Management of Wounds in Patients with Lower-Extremity Venous Disease (LEVD)

Publication Date: March 1, 2020
Last Updated: March 14, 2022

RECOMMENDATIONS

A. Assessment

1. Prior to treatment, assess causative and contributive factors and significant signs and symptoms to differentiate among the types of lower-extremity wounds, which have different etiologies and treatment requirements, in order to establish an appropriate treatment plan.

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2. Review and document the relevant health history.

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3. Assess the risks and contributing factors for developing LEVD such as family history, female sex, pregnancy, older age, tobacco use, systemic inflammation, obesity, comorbid conditions (cardiovascular disease), venous thromboembolism/ deep vein thrombosis (VTE/DVT), excessive sitting or standing, physical inactivity, trauma, injection drug use, impaired calf muscle function, and impaired ankle range of motion.

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4. Assess the risks and contributing factors for developing a VLU, which are similar to those for LEVD: previous leg surgery, previous VLU, obesity, family history, venous reflux, VTE/DVT, physical inactivity, older age (>50 years), female sex, multiple pregnancies, and prolonged sitting or standing.

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5. Assess for specific triggers associated with development of VLUs: cellulitis, penetrating injury/trauma, dry skin and itching, contact allergic dermatitis, rapid onset of leg edema, burns, and insect bites.

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6. Assess the history of present and prior leg ulcers: previous treatments and tolerance (eg, medications and compression), ulcer recurrences, unusual or atypical presentations of ulcers, and/or surgical interventions or biopsies.

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7. Assess for lower-extremity symptoms associated with LEVD: pain, sleep disturbances, and leg symptoms (ie, itching, heaviness, tightening, swelling, and aching).

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8. Assess quality of life using valid/reliable instruments such as the Venous Insufficiency Epidemiologic and Economic Study (VEINES/QOL/Sym), Aberdeen Varicose Vein Questionnaire, and the Chronic Venous Insufficiency Quality of Life Questionnaire; and repeat the assessment on a regular basis.

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9. Assess self-efficacy using a validated instrument such as the Venous Leg Ulcer Self-Efficacy Tool to determine the patient’s perception of his/her ability to perform self-management.

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10. Assess the nutritional status of the patient including intake and the availability and ability to obtain adequate food.

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11. Assess biomarkers associated with risks of LEVD as appropriate: C-reactive protein, fibrinogen, interleukin-10, and interleukin-8.

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12. Conduct a physical examination of the lower leg:

• Inspect the lower extremity for skin changes including hemosiderosis/hemosiderin staining, venous eczema/ dermatitis, hyperpigmentation, atrophie blanche, varicose veins, ankle flaring, scarring from previous ulcers, and lipodermatosclerosis.
• Determine the type and characteristics of lower-extremity edema to differentiate the clinical presentation of edema due to LEVD from other conditions such as lymphedema and lipedema, which may be misdiagnosed.
• Determine perfusion status:

−−Assess skin temperature (cool skin), capillary and venous refill, paresthesia, and color changes of the skin with elevation or dependency of the limb.
−−Determine presence or absence of pedal pulses. Palpate both dorsalis pedis and posterior tibial pulses of each lower extremity. Presence of palpable pulses does not rule out lower-extremity arterial disease; nor does absence of pulses indicate arterial disease, especially, in the presence of edema.
−−Perform a screening ABI to identify/rule out arterial insufficiency.

• Recheck the ABI periodically (every 3 months) for patients with nonhealing, lower-extremity ulcers.

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• Measure the skin temperature using a noncontact infrared thermometer, including areas over previously healed VLUs, to identify areas of potential inflammation or infection.

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• Determine neurosensory status: Screen both feet for loss of protective sensation with a monofilament (5.07/10-g Semmes-Weinstein monofilament); check vibratory sensation with a tuning fork (128 Hz); and check the Achilles tendon reflex with a reflex percussion hammer.

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• Determine the functional ability including ankle range of motion and use of any assistive devices.

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13. Classify the clinical manifestations of LEVD according to the “C” component of the basic Clinical, Etiological, Anatomical, Pathophysiological (CEAP) classification.

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14. Determine and document the characteristics of the wound and periwound at each dressing change: location; size and shape; wound edges; wound bed; exudate; condition of periwound skin; and absence/presence of odor, bleeding, and complications (eg, cellulitis and eczema/dermatitis).

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15. Monitor the healing status of the wound at least weekly: Measure the percentage change in ulcer area to assess healing and determine whether adjunctive therapies are warranted for ulcers that do not heal or show significant healing within 4 weeks of appropriate treatment.

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16. Measure the ankle and calf circumference on a weekly basis to determine the effectiveness of treatments (eg, compression therapy, leg elevation, and exercise) to reduce edema.

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17. Identify factors that may impede wound healing: location, long duration, large size of the wound, comorbid conditions, suspected biofilm, inflammation, infection, lack of adherence to prevention and treatment programs (especially compression therapy), psychosocial factors including depression and social isolation, and use of medications such as steroids or long-term topical or systemic antibiotics.

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18. Identify, monitor, and document pain in the lower-extremity and/or wound pain using a valid and reliable pain scale to determine the following: onset; duration; location; exacerbating and alleviating factors; use and response to analgesics; severity/intensity (mild to severe); characteristics of leg pain (eg, variability; stinging, throbbing, cramping, or sharp/shooting; leg heaviness and achiness; and worsens with prolonged leg dependency); and changes or alterations in pain, which may indicate a change in healing status or disease.

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19. Differentiate venous claudication from arterial, ischemic claudication:

Venous claudication: Exercise-related leg pain due to venous outflow obstruction occurs in the absence of arterial disease and is relieved by leg elevation.
Arterial, ischemic claudication and pain: Reproducible cramping, aching, fatigue, weakness, and/or frank pain in the buttock, thigh, or calf muscles (rarely the foot) that occurs after exercise is typically relieved with 10 minutes’ rest and is increased by leg elevation and alleviated by dependency of the limb or rest. Pain that occurs at rest in the absence of activity indicates severe arterial disease.
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20. Evaluate laboratory parameters such as albumin, prealbumin, hemoglobin, hematocrit, homocysteine, hemoglobin A1c (HbgA1c), prothrombin time, and inflammatory biomarkers (eg, C-reactive protein and fibrinogen) to establish potential for healing.

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21. Identify factors that are associated with VLU recurrence: long duration of a VLU, decreased physical activity, lack of leg elevation, not wearing compression, high body mass index, malnutrition, depression, low self-efficacy, and presence of comorbid conditions and other general risks for LEVD and VLUs.

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22. Refer patients as indicated for further evaluation and diagnostic testing to determine the severity of LEVD with vascular studies such as a venous duplex ultrasound, which is the most reliable noninvasive test to diagnose anatomical and hemodynamic abnormalities, reflux, or obstruction in any venous segment (superficial and deep).

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23. Refer patients with the following conditions for further evaluation and treatment: cellulitis, VTE/DVT, variceal bleeds, intractable pain, eczema/dermatitis that is unresponsive to appropriate topical therapy and/or short-term topical steroids, and ulcers that are atypical in appearance or unresponsive to 4 weeks of appropriate therapies.

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B. Prevention and Management of LEVD and VLU Risk Reduction

24. Encourage patients to undertake a program of physical activity to strengthen the calf muscle and increase ankle range of motion.

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25. Recommend patients with varicosities wear compression stockings, manage their weight, engage in physical activity such as walking and avoid wearing constricting garments and crossing legs to reduce the risk of VLUs.

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26. Consider using the WOCN Society’s algorithm, Compression for Primary Prevention, Treatment, and Prevention of Recurrence of Venous Leg Ulcers: An Evidence-and Consensus- Based Algorithm for Care Across the Continuum (http:// vlu.wocn.org/#home), to identify the appropriate type and level of compression for adults.

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27. Screen patients for arterial disease with a Doppler measurement of the ABI by suitably trained staff prior to the use of compression.

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28. Educate individuals with sufficient blood flow (ABI ≥0.80) to use the strongest compression they can apply or tolerate to prevent VLUs or reduce recurrence.

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29. Consider light compression for individuals with LEVD and lipodermatosclerosis, who are unable to apply, tolerate, or afford the cost of high-level compression garments.

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30. Have compression stockings fitted by trained personnel.

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31. Closely supervise and monitor the use of reduced compression (23-30 mmHg) for individuals with mixed venous/ arterial insufficiency (ABI >0.50 to <0.80), which should be provided under the direction of wound care specialists.

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32. Educate patients that compression must be worn every day for the prevention of venous edema and ulceration for all CEAP classifications, and for prevention of VLU recurrence.

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33. Avoid compression if ABI is less than 0.50, the ankle pressure is less than 70 mmHg, or the toe pressure is less than 50 mmHg; and refer the patient for further evaluation and treatment.

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34. Consider use of cryotherapy/cooling treatment to manage symptoms of LEVD.

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35. Consider vein surgery or minimally invasive procedures to treat varicose veins:

• Endovascular laser ablation.

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• Open surgery, endovascular surgery, or subfascial endoscopic perforator vein surgery.

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36. Consider medications/supplements such as phlebotonics/flavonoids to decrease lower-extremity symptoms associated with LEVD (ie, pain, heaviness, edema, pruritus, and cramps):

• Micronized purified flavonoid fraction.

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• Horse chestnut seed oil extract.

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• Dobesilate calcium.

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• Mesoglycan.

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37. Educate patient/caregivers about risk factors and triggers for developing VLUs and self-management strategies to minimize risks: using lifelong compression; daily leg elevation; weight management; engaging in daily physical activities; maintaining a well-balanced diet; avoiding trauma; seeking professional health care for signs of increased swelling, redness, pain, or skin breakdown in the lower extremity; abnormal sensations in the skin; and medication options.

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C. Wound Management

38. Recommend patients with LEVD and lower-extremity ulcers seek care guided by a clinical wound expert.

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Wound Treatment

39. Cleanse the ulcer and periwound skin at each dressing change with a noncytotoxic cleanser (eg, potable tap water, distilled water, cooled boiled water, or saline/salt water), while minimizing trauma to the ulcer and surrounding skin ulcers. No one cleanser has been shown to be optimal for VLUs.

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40. Avoid the use of known skin irritants and allergens on the skin especially in patients with venous eczema/dermatitis because a high percentage of individuals with LEVD/ VLUs experience hypersensitivity to various ingredients and products.

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41. Patch test individuals with known sensitivities or delayed wound healing prior to use of new products.

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42. Use a topical steroid for patients with eczema/dermatitis for 1 to 2 weeks to reduce inflammation and itching, and refer to a dermatologist if the treatment is ineffective. In severe cases, a prolonged treatment with a topical steroid and/or use of systemic steroids might be warranted.

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43. Debride the ulcer to remove devitalized tissue when debridement is consistent with the patient’s condition and goals of therapy. No one method of debridement has been shown to be optimal for VLUs.

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44. Consider debridement if there is a high index of suspicion that biofilm is present (ie, wound fails to heal, despite proper wound care and antimicrobial therapy).

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45. Choose the method of debridement based on an assessment of the condition of the ulcer (eg, presence or absence of infection and amount of necrotic tissue), pain tolerance, and individual circumstances such as the setting and availability of various debridement methods.

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46. Closely monitor the ulcer when any debridement method is used.

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47. Consider topical anesthetic agents to provide pain relief during debridement such as a lidocaine and prilocaine- based cream.

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48. Select dressings according to accepted wound care principles: characteristics of the ulcer/periwound skin; level of exudate; patient needs such as comfort, cost, and ease of application; and availability of dressings. There is no one optimal type of dressing for treatment of VLUs and/or for use under compression wraps.

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49. Assess the wound at every dressing change to determine whether the type of dressing or frequency of changes should be modified.

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50. Identify and treat infection:

• Avoid the routine use of topical or systemic antibiotics in VLUs without signs of clinical infection.

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• Determine the bacterial bioburden by tissue biopsy or Levine quantitative swab technique when clinical symptoms of infection are present, or if biofilm is suspected due to wound deterioration or lack of healing.

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• Consider topical antibiotics for superficial infection, using culture-guided antibiotic therapy.

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• Consider a trial of nontoxic, topical antimicrobials/antiseptics for localized, clinical infection as an alternative to topical antibiotics:

−− Silver-based dressings.

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−−Cadexomer iodine.

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• Treat deep tissue infection, cellulitis/advancing cellulitis, bacteremia, or sepsis with systemic, culture-guided antibiotic therapy.

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51. Consider use of analgesic-containing dressings such as ibuprofen-releasing dressings to reduce wound pain.

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Compression Therapy

52. Select the type and level of compression based on a careful assessment of the patient.

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53. Use the highest level and type of compression with which the patient will comply to promote healing of VLUs and prevent VLU recurrence taking into consideration that high compression, multicomponent systems, and compression with an elastic component may be more effective.

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54. Have compression bandages and wraps applied by skilled personnel.

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55. Do not rely on antiembolism stockings or hose that provide low pressure (≤20 mmHg) and are not designed for therapeutic compression to prevent or treat LEVD or VLUs.

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56. Use a carefully supervised trial of modified, reduced compression bandaging (23-30 mmHg at the ankle) for individuals with mixed venous/arterial disease and moderate arterial insufficiency (ABI >0.50 to <0.80) who present with ulcers and edema.

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57. Avoid compression if the ABI is less than 0.50, the ankle pressure is less than 70 mmHg, or the toe pressure is less than 50 mmHg, and refer the patient for further testing and evaluation.

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58. Consider using intermittent pneumatic compression for patients who have not responded to stockings/wraps, are immobile, need higher levels of compression than can be provided with stockings or wraps (ie, those with extremely large legs) or who are intolerant of stockings or wraps.

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59. Monitor and reassess the use of compression on a regular basis to determine the effectiveness, patient’s tolerance and adherence, and if any complications have developed (eg, pain, pressure injury, skin irritation, and wasting of the calf muscle).

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Adjunctive Therapies

60. Consider adjunctive therapies as indicated:

• Electrical therapy.

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• Negative pressure wound therapy.

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• Ultrasound (high-frequency ultrasound; noncontact low-frequency ultrasound).

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Medications

61. Consider use of medications combined with usual care (eg, compression, leg elevation, and exercise) to promote ulcer healing or the rate of healing:

• Pentoxifylline.

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• Simvastatin.

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• Sulodexide.

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• Doxycycline.

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Nutrition

62. Refer individuals with nonhealing VLUs and suspected nutritional deficits to a registered dietitian for assessment and appropriate interventions.

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Surgical Options

63. Consider invasive and noninvasive surgical procedures to improve VLU healing and reduce VLU recurrence:

• Surgery.

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• Subendoscopic perforator surgery.

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• Skin grafts, biological dressings, and human skin equivalents:

−−Allograft.

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−−Bilayered skin equivalent.

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−−Human fibroblast dermal substitute.

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−−Split-thickness skin grafts.

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−−Hair follicle grafts.

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64. Consider endovascular minimally invasive ablation of varicose veins to promote ulcer healing:

• Thermal ablation (radiofrequency, endovenous laser).

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• Nonthermal ablation (foam sclerotherapy).

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D. Patient Education and Risk Reduction Strategies for Self-management to Prevent and Treat VLUs and Prevent VLU Recurrence

65. Educate patients/caregivers about the risks, pathophysiology, disease process of LEVD, and the risks of VLUs and VLU recurrence.

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66. Utilize varied educational approaches to teach patients’ self-management including individual education and counseling, print materials, and video programs.

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67. Educate the patient and caregivers in measures/strategies for self-management to reduce risks, prevent and manage VLUs, prevent VLU recurrence, and promote overall health and wellness:

• Lifelong commitment to wearing compression, proper fitting and use of compression stockings and/or use and application of compression bandages/devices.
• Monitor for signs/symptoms of problems/risks of compression bandages: If problems occur, loosen or remove the compression and seek immediate professional health care if the symptoms persist.
• Observe for signs of variceal bleeds: Elevate the extremity and apply pressure; seek immediate professional health care if the bleeding persists.
• Practice good skin hygiene of the lower extremities: Use mild soap for cleansing and emollients to hydrate the skin, and avoid known sensitizing topical agents.
• Engage in measures to improve overall health and wellness: tobacco cessation, healthy nutritional practices and weight management. Discuss medication/supplement options with a health care provider, avoid crossing legs and prolonged standing and avoid high-heeled shoes.
• Elevate legs above the level of the heart for 30 minutes, 3 to 4 times per day, if not medically contraindicated.
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68. Teach patients to engage in regular and frequent exercise and physical activity, including home-based physical activity programs and resistance activities, to improve calf muscle pump function and reduce healing time.

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E. Health Care Provider Follow-up

69. Regularly assess and monitor patient adherence to recommendations; for problems or complications: use of compression and the condition of stockings or bandages/ wraps; functional abilities; activities of daily living; presence of depression, sleep disturbances, and other concomitant illnesses; pain; and use and response to prescribed and self-prescribed pharmacologic agents.

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Recommendation Grading

Disclaimer

Overview

Title

Management of Wounds in Patients with Lower-Extremity Venous Disease (LEVD)

Authoring Organization

Publication Month/Year

March 1, 2020

Last Updated Month/Year

July 6, 2023

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D035002 - Lower Extremity, D014947 - Wounds and Injuries

Keywords

lower extremity, Venous Disease, Stasis ulcer, Wounds in Patients