Venous stasis ulcers are often on the ankle or calf and are painful and red. Referral to a wound subspecialist should be considered for ulcers that are large, of prolonged duration, or refractory to conservative measures. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Copyright 2023 American Academy of Family Physicians. She has worked in Medical-Surgical, Telemetry, ICU and the ER. Copyright 2010 by the American Academy of Family Physicians. Early venous ablation and surgical intervention to correct superficial venous reflux can improve healing and decrease recurrence rates. Even under perfect conditions, a pressure ulcer may take weeks or months to heal. Wound, Ostomy, and Continence . Nonhealing ulcers also raise your risk of amputation. The first step is to remove any debris or dead tissue from the ulcer, wash and dry it, and apply an appropriate dressing. Figure Traditional negative pressure wound therapy systems are bulky and cannot be used with compression therapy. 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. Conclusion The synthetic prostacyclin iloprost is a vasodilator that inhibits platelet aggregation. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. The student can make adjustments as soon as they receive feedback, as opposed to practicing the skill incorrectly. Encourage performing simple exercises and getting out of bed to sit on a chair. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). Impaired Skin Integrity ADVERTISEMENTS Impaired Skin Integrity Nursing Diagnosis Impaired Skin Integrity May be related to Chronic disease state. Venous ulcers are the most common lower extremity wounds in the United States. Statins have vasoactive and anti-inflammatory effects. 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. -. 11.0 Low level laser treatment 11.1 There is no evidence that low level laser therapy speeds the healing of venous leg ulcers. SAGE Knowledge. Other associated findings include telangiectasias, corona phlebectatica, atrophie blanche, lipodermatosclerosis, and inverted champagne-bottle deformity of the lower leg. Other findings suggestive of venous ulcers include location over bony prominences such as the gaiter area (over the medial malleolus; Figure 1), telangiectasias, corona phlebectatica (abnormally dilated veins around the ankle and foot), atrophie blanche (atrophic, white scarring; Figure 2), lipodermatosclerosis (Figure 3), and inverted champagne-bottle deformity of the lower leg.1,5, Although venous ulcers are the most common type of chronic lower extremity ulcers, the differential diagnosis should include arterial occlusive disease (or a combination of arterial and venous disease), ulceration caused by diabetic neuropathy, malignancy, pyoderma gangrenosum, and other inflammatory ulcers.13 Among chronic ulcers refractory to vascular intervention, 20% to 23% may be caused by vasculitis, sickle cell disease, pyoderma gangrenosum, calciphylaxis, or autoimmune disease.14, Initial noninvasive imaging with comprehensive venous duplex ultrasonography, arterial pulse examination, and measurement of ankle-brachial index is recommended for all patients with suspected venous ulcers.1 Color duplex ultrasonography is recommended to assess for deep and superficial venous reflux and obstruction.1,15 Because standard therapy for venous ulcers can be harmful in patients with ischemia, additional ultrasound evaluation to assess arterial blood flow is indicated when the ankle-brachial index is abnormal and in the presence of certain comorbid conditions such as diabetes mellitus, chronic kidney disease, or other conditions that lead to vascular calcification.1 Further evaluation with biopsy or referral to a subspecialist is warranted if ulcer healing stalls or the ulcer has an atypical appearance.1,5, Treatment options for venous ulcers include conservative management, mechanical modalities, medications, advanced wound therapy, and surgical options. Risk Factors Trauma Thrombosis Inflammation Embolism Chronic venous insufficiency can develop from common conditions such as varicose veins. Otherwise, scroll down to view this completed care plan. She moved into our skilled nursing home care facility 3 days ago. Patients typically experience no pain to mild pain in the extremity, which is relieved with elevation. mostly non-infectious condition in association with venous insufficiency and atrophy of the skin of the lower leg during long . This will enable the client to apply new knowledge right away, improving retention. As the patient is experiencing pain, have him or her score it on a scale of 0 to 10 and describe it. Slough with granulation tissue comprises the base of the wound, with moderate to heavy exudate. Abstract. What is the most appropriate intervention for this diagnosis? Inelastic compression wraps, most commonly zinc oxideimpregnated Unna boots, provide high compression only during ambulation and muscle contraction. As an Amazon Associate I earn from qualifying purchases. Over time, as the veins become increasingly weak, they have more trouble sending blood to the heart. This prevents overdistention and quickly empties the superficial and tibial veins, which reduces tissue swelling and boosts venous return. Debridement may be sharp, enzymatic, mechanical, larval, or autolytic. Oral antibiotics are preferred, and therapy should be limited to two weeks unless evidence of wound infection persists.1, Hyperbaric Oxygen Therapy. The highest CEAP severity score is applied to patients with ulcers that are active, chronic (greater than three months' duration, and especially greater than 12 months' duration), and large (larger than 6 cm in diameter).19,20 Poor prognostic factors for venous ulcers include large size and prolonged duration.21,22. Venous leg ulcers are open, often painful, sores in the skin that take more than 2 weeks to heal. Print. 3M can help manage challenges related to VLUs and help improve patient outcomes so that people can fully engage and participate in normal everyday activities. 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. See permissionsforcopyrightquestions and/or permission requests. Although numerous treatment methods are available, they have variable effectiveness and limited data to support their use. On initial assessment, it is crucial to cover the history of health: associated co-morbidities, habitual therapy, psycho-emotional state, influence of odour on social life, nutritional state, presence and intensity of pain and individual treatment preference. St. Louis, MO: Elsevier. VLUs are the result of chronic venous insufficiency (CVI) in the legs. Characteristic differences in clinical presentation and physical examination findings can help differentiate venous ulcers from other lower extremity ulcers (Table 1).2 The diagnosis of venous ulcers is generally clinical; however, tests such as ankle-brachial index, color duplex ultrasonography, plethysmography, and venography may be helpful if the diagnosis is unclear.1518. Venous ulcers are believed to account for approximately 70% to 90% of chronic leg ulcers. . Surgical management may be considered for ulcers that are large in size, of prolonged duration, or refractory to conservative measures. 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. Although intermittent pneumatic compression is more effective than no compression, its effectiveness compared with other forms of compression is unclear. Clean, persistent wounds that are not healing may benefit from palliative wound care. SUSAN BONKEMEYER MILLAN, MD, RUN GAN, MD, AND PETRA E. TOWNSEND, MD. The ultimate aim is to promote evidence-based nursing care among patients with venous leg ulcer. It is performed with autograft (skin or cells taken from another site on the same patient), allograft (skin or cells taken from another person), or artificial skin (human skin equivalent).41,42,49 However, skin grafting generally is not effective if there is persistent edema, which is common with venous insufficiency, and the underlying venous disease is not addressed.40 A recent Cochrane review found few high-quality studies to support the use of human skin grafting for the treatment of venous ulcers.41, The role of surgery is to reduce venous reflux, hasten healing, and prevent ulcer recurrence. such as venous ulcers and lymphoedema, concomitant bacterial and fungal colonisation or infection may be present. Position the patient back in his or her comfortable or desired posture. All Rights Reserved. They typically occur around the medial malleolus, tend to be shallow and moist, and may be malodorous (especially when poorly cared for) or painful. Peripheral vascular disease is the impediment of blood flow within the peripheral vascular system due to vessel damage, which mainly affects the lower extremities. After administering the analgesic, give the patient 30 to 60 minutes to rate their acute pain again. When seated in a chair or bed, raise the patients legs as needed. Venous stasis ulcers may develop spontaneously or after affected skin is scratched or injured. Cellulitis or sepsis may develop in complicated wounds, necessitating antibiotic therapy. Historically, trials comparing venous intervention plus compression with compression alone for venous ulcers showed that surgery reduced recurrence but did not improve healing.53 Recent trials show faster healing of venous ulcers when early endovenous ablation to correct superficial venous reflux is performed in conjunction with compression therapy, compared with compression alone or with delayed intervention if the ulcer did not heal after six months.21 The most common complications of endovenous ablation were pain and deep venous thrombosis.21, The recurrence rate of venous ulcers has been reported as high as 70%.35 Venous intervention and long-term use of compression stockings are important for preventing recurrence, and leg elevation can be beneficial when used with compression stockings. document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. Pentoxifylline (Trental) is an inhibitor of platelet aggregation, which reduces blood viscosity and, in turn, improves microcirculation. All Rights Reserved. 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 Oral antibiotics are recommended to treat venous ulcers only in cases of suspected cellulitis. The patient will demonstrate increased tolerance to activity. 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. Compression therapy Treatment focuses on preventing new ulcers, controlling edema, and reducing venous hypertension through compression therapy. The patient will employ behaviors that will enhance tissue perfusion. Poor venous return is due to damage of the valves in leg veins that facilitate the return of the blood to the heart. More analgesics should be given as needed or as directed. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Some evidence supports the use of cadexomer iodine to improve healing of venous ulcers, but evidence for other agents is lacking.38. These actions are intended to improve overall muscle tone and strength, as well as boost venous return from the lower extremities and decrease venous stasis. This process is thought to be the primary underlying mechanism for ulcer formation.10 Valve dysfunction, outflow obstruction, arteriovenous malformation, and calf muscle pump failure contribute to the pathogenesis of venous hypertension.8 Factors associated with venous incompetence are age, sex, family history of varicose veins, obesity, phlebitis, previous leg injury, and prolonged standing or sitting posture.11 Venous ulcers result from a complex process secondary to increased pressure (venous hypertension) and inflammation within the venous circulation, vein wall, and valve leaflet with extravasation of inflammatory cells and molecules into the interstitium.12, Clinical history, presentation, and physical examination findings help differentiate venous ulcers from other lower extremity ulcers (Table 15 ). Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. Continuous stress to the skins' integrity will eventually cause skin breakdowns. Pressure Ulcer/Pressure Injury Nursing Care Plan. Her Waterlow Scale is 16, and her skin is intact except for the venous stasis ulcer on the right medial malleolus. Nursing Care Plan for: Impaired Skin Integrity, Risk for Skin Breakdown, Altered Skin Integrity, and Risk for Pressure Ulcers. Copyright 2019 by the American Academy of Family Physicians. They usually develop on the inside of the leg, between the and the ankle. Granulation tissue and fibrin are often present in the ulcer base. 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. Venous ulcers, also known as venous stasis ulcers are open sores in the skin that occur where the valves in the veins don't work properly and there is ongoing high pressure in the veins. 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. 2 Irrigate in the shower or bathe in buckets or bowls lined with a clean plastic bag to reduce the risk of cross-infection. It can eventually lead to ulcerations or skin breakage on the skin making the person prone infections. Human skin grafting may be used for patients with large or refractory venous ulcers. 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. Because bacterial colonization and infection may contribute to poor healing, systemic antibiotics are often used to treat venous ulcers. Debridement may be sharp (e.g., using curette or scissors), enzymatic, mechanical, biologic (i.e., using larvae), or autolytic. Preamble. Nursing Diagnosis: Risk for Infection related to poor circulation and oxygen delivery and ischemia secondary to venous pressure ulcers. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. They can affect any area of the skin. Oral zinc therapy has been shown to decrease healing time in patients with pilonidal sinus. 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. Author disclosure: No relevant financial affiliations. 2 In some studies, 50% of patients had venous ulcers that persisted for more than 9 months, and 20% had ulcers that did . These ulcers are caused by poor circulation, diabetes and other conditions. Additionally, patients with pressure ulcers lose a lot of protein through their wound exudate and may need at least 4,000 calories per day to maintain their anabolic state. They should not be used in nonambulatory patients or in those with arterial compromise. Compression therapy is beneficial for venous ulcer treatment and is the standard of care. Make a chart for wound care. Ackley, Nursing Diagnosis Handbook, Page 153 Nursing CLINICAL WORKSHEET Dat e: 10/2/2022 Student Name: Michele Tokar Assigned vSim: Vernon Russell Initia ls: VR Diagnosis: Right sided ischemic Treat venous stasis ulcers per order. Colonization refers to the presence of replicating bacteria without a host reaction or clinical signs of infection.45 Colonized venous ulcers generally should not be treated with antibiotics. Examine the patients skin all over his or her body. Nursing Times [online issue]; 115: 6, 24-28. The oldest term for pressure ulcers is decubitus, which evolved into decubitus ulcers or ischemic ulcer s in the 1950s. Venous Ulcers. It allows time for the nursing team to evaluate the wound and the condition of the leg. The consent submitted will only be used for data processing originating from this website. Unna boots have limited capacity for fluid absorption in patients with highly exudative ulcers and are best used for early, small, dry ulcers and for venous dermatitis because of the skin soothing effects of zinc oxide.30, Stockings. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). How to Cure Venous Leg Ulcers Mark Whiteley. A yellow, fibrous tissue may cover the ulcer and have an irregular border. The nurse is caring for a patient with a large venous leg ulcer. On physical examination, venous ulcers are generally irregular, shallow, and located over bony prominences. Buy on Amazon, Silvestri, L. A. Aspirin. 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. If necessary, recommend the physical therapy team. C) Irrigate the wound with hydrogen peroxide once daily. 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. Four trials showed that pentoxifylline alone improved healing compared with placebo alone.19 Common adverse effects of pentoxifylline include nausea, gastrointestinal discomfort, headaches, dizziness, and prolonged bleeding time. Two prospective randomized controlled trials reviewed the effect of sharp debridement on the healing of venous ulcers. Surgical options for treatment of venous insufficiency include ablation of the saphenous vein; interruption of the perforating veins with subfascial endoscopic surgery; treatment of iliac vein obstruction with stenting; and removal of incompetent superficial veins with phlebectomy, stripping, sclerotherapy, or laser therapy.19,35,40, In one study, ablative superficial venous surgery reduced the rate of venous ulcer recurrence at 12 months by more than one half, compared with compression therapy alone.42 In another study, surgical management led to an ulcer healing rate of 88 percent, with only a 13 percent recurrence rate over 10 months.43 There is no evidence demonstrating the superiority of surgery over medical management; however, evaluation for possible surgical intervention should occur early.44. Exercise should be encouraged to improve calf muscle pump function.35,54 Good social support and self-efficacy have also been shown to help prevent venous ulcer recurrence.35, This article updates a previous article on this topic by Collins and Seraj.55. Examine the patients vital statistics. Most patients have venous leg ulcer due to chronic venous insufficiency. Common drugs in this class include saponins (e.g., horse chestnut seed extract), flavonoids (e.g., rutosides, diosmin, hesperidin), and micronized purified flavonoid fraction.43 Although phlebotonics may improve edema and other signs and symptoms of chronic venous insufficiency (e.g., trophic disorders, cramps, restless legs, swelling, paresthesia), there was no difference in venous ulcer healing when compared with placebo.44, Antibiotics. Elastic bandages (e.g., Profore) are alternatives to compression stockings. However, data to support its use for venous ulcers are limited.35, Overall, acute ulcers (duration of three months or less) have a 71 to 80 percent chance of healing, whereas chronic ulcers have only a 22 percent chance of healing after six months of treatment.7 Given the poor healing rates associated with chronic ulcers, surgical evaluation and management should be considered in patients with venous ulcers that are refractory to conservative therapies.48. 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). Author: Leanne Atkin lecturer practitioner/vascular nurse consultant, School of Human and Health Sciences, University of Huddersfield and Mid Yorkshire Trust. Choice of knee-high, thigh-high, toes-in, or toes-out compression stockings depends on patient preference. This content is owned by the AAFP. Medical-surgical nursing: Concepts for interprofessional collaborative care. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. Less often, patients have arterial leg ulcer resulting from peripheral arterial occlusive disease, the most common cause of which is arteriosclerosis. Please follow your facilities guidelines, policies, and procedures. Pentoxifylline (400 mg three times per day) has been shown to be an effective adjunctive treatment for venous ulcers when added to compression therapy.31,40 Pentoxifylline may also be useful as monotherapy in patients who are unable to tolerate compression bandaging.31 The most common adverse effects are gastrointestinal (e.g., nausea, vomiting, diarrhea, heartburn, loss of appetite). What intervention should the nurse implement to promote healing and prevent infection? Sacral wounds are most susceptible to infection from urine or feces contamination due to their closeness to the perineum. 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. 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. 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. Peripheral vascular disease (PVD) NCLEX review questions for nursing students! Venous ulcers are believed to account for approximately 70% to 90% of chronic leg ulcers. This usually needs to be changed 1 to 3 times a week. Pentoxifylline (Trental) is effective when used with compression therapy for venous ulcers, and may be useful as monotherapy. See permissionsforcopyrightquestions and/or permission requests. To prevent the infection from getting worse, it is best to discourage the youngster from scratching the sores, even if they are just mildly itchy. These venoactive drugs theoretically work by improving venous tone and decreasing capillary permeability. The 10-point pain scale is a widely used, precise, and efficient pain rating measure. For wound closure to be effective, leg edema must be reduced. Examine the clients and the caregivers wound-care knowledge and skills in the area. The venous stasis ulcer is covered with a hydrocolloid dressing, . Nursing Care of the Patient with Venous Disease - Fort HealthCare 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. 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. Isolating the wound from the perineal region can occasionally be challenging. Here are three (3) nursing care plans (NCP) and nursing diagnosis for pressure ulcers (bedsores): ADVERTISEMENTS Impaired Skin Integrity Risk For Infection Risk For Ineffective Health Maintenance 1. In comparison to a single long walk, short, regular walks are healthier for the extremities and the prevention of pulmonary problems. Anna Curran. She has brown hyperpigmentation on both lower legs with +2 oedema. Venous stasis ulcers may be treated with gauze impregnated with a zinc oxide tincture (Unna boot). Learn how your comment data is processed. The most common method of inelastic compression therapy is the Unna boot, a zinc oxideimpregnated, moist bandage that hardens after application. 1 The incidence of venous ulceration increases with age, and women are three times more likely than men to develop venous leg ulcers. A more recent article on venous ulcers is available. Effective treatments include topical silver sulfadiazine and oral antibiotics. Possible causes of venous ulcers include inflammatory processes resulting in leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema. Encouraging the patient through physical therapy to get out of bed and sit down and carry out the necessary exercises. 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. B) Apply a clean occlusive dressing once daily and whenever soiled. Any of the lower leg veins can be affected. Nursing Diagnosis: Ineffective Tissue Perfusion (multiple organs) related to hyperviscosity of blood. o LPN education and scope of practice includes wound care. Some of our partners may process your data as a part of their legitimate business interest without asking for consent. This means they can't stop blood which should be headed upward to your heart from being pulled down by gravity. It can related to the age as well as the body surface of the . Tiny valves in the veins can fail. A 25-year-population research found that it typically takes 5 years from the diagnosis of chronic venous insufficiency to the development of an ulcer. The recurrence of an ulcer in the same area is highly suggestive of venous ulcer. 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.