Module 5 - Lower leg ulcers and neuro-ischaemic foot Flashcards
Types of Ulcers?
- Venous Ulcers
- Arterial Ulcers
- Mixed Venous / Arterial Ulcers
- Neuropathic
- Neuro-ischaemic
Define an ulcer?
An ulcer is a loss of skin or mucosa integrity. The most common causes of leg ulcers are associated with vascular or neuropathic disorders and are referred to as:
Arterial - involving arteries and arterioles
Venous - involving veins and venules
Mixed arterial/venous - involving arteries, arterioles, veins and venules
neuropathic - due to loss of protective sensation
Aetiology of venous ulcers
- Increased venous pressure
- increased permeability of capillaries
- leakage of fluid and macromolecules
leads to –>
venous stasis
valvular insufficiency
causing venous ulcers
Aetiology of arterial leg ulcers
- Arterial insufficiency
- arteriolosclerosis
- Emboli
leads to –>
Peripheral arterial disease Lower-extremity arterial disease Peripheral vascular disease Peripheral arterial occlusive disease
Explain neuropathic ulcers
loss of sensation - commonly on the foot
Explain neuroischaemic ulcers
loss of sensation
loss of circulation
Aims of treatment
- identify and treat precipitating cause
- promote circulation and improve venous return
- promote healing
- promote preventative care
Essential guidelines for assessment of ulcers (page 133)
- Clinical History
- clinical examination
- palpation of pedal and leg pulses - hand held Doppler ultrasound
- ankle/brachial pressure index (ABPI)
Predisposing factors of an arterial ulcer
- arteriosclerosis
- Advanced age
- Diabetes
- Hypertension
- Smoking
Associated changes in the leg?
- Thin, shiny dry skin
- Absence of hair growth
- Thickened nails
- Pallor on elevation
- Limb may be cool
Arterial ulcer locations
Over phalangeal heads Between toes or at tip of toes Above lateral malleolus Over metatarsal heads On side or sole of foot
Arterial ulcer characteristics?
Well demarcated edges
pain at rest, relieved by lowering leg to a dependent position
pain factor of arterial leg ulcer?
Exceedingly painful
Pain when legs elevated
Relieved by lowering legs
or walking
surrounding skin of arterial leg ulcer?
May have neuropathy
Thin, shiny, hairless legs
pedal pulse of an arterial ulcer?
Diminished or absent foot and leg pulses
Predisposing factor of a venous ulcer?
- History of deep venous thrombosis
- Valvular incompetence in the perforating veins
- Obesity
- deficits in calf muscle pump
*chronic constipation (Joys thing)
Associated changes in venous leg ulcers?
-Firm “brawny” oedema haemosiderin (Reddish brown pigmentation) -Evidence of healed ulcers -dilated and tortous superficial veins (Varicosities) Warm leg Hair on leg/toes
Venous leg ulcers locations?
Anterior to medial malleolus
Pretibial area
Generally lower 1/3 leg
(gaiter area)
Venous leg ulcer characteristics?
- uneven edges
- ruddy granulation tissue
- no necrotic tissue
Pain factor for venous leg ulcer?
- moderate to no pain
- discomfort relieved by elevation of leg
Venous ulcers surrounding skin?
Leaking oedema may result in maceration, pruritus and scale
Venous ulcer pedal pulses
Normal foot and leg pulses
General ulcer education/advice
Daily inspection Skin hygiene Moisturise skin Stop smoking Avoid trauma Nutritious diet Lose weight
venous ulcer education for patient
- Regular ambulation
- Calf and foot muscle exercises
- Elevate feet when sitting(above heart level)
- Elevate foot of bed
arterial ulcer education for patient
Avoid constrictive leg wear Sit with legs down in neutral position Elevate head of bed if night pain Increase exercise as tolerated Avoid trauma Regular podiatry care Avoid sudden temperature changes in feet
Consultant investigation/interventions
- management of underlying disease
- review of medications
- duplex ultrasound
- angiography/angioplasty
- chemical or surgical sympathectomy
- by-pass surgery
- amputation
Goal of treatment for arterial leg ulcers
-Pain management
-Prevent infection
-Healing if tissue perfusion
adequate
Goal of compression therapy
Improve calf muscle pump function
Improve venous return
Reduce venous hypertension
Control venous oedema
Types of bandages?
Short stretch:
cotton without elastomers, extension 40-90%,
low resting pressure
Long stretch:
contain elastomers, extension 90-140%, higher resting pressure
Systems:
a combination of short & long stretch multi-layers
ABI <0.5
- arterial ulcer
- no compression
ABI 0.5-0.7
Mixed arterial/venous ulcer
- trial bandage according to tolerance
- 20-30mm HG
- light to moderate compression
ABI 0.7-0.8
Mixed arterial/venous ulcer
- trial bandage according to tolerance
- 20-30mm HG
- light to moderate compression
ABI 0.8-1.2
venous ulcer
trial bandage according to tolerance
30-40 mm Hg
moderate to high compression
ABI >1.2
possibly calcified vessels
trial bandage according to tolerance
30-20mm Hg
moderate to light compression’
***ARTERIAL CALCIFACTION CAN GIVE A FALSELY ELEVATED ABI (USUALLY >1.2) IN WHICH CASE COMPRESSION IS USED WITH EXTREME CAUTION – SEEK FURTHER ADVISE _ sorry about the caps :)
What are the pedal pulses do you palpate in a leg ulcer assessment?
dorsalis pedis pulse (on central dorsal part of the foot)
- posterior tibial pulse (behind the medial malleolus)
- peroneal pulse (lateral dorsal part of foot
- popliteal pulse (behind the knee)
- femoral pulse (in the groin)
how do you measure a Ankle brachial pressure index?
lie down for 20-30 minutes
- palpate pedal pulse s
- record systolic BP for ankle and brachial SBP’s
brachial SBP
=
ABI
Assessments involved in Neuroischaemic exam
Doppler pressures (pedal pulses) Capillary refill test peripheral neuropathy (10 gram filament) ABI patellar and achillies tendon reflexes Duplex ultrasound Blood pathology FBC, Hb, CRP, BSL Rh factor. Angiography Venography Biopsy X ray
Foot care and advise
Daily inspection Regular podiatry visits Early report of problems Wash feet daily Avoid extremes of temperature Wear shoes Moisturise but not between toes Cotton socks Buy shoes in afternoon & wear in gradually
