Written by: Janis Harrison, RN, BSN, WOCN, CFCN
Edema (swelling) is a Precursor to Venous Insufficiency
Veins have one-way valves in them that assist in moving blood from the feet back to the heart. As the muscles in the leg contracts the pressure created by the muscle pushes the blood upward through the valves. As the muscle relaxes the valve closes, preventing the blood from back-flowing.
When we understand the hydraulics of the vein, we can see those problems that can confound the upward motion of the blood.
A sedentary lifestyle would reduce the number and or strength of the muscle’s contractions acting on the vein. Trauma to the leg could either interrupt the healthy contraction cycle of the muscle or impair the action of the valves. Obesity, pregnancy, age, smoking, varicose veins, clots and surgery can all lead to a functional weakening of the valves and allow a back flow of the circulation, thus resulting in an increase of fluid in the lower leg. These are the likely paths leading to ulceration. Ulcerations are what bring patients to me after having bumped their leg on a table, bedpost, or car door and they just cannot heal the wound. Often time they have the wound for weeks or even years before I find them at my door looking for help.
Grocery shopping is a time when you can witness the effects of edema. Nearly everyone starts shopping at one end of the store and moves through the store in the same direction until they end at the register. I challenge you to begin watching the effects of edema on the individual’s quality of life as they negotiate what for many is the greatest physical challenge in their life. The grocery stores. Upon first entering keep an eye out for someone that is limping slightly or trudging. Then look at their ankles. Those that show symptoms of an impaired gait are who you are looking to study. Many times, I will notice a great amount of swelling (edema) where it looks like there is no ankle and the skin is rolling over the sides of their shoe. Frequently, I will notice wet spots on the pant legs or a make shift bandage wrapped around the lower leg. It makes me wonder.... Venous Stasis Disease? When addressing the patient’s edema take into consideration your observations at the grocery store. You as a healthcare provider have the ability to not just heal the ulceration, but to immediately influence the patient’s quality of life. First, an ankle/brachial index (ABI) - normal 1.0-1.3 - should be a diagnostic non-invasive test to be performed to make sure the arterial flow is not compromised. Second it is imperative to get the edema under control. The cells of the wound cannot come together to heal as long as there is a large amount of fluid in the tissues holding the cells apart. Venous insufficiency and ulceration are complicated so we will just talk about the concepts around the basic care.
Symptoms of Venous Stasis Ulcers
• A venous ulcer is often itchy, burning and aching and normally shallow.
• Edema or swelling
• Brownish discoloration around the ankle known as hemosiderin staining and white areas known as Atrophe Blanche
• Large amounts of exudate with an odor coming from the wound.
• Signs of infection include redness, increase in pain, and fever
Evaluating and Treatment for Venous Leg Ulcers
If it appears to be infected, it is important for a physician or medical provider to see the wound and lower leg. Treatment is needed for the infection. Edema or swelling is to be treated with a form of compression.
A compression wrap is the gold standard treatment for these wounds.
You may notice your wound nurse is using a compression kit that comes with 3 or 4 rolls. Each of these layers works together with part of your deep to peripheral veins to improve the pressure and assist the valves in the veins to close so the blood will continue to circulate correctly through your veins back to the heart. In the beginning of treatment, the wrap is used to treat the swelling and use of absorptive dressings over the wound such as a foam or alginate is used to collect the drainage. The wrap may have to be changed 1-2 x a week depending on how much drainage is seen. Once the edema is better controlled and minimized a compression garment is chosen for the patient. Since the venous ulcer is seen frequently in the elderly and obese patient you will have to check their hand dexterity to see if they are agile and strong enough to pull on the tight compression stockings. Compression comes in many forms for prevention of edema. Once your patient understands they will have to wear compression for life, they are better at helping decide which compression garment will work best for them.
Compression Stockings (one and two layers available)
• Zipper stockings (Jobst)
Compression Garments (reusable inelastic device)