Kelly Spong, RN, BSN, MBA, CWOCN, CHRN & Sandra Macfarlane ... de Compression - The Acrobratics of... · Chronic venous insufficiency accounts for 70% of leg ulcers (mostly female)

Kelly Spong RN BSN MBA CWOCN CHRN amp Sandra Macfarlane PT DPT

List the characteristics of lower extremity ulcers

Compare and contrast arterial and venous leg ulcers

Verbalize what an ABI test is and what the results indicate

Chronic venous insufficiency accounts for 70 of leg ulcers (mostly female)

Arterial insufficiency accounts for 10 Mixed disease accounts for 10-15 of the

ulcers Other trauma neoplasms etc

General appearance of the limb Edema color changes elevational pallor dependent

rubor skin temperature Perfusion capillary refill time le3 seconds Skin temperature Pulses Ankle-brachial index (ABI) Toe-brachial index (TBI)

Sensory function Range of motion Pain

Extravasation of the skin and underlying tissues and structures from ischemia due to insufficient perfusion to an extremity or location

Atherosclerosis is the most common cause (thickening and decreased elasticity of the arterial walls)

Accumulation of plaque fibrin platelets and cellular debris in arteries

Diabetes and smoking accelerates development of atherosclerosis

Hyperlipidemia and hypertension contribute to the development of atherosclerosis

Pain Pain with exercise Rest pain with elevation Decreased pain with limb in dependent position

Pulse Diminished or absent

Pallor Pallor with elevation Dependent rubor Skin appears shiny smooth and hairless Thickened yellow nails

Gangrene Gangrene wet or dry

History and physical Ulcer Location distal lower leg (usually ankle area down) Pulses proximal an distal (may be weak to absent) ldquopunched outrdquo appearance and wound edges Pale or necrotic ulcer base Usually deeper in nature Minimal exudate Infection common Surrounding skin (erythema possible induration or

cellulitis) More common in males

Non-invasive Ankle-brachial index normal= 10-095 Mild insufficiency= 094-074 Moderate insufficiency= 074-050 Severe insufficiency= below 05

Toe pressures (should be done with DM) Dopplers with waveforms Transcutaneous oxygen tension Pulse volume recording Segmental pressure recordings Color duplex imaging

Invasive Angiography (arteriogram)

Manage cause and correct underlying pathology Revascularization (bypass grafts angioplasty) Control diabetes (monitor routinely HgA1c) Lifestyle changes (smoking obesity caffeine BP) Therapies HBO proper wound care Pharmacotherapy (antiplatelet vasodilators

antilipemics analgesics)

Impaired return of venous blood from the tissues to the heart Aka Lower extremity venous disease (LEVD) More common than arterial 70-90 of leg ulcers Female dominant Valvular incompetence results in venous congestion Obstruction of deep venous system Calf muscle dysfunction

Venous System Veins Deep veins-femoral popliteal tibial Superficial veins- greaterlessor saphenous Perforator veins

Location Medial aspect of the lower leg and ankle Superior to medial malleolous Seldom occur on foot or above knee

Wound appearance Irregular wound margins Granulation frequently present Usually shallow in depth Exudate usually moderate to heavy

Surrounding skin Erythema Cellulitis Hemosiderin staining

Painpulse Minimal unless infected Present

Patient history Lower extremity characteristics Edema Hemosiderosis Dermatitis Atrophie blanche (picture) Varicose veins Ankle flaringvisible capillaries in sunburst pattern Scaring Tinea pedis (athletes foot) Lipodermatasclerosis (picture)

Non-invasive Ankle brachial index (to rule out arterial or mixed

disease) Toe pressure Doppler

Invasive Venography uses dye

Gold standard Compression Therapy Provide gradient pressure from ankle to knee Ranges in compression from 20-60 mm HG LEVD needs at least 30-40 mm Hg at ankle Contraindicated with moderate to severe arterial disease

ABIrsquos must be done prior to compression Normal ge10-13 Borderline le06-08 Severe ischemia le05 Critical limb ischemia le04 gt13=abnormally high typically due to calcification of

vessel wall in patients with DMmdashneed to perform TBI

Physical therapy and exercise Eliminate edema Weight control Pharmacologic Trental-reduces capillary

plugging Topical Therapy absorb drainage Treat dermatitis protect periwound skin Prevent recurrence

• Cirque de CompressionLower Extremity Ulcers Arterial and Venous
• Objectives
• Lower Extremity ulcers
• Assessment of the lower extremity
• Arterial leg ulcers
• Peripheral Arterial Disease
• Characteristic of arterial insufficiency
• Assessment
• Diagnostic tests
• How to manage arterial ulcers
• Venous Disease
• Venous leg ulcers characteristics
• Assessment of LEVD
• Diagnostic Tests
• How to manage LEVD
• LEVD management continued
• Compression options
• Questions