The nurse is caring for a 27-year-old female client with venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?
A. Apply dressing using sterile technique
B. Improve the client’s nutrition status
C. Initiate limb compression therapy
D. Begin proteolytic debridement
Correct Answer: B. Improve the client’s nutrition status
Venous stasis occurs when venous blood collects and stagnates in the lower leg due to incompetent venous valves. Eventually, little oxygen and nutrients are supplied to the cells of the lower extremities causing the cells to die or necrose. This ultimately leads to the formation of venous stasis ulcers characterized by shallow but large brown wounds with irregular margins that typically develop on the lower leg or ankle. The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. Nutritional deficiencies are common causes of venous ulcers. Alterations in the diet to include foods high in protein, iron, zinc, and vitamins C and A are encouraged to promote wound healing.
Option A: Dressings are often used under compression bandages to promote faster healing and prevent adherence of the bandage to the ulcer. A wide range of dressings are available, including hydrocolloids (e.g., Duoderm), foams, hydrogels, pastes, and simple non-adherent dressings.
Option C: Compression therapy is the standard of care for venous ulcers and chronic venous insufficiency. A recent Cochrane review found that venous ulcers heal more quickly with compression therapy than without. Methods include inelastic, elastic, and intermittent pneumatic compression. Compression therapy reduces edema, improves venous reflux, enhances healing of ulcers, and reduces pain.
Option D: Removal of necrotic tissue and bacterial burden through debridement has long been used in wound care to enhance healing. Debridement may be sharp (e.g., using a curette or scissors), enzymatic, mechanical, biologic (i.e., using larvae), or autolytic.