer will return. Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with reco Negative pressure wound therapy is not recommended as a primary treatment of venous ulcers.48 There may be a future role for newer, ultraportable, single-use systems that can be used underneath compression devices.49,50, Venous ulcers that do not improve within four weeks of standard wound care should prompt consideration of adjunctive treatment options.51, Cellular and Tissue-Based Products. St. Louis, MO: Elsevier. Color duplex ultrasonography is recommended in patients with venous ulcers to assess for venous reflux and obstruction. After administering the analgesic, give the patient 30 to 60 minutes to rate their acute pain again. Compression therapy Treatment focuses on preventing new ulcers, controlling edema, and reducing venous hypertension through compression therapy. mostly non-infectious condition in association with venous insufficiency and atrophy of the skin of the lower leg during long . This content is owned by the AAFP. Nursing diagnoses handbook: An evidence-based guide to planning care. Compression stockings are removed at night, and should be replaced every six months because they lose pressure with regular washing.2. 2 Irrigate in the shower or bathe in buckets or bowls lined with a clean plastic bag to reduce the risk of cross-infection. 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. 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. 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. Venous stasis ulcers may be treated with gauze impregnated with a zinc oxide tincture (Unna boot). Although the main goal of treatment is ulcer healing, secondary goals include reduction of edema and prevention of recurrence. Aspirin (300 mg per day) is effective when used with compression therapy for venous ulcers. Caused by vein problems, these make up the majority of vascular ulcers. Debridement may be sharp, enzymatic, mechanical, larval, or autolytic. Cellulitis or sepsis may develop in complicated wounds, necessitating antibiotic therapy. Saunders comprehensive review for the NCLEX-RN examination. Most patients have venous leg ulcer due to chronic venous insufficiency. 34. Evidence has not shown that any one dressing is superior when used with appropriate compression therapy. Aspirin. However, a recent Cochrane review of 22 RCTs of systemic and topical antibiotics and antiseptics for venous ulcer treatment found no evidence that routine use of oral antibiotics improves healing rates.1 Studies comparing topical antibiotics and antiseptics, such as povidone-iodine solution (Betadine), peroxide-based preparations, ethacridine lactate (not available in the United States), and mupirocin (Bactroban), have found some evidence to support the use of the topical antiseptic agent cadexomer iodine (not available in the United States; a pooled estimate from two trials suggests an increased healing rate at four to six weeks compared with placebo).1 More high-quality data are needed to better evaluate the effectiveness of topical preparations, however.1. Statins have vasoactive and anti-inflammatory effects. To encourage numbing of the pain and patient comfort without the danger of an overdose. Encourage performing simple exercises and getting out of bed to sit on a chair. The 10-point pain scale is a widely used, precise, and efficient pain rating measure. It allows time for the nursing team to evaluate the wound and the condition of the leg. PVD can be related to an arterial or venous issue. A more recent article on venous ulcers is available. The essential requirements of management are to debride the ulcer with appropriate precautions, choose dressings that maintain adequate moisture balance, apply graduated compression bandage after evaluation of the arterial circulation and address the patient's concerns, such as pain and offensive wound discharge. Nursing Care Plan for: Impaired Skin Integrity, Risk for Skin Breakdown, Altered Skin Integrity, and Risk for Pressure Ulcers.

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