Exam 2: Week 8, Arterial/Venous Flashcards
List the different types of ulcers
- Arterial
- Venous
- Diabetic/neuropathic
- Mixed
- Other
What do the abbreviations PAD, PVD, CVI, and CAD mean?
- Peripheral artery disease
- Peripheral vascular disease
- Chronic venous insufficiency
- Coronary artery disease
What are the risk factors for arterial disease?
Arteriosclerosis, HTN, Smoking, Diabetes, Hyperlipidemia, CVD/CAD, Sedentary lifestyle, Advanced age, Family history, Obesity, Trauma
What are some clinical symptoms of arterial disease?
- Decreased skin temp
- Cyanosis
- Intermittent claudication
- Dry, scaly, or shiny skin
List and describe the 3 types of arterial insufficiency
Arterial Insufficiency Ulcer
- Ulceration and gangrene result when oxygen requirements of local tissue exceed perfusion
- Most common due to trauma
- Can be spontaneous
Intermittent Claudication
- Pain occurs during activity, but feels better at rest
- Activity specific discomfort due to local ischemia (lack of blood)
- Pain is typically described as cramping, burning, fatigue
Ischemic Rest Pain
- “Burning” pain
- Becomes worse with elevation, but relieved by dependency
- If the patient’s arteries are 70% narrowed (stenotic), he/she will typically have ischemic rest pain
Differentiate between arterial and venous ulcers
Arterial Ulcers:
- Location: Lower leg, foot/ankle
- Appearance: Small, deep hole (sometimes w/necrotic base)
- Peri wound: Dry, pale, shiny, hairless
- Risk Factors: Atherosclerosis, smoking, diabetes, high BP
Venous Ulcers:
- Location: Lower leg, foot/ankle
- Appearance: Irregularly shaped, shallow w/granulation tissue
- Peri wound: Dark, swollen, warm
- Risk Factors: Usually linked to poor varicose veins. Pregnancy, obesity, history of blood clots
List and describe the stages of Rutherford’s classification of peripheral artery disease
Stage 0: Patient is asymptomatic
Stage 1: Mild intermittent claudication is present
Stage 2: Moderate intermittent claudication is present
Stage 3: Severe intermittent claudication
Stage 4: Ischemic rest pain is present
Stage 5: Patient has minor tissue loss
Stage 6: Patient has major tissue ulceration/gangrene
List and describe the pulse scale
0: Absent pulse
1+: Thready pulse
2+: Weak pulse
3+: Normal pulse
4+: Strong/Pounding pulse
Describe the capillary refill test
Compress fleshy part of big toe until it blanches (turns white)
- Should return within 3 seconds for capillary refill
Describe the rubor of dependency test
Elevate legs while supine for 45-60 seconds, then return to a normal position
Check plantar surface of foot to observe how long it takes for it to become pink again
- Normal: 15-20 secs
- Severe Arterial Insufficiency: >30 seconds or dark red
Describe the “elevation pallor” part of the rubor of dependency test
Limb is elevated 45-60 degrees for 60 seconds, then observe the color change
Normal: No change in color
Mild Occlusive Disease: Pallor within 45-60 seconds
Moderate Disease: Pallor within 30-45 seconds
Severe Disease: Pallor within 25 seconds [anticipate rubor (redness) when foot is not elevated]
Describe the ABI test
A test that measures the blood pressure difference between the arm and ankle
(use posterior tibial artery or dorsal pedis artery when checking pulse)
To get the number, divide the ankle systolic pressure by brachial systolic pressure
1.1 to 1.3: Vessel calcification
.9 to 1.1: Normal
.7 to .9: Mild to moderate arterial insufficiency
.5 to .7: Moderate arterial insufficiency, intermittent claudication
<.5: Severe arterial insufficiency, rest pain
<.3: Rest pain and gangrene
Describe the appearance of an arterial wound
Will look like a small hole
- “Punched out”
- Well defined wound edges
- Wound bed is often necrotic, dry, pale
- Very painful
- Peri wound may have edema
- Pallor with elevation
What are some precautions and contraindications of arterial ulcers
- SHARP DEBRIDEMENT
- Compression
- Adhesive dressings
- NPWT (because it is dry)
- Non healing ulcer (referral will be needed)
- Risk of infection (can be subtle or silent)
A classification system that can be used to classify arterial and diabetic ulcers is called
Wagner scale
What is the Marion scale used for?
To assess the color
How should you treat an arterial wound?
- Enhance blood flow by exercise, walking, referring patient to surgeon if ABI is <.5
- Enzymatic/autolytic debridement, pulse lavage (NO SHARP)
- HBOT
- Proper footwear
- Patient positioning
- Flexibility exercise
- BuergerAllen exercises
(always monitor vitals)
How would you educate a patient with an arterial wound?
- Modify risk factors (smoking, health habits, etc.)
- Protect against external trauma
- Head of bed (HOB) elevated 5-7 degrees (helps blood reach the lower extremities)
- Heat to femoral triangle
- Lubricate skin to avoid cracks and fissures
How is a prognosis determined with an arterial ulcer?
- Consider wound size/depth
- Consider local tissue perfusion
- Whether or not physical therapy is needed
What are the 4 types of surgical intervention with arterial wounds? (DON’T SPEND TOO MUCH TIME ON THIS)
- Debridement
- Revascularization
- Angioplasty
- Amputation
T or F? Arterial ulcers are less prevalent, but more severe compared to venous ulcers
True
T or F? 10 to 15% of adults in the US have chronic venous insufficiency (CVI)
True
T or F? 25% of leg ulcers are due to venous insufficiency
False, 70-90%
What do AI and VI stand for?
Arterial insufficiency, Venous Insufficiency
T or F? Women have a greater risk of venous insufficiency due to pregnancy
True
What are the common causes (etiology) of venous insufficiency (VI)?
- Venous hypertension
- Vein dysfunction
- White blood cell (WBC) trapping theory
- Fibrin cuff theory
List some risk factors for developing a venous ulcer
- History (Hx) of varicose veins
- Venous hypertension
- DVT
- Pregnancy
- Diabetes mellitus (DM)
- Family history (Hx) of clotting disorders
- Obesity
- Lower extremity trauma
List some clinical features of venous ulcers
- Hemosiderin pigmentation
- Shallow with flat, jagged wound edges
- Proximal to medial malleolus
- Lipodermatosclerosis
- Edema
- Dermatitis of periwound area
- Localized pain
- Large amount of exudate
- Palpable pulses
- Abnormal venous refill time
- Increased time
Which tests are used to assess venous insufficiency (VI)?
ABI, Venous Fill Time, Edema measurement
What is the wells criteria?
A clinical tool used to assess the risk of DVT
What is the buerger allen exercise?
Goal: Promote blood flow
Elevate legs (60-90 degrees) for 30-80 seconds (or until blanching) while having the patient dorsi and plantarflex, then have patient dangle legs over the table for 2-5 mins until hyperemia is achieved, then add one minute
What are the 3 phases of the venous hypertension cycle?
- Venous hypertension
- Retrograde venous flow
- Venous distention
Describe the venous refill time test
The “gold standard” test to predict venous insufficiency
Have patient in a supine position, then observe the superficial veins on the dorsal aspect of the foot
AI: Blood takes >20 secs to return
Normal: Blood returns within 5-15 secs
VI: Blood takes <5 secs to return
Why is it important to take a patient’s ABI before using compression?
To make sure that the patient has adequate blood flow
For example, if a patient has PAD, he or she already has impaired blood flow to the extremities meaning if compression is applied, blood flow will restrict it even more which could lead to severe issues
Which grading system is used for pressure?
NPIAP
What mechanism is considered to be the gold standard to assessing chronic venous insufficiency (CVI) in a medical setting
Doppler Ultrasound
List the Edema Scale grades
0: No clinical edema
1+: Barely noticeable depression (<2mm)
2+: Easily noticeable depression, takes <15 secs to return to normal (2-4mm)
3+: Depression rebounds in 15-30 secs (5-7mm)
4+: Depression lasts for >30 secs (>7mm)
Describe and list the Clinical Etiology - Anatomy - Pathophysiology (CEAP) classification system
A classification system used to assess chronic venous insufficiency
C0: Asymptomatic
C1: Spider veins <3mm
C2: Varicose veins >/= 3mm
C3: Leg edema
C4: Skin and subcutaneous tissue changes
C5: Healed venous ulcer
C6: Current venous ulcer
CS: Symptoms of leg achiness, heaviness, tightness, and/or pain caused by venous dysfunction
Differentiate between pitting and non-pitting edema
Pitting Edema: When pressure is applied to skin, it will leave a dent that remains even after you remove your finger
Non-Pitting Edema: When pressure is applied to skin, it will not leave any indentation
What are the healing times for full-thickness venous ulcers with appropriate interventions?
- 8 weeks average
- 5-7 weeks (smaller ulcers)
- 10-16 weeks (larger ulcers)
T or F? Wounds that do not show signs of healing in 4 weeks should be referred back to an MD
True
T or F? If bone or capsule is exposed with a venous ulcer, he/she should be sent back to an MD
True
What are some predictors for good CVI ulcer healing?
- Smaller ulcer size
- Decreased size within the first 2-3 weeks
- No deep vein involvement
- Will adhere to compression therapy
What are some predictors for poor CVI healing
- Large ulcer size
- Ulcer present for 3 months prior to intervention
- Increased wound size after 4 weeks of intervention
- Concomitant arterial insufficiency
- Old age
- High BMI
How are venous ulcers treated?
- COMPRESSION
(reduces diameter of major veins, increases cardiac pre-load and output by 5%, reduces white cell adhesion to capillaries, increases tissue pressure and oxygen, enhances muscle pump) - Elevation (7-8 inches)
- Therex
- Antibiotics (if infected)
- NPWT
- Pulse lavage
How should compression be applied?
Sustained compression with the most at the foot, and least at the knee (moves blood back to heart)
If a patient has a low ABI of .71-.90 (mild/mod PAD), how much compression should be used?
Low to Medium compression
If a patient has an ABI of <.70 (Mod arterial disease), how much compression should be used?
Cannot use (contraindicated)
If a patient has an ABI of .9-1.1 (normal), how much compression can be used?
Any amount… Patient is healthy
What are the contraindications to compression therapy?
- ABI <.7
- Acute infection
- Pulmonary/cardiac edema
- Congestive heart failure
- Active DVT
- Claustrophobia
- Spasticity
- Complex regional pain syndrome
Explain the compression standard table
Class 0 (<20mmHg): Non-ambulatory patients
Class 1 (20-30mmHg): Mild venous insufficiency, or venous insufficiency with mild arterial insufficiency
Class 2 (30-40mmHg): Moderate venous insufficiency
Class 3 (40-50mmHg): Severe venous insufficiency
Class 4 (>50mmHg): Severe venous insufficiency (compression rarely required)
Differentiate between in-elastic systems, elastic systems, and multilayer systems
Inelastic: minimal stretch (unna boot)
Elastic: more stretch
Multilayer: combination of both
T or F? Short-stretch compression is best for ambulatory patients
True
Describe paste bandages
- Nonelastic compression
- Gauze that is impregnated with zinc oxide, calamine, glycerin, or gelatin
- Hardens into semi-rigid support
- Stays on for about 1 week
- Used on AMBULATORY patients (must encourage the patient to walk)
Describe multilayer compression bandages
Inner layer: absorbs excess drainage and provides padding
Middle layer: absorbs drainage
Outer layer: provide compression
- Reusable
- Stays in shape well
Describe compression garments
- Used for long term management
- Most garments range form 20-55mmHg (at the ankle)
- can lose shape over time (leads to innefectiveness)
- Replace every 3-6 months
- Donning aid can be used to independently put garment on
T or F? Patients with Unna boots should be walking often
True
What are the types of surgical interventions used with venous ulcers?
- Debridement
- Skin grafting
- Vein surgery (ligation, stripping, sclerotherapy, SEPS, PAPS)
T or F? The only contraindication to an ABI test is a blood clot
True
T or F? Compression pressure should be ______ to _____mmHg at the ankle, and __________ at the knee
30-40 mmHg, 10mmHg
(if patient has severe VI, increase to 40-50 mmHg at the ankle)
T or F? Unna boots and short stretch are best for ambulatory patients
True
T or F? Mixed ulcers account for 15-25% of all LE ulcers
True
T or F? The ABI assessment is contraindicated for suspected DVT (blood clots)
True
T or F? Always use wells criteria before ABI when working with a venous wound
True
