Instructor’s Overview: Josephine
Morrow—Skin Integrity, Providing
Wound Care to a Patient with a Venous
Stasis Ulcer
Scenario Overview
Patient: Josephine Morrow
Diagnosis: Chronic venous insufficiency with venous stasis ulcer
Brief Summary:
This case presents Josephine Morrow, a white, obese 80-year-female who moved to a skilled
nursing home care facility 3 days ago. The patient has a venous stasis ulcer that developed
while still living on her own. The students are expected to assess the leg wound, assess the
patient’s pain, perform a dressing change, reapply elastic bandage and antiembolism stocking,
and communicate findings. The students are also expected to assess lab values and provide
patient education on interventions to promote venous return.
Learning Objectives
General:
□ Assess patients to recognize normal versus abnormal findings
□ Respond to changes in patient status
□ Assume accountability for the plan of care by order of priority, implementation, and evaluation
□ Use standard precautions when caring for the patient
□ Ensure patient and healthcare provider safety
□ Collaborate appropriately with the healthcare team in a timely, organized, and patient-specific
manner
□ Use critical thinking when making clinical judgments and decisions
□ Establish a therapeutic environment for the patients and their families
□ Use therapeutic communication techniques in a manner that illustrates caring for the patient’s
overall well-being
Scenario-Specific:
 Recognize signs and symptoms of chronic venous insufficiency
 Assess the size and appearance of a venous stasis ulcer
 Interpret laboratory results and their relationship to skin integrity
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vSim for Nursing | Fundamentals
Josephine Morrow
 Perform a simple dressing change
 Provide patient education on measures to improve venous return and prevent venous stasis
ulcers
Patient Case Introduction to Students
Location: Skilled Nursing Home Care Facility 0800
Report from charge nurse:
Situation: Mrs. Morrow is an obese, 80-year-old white female who developed a venous stasis ulcer on
her right medial malleolus while still living at home. She moved into our skilled nursing home care
facility 3 days ago. The current plan of care is focused on promoting wound healing, improving venous
return, and preventing skin breakdown.
Background: Mrs. Morrow has a past medical history of chronic obstructive pulmonary disease (COPD),
chronic venous insufficiency, and deep vein thrombosis (DVT). Peripheral arterial disease is ruled out by
duplex ultrasound. Her daughter had her admitted to this skilled nursing home care facility due to
concern for her safety with impaired mobility, an unhealthy diet, and inability to adequately care for
herself at home.
Assessment: Mrs. Morrow is alert and oriented, but sometimes forgetful of recent events. Vital signs
have been within normal limits and are performed weekly. Results from yesterday's labs are in the chart.
She is on a regular diet with nutritional supplement and has been eating the majority of her meals since
admission. She requires assistance with positioning in bed and assistance times 1 to get out of bed to
the chair or ambulate. Her gait is unsteady, and she is easily fatigued. Her Braden Scale score is 16, and
her skin is intact except for the venous stasis ulcer on the right medial malleolus. She has brown
hyperpigmentation on both lower legs with +2 edema. The venous stasis ulcer is covered with a
hydrocolloid dressing, which is due to be changed. In preparation for her dressing change, she was
medicated for pain half an hour ago.
Recommendation: You should complete a basic assessment, review the labs, perform a wound
assessment and dressing change, and then reposition the patient to optimize venous return. Please
provide patient education on improving venous return to prevent further stasis ulcers, and continue
compression therapy with the use of elastic bandage and an antiembolism stocking.
Patient Details
Patient Data: Female, White, 80 years. Weight: 90 kg (198 lb), Height: 160 cm (63 in.)
DOB: 02/23/XX
Allergies: Penicillin
Immunizations: Up to date
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Josephine Morrow
Past Medical History:
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COPD
DVT 5 years ago
Provider’s Orders
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Admit to skilled nursing home care facility
Vital signs once a week
Diet: Regular, with nutritional protein supplement twice daily
Activity: Out of bed ad lib., keep legs elevated
Labs: CBC, BMP, total protein, albumin, and prealbumin monthly
Hydrocolloid dressing to right lower leg ulcer
Change dressing every 3 days; clean and irrigate wound with normal saline
Antiembolism stocking to left leg (knee-length) and elastic bandage to right leg
Medication:
o Multivitamin one tablet orally daily at 0900
o Zinc supplement one tablet orally daily at 0900
o Aspirin 81 mg orally daily at 0900
o Albuterol inhaler 360 mcg prn for wheezing
o Acetaminophen 650 mg orally every 6 hours prn pain
Call orders:
o HR less than 60/min, greater than 120/min
o RR less than 10/min, greater than 30/min
o SpO2 less than 92%
o Systolic BP less than 90 mm Hg, greater than 160 mm Hg
o Diastolic BP less than 50 mm Hg, greater than 95 mm Hg
o Temperature less than 36 °C (97 °F), greater than 38.5 °C (101.4 °F)
Nursing Diagnoses
Impaired Skin Integrity related to physical immobilization, altered venous circulation, and
obesity
Defining characteristics:
 Right lower leg skin ulceration
 Skin hyperpigmentation of lower extremities
 Edema
 Decreased mobility
Impaired Physical Mobility related to activity intolerance and decreased strength
Defining characteristics:
 Reluctance to attempt movement
 Decreased muscle strength and movement
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vSim for Nursing | Fundamentals
Josephine Morrow
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Fatigue
Requires assistance for bed mobility, transfer, and ambulation
Deficient Knowledge related to unfamiliarity with information resources on improving venous
return and preventing venous stasis ulcers
Defining characteristics:
 Lack of knowledge on benefits of leg positioning, activity, and compression therapy
 Unfamiliar with the use of antiembolism stockings
 Lack of recall on keeping legs elevated and increasing mobility
Risk for Infection related to impaired skin integrity, altered venous circulation, and poor
nutrition
Overview of Proposed Correct Treatment
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Wash hands, introduce self, and identify patient
Obtain vital signs, including asking about allergies and pain level
Check the provider’s orders, diagnostics, and medication administration record (MAR) in the
electronic health record (EHR)
Assess dressing, remove dressing
Assess ulcer, irrigate ulcer
Apply new dressing
Apply elastic bandage and antiembolism stocking on patient’s legs
Provide patient education on wound care and improving venous return
Position patient with elevated legs
Case Considerations
This patient is an obese, 80-year old female in a skilled nursing home care facility with a venous stasis
ulcer. The students are expected to assess the leg wound, assess the patient's pain, and perform a
dressing change. The students are also expected to assess lab values, and provide patient education on
interventions to promote venous return. Venous stasis ulcers occur in the lower extremities from
impaired venous circulation and are usually shallow with an irregular shape over bony prominences,
particularly the medial malleolus. Hypertension in the venous system of the legs can lead to pain,
edema, varicose veins, skin changes, dermatitis, hyperpigmentation, and venous stasis ulcer formation.
The most important aspect of venous ulcer treatment is prevention with adequate compression therapy,
using an elastic bandage and antiembolism stocking, and optimizing venous return. The surrounding skin
should be inspected daily, and kept clean and well lubricated. Legs should be elevated above the heart
to reduce edema.
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