1. 1-1.3 arterial calcification- refer to MD 0. 9-1.1 normal 0. 7- 0.9 mild to mod 0. 5-0.7 mod with claudication 0. 5 or less- severe with rest pain 0. 3 or less gangrene and rest pain

Vascular Leg Ulcers Flashcards by Jared winston

What parts of exam can give you an indication if they have an arterial wound?

PMH: diabetes, HLD, HTN, smoking, syncope

pulses, lack of hair, location of wound

risk factors: sedentary life, age, family history, obesity

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Are arterial or venous ulcers more common?

arterial are less common however more serious

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What are clinical symtpoms of arterial ulcer?

cold skin, trophic changes, intermittent claudication, pain increased with elevation (usually in calf), nocturnal pain or at rest, decreased pulses and ABI, pallor with elevation, delayed cap refill, rubor with dependency

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What is the cause of intermittent claudication?

due to local iscehmia, can also cause muscle cramp

pain is usually distal to occlusion site

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What is ischemic rest pain?

burning pain, nerve ischemia, exacerbated with elevation relieved with dependency

arterial ulcers more likely if you have rest pain

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What is the best test for arterial insufficiency?

ABI is best and others can support findings

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What is palpation of pulse grades system?

0= no pulse
1+ = barely perceptible, weak pulse
2+= normal
3+ = moderately increased
4+ = stronger than normal, possible aneursym

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What is rubor of dependency?

indirectly assesses arterial blood flow

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What is procedure or rubor?

elevate legs in supine to 45-60 degrees for one minute observing plantar surface

return to starting position or more dependent to and time how long for color to return

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What are norms for rubor?

normal- 15-20 seconds with little or no color change

severe AI over 30 seconds and dark red due to reactive hyper anemia

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What is elevation of pallor?

can coincide with rubor and is also predictor of AI

only difference is your monitoring color change during elevation

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What are norms for pallor?

normal- no change
mild AI- pallor w/ 45-60 seconds
mod- pallor within 30-45 sec
severe- pallor with 25 seconds

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What is cap refill?

indicates surface arterial blood flow

hold big toe for 3 seconds and watch how fast it returns color

normal less than 3 seconds

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What are ABI norms?

1-1.3 arterial calcification- refer to MD
9-1.1 normal
7- 0.9 mild to mod
5-0.7 mod with claudication
5 or less- severe with rest pain
3 or less gangrene and rest pain

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At what ABI level is compression contraindicated?

0.7 or below it is contraindicated

if 0.7-0.9 low to medium compression may be used

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What are clinical features of arterial wound?

punched out/symmetrical, often necrotic dry wound bed, very painful, atrophy of calf muscle

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What is usual location of arterial wounds?

pretibial area, dorsum of toes and feet, lateral malleolus

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Can sharp debridement be done with these pts?

no, PAD is contraindication

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Tx for arterial ulcers?

treat underlying cause, enhance blood flow with exercise walking surgery, enzymatic debridement

HBO, NPWT- if min exudate and free of dry necrotic tissue

proper footwear

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What is very important for practical when describing to pts how walking will help?

you will have pain but as long as its not excruciating you have to push through as it will help

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How will therex for arterial ulcers?

patient positioning- no elevation

flexibility- tight muscles constrict vessels

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What are areas for pt education?

modify risk factors, protect against trauma, bed rest- elevate hob 5-7 degrees, PROM, resting splints

What is prognosis?

consider size but should see 20-40% increase within 2-4 weeks

What are stats of VI?

9.4% of people have CVI, 70-90% of venous ulcers caused by CVI

women 3x greater risk likely due to less muscle mass

risk is 7.5 greater after 65

recurrence rate -13-81%

Why is re-occurence rate so high?

CVI and VU need to be treated by constant management of it, so any non adherence could have large effects

What are common causes of CVI?

sustained venous HTN, vein dysfunction, calf muscle muscle pump failure fibrin cuff theory, white blood cell trapping theory

What are risk factors for Venous wounds?

hx of varicose veins or surgery, DVT, pregancy, trauma, age, obesity, lower extremity dependence

How does venous HTN start?

1. retrograde venous blood flow- veins stay open due to pooling of blood therefore loss of valve function 2. venous distention 3. venous htn

What are clinical features of venous ulcers?

hemisoderin, proximal to medial malleolus, edema, large amount of exudate, palpable pulse

What are clinical assessment tests for VU?

1. clinical assessment for DVT 2. Venous filling time 3. ABI

What is venous refill time?

predictor of venous or arterial insufficiency patient long sits or over edge of table elevate 60 degrees for one minute record time for veins on dorsum on foot to refill

What are norms for venous refill?

normal- 5-15 seconds VI- less than 5 AI- greater than 20

Why do an ABI if venous ulcer is suspected?

AI and VI coexist in 15-25% of all LE ulcers also to see if they are appropriate for compression

When can you not do an ABI in venous ulcer?

if they have a DVT

What is the CVI classification?

``` 0- no signs of venous dz 1- spiders veins less than 3 mm 2- varicose veins greater than 3 mm 3- leg edema 4- skin changes 5- healed ulceration 6- active ulceration ```

What is prognosis for VI ulcer healing?

avg 8 weeks small ulcers- 5-7 wks large 10-16

What is most important factor for VI healing?

adherence with compression

When would you refer to MD?

dvt score over 3, wounds that don't heal, infxn suspected

What is main treatment for VI ulcer?

compression, compression, compression unless contraindicated from ABI elevation, restore muscle pump

What is another important part about treatment?

educate pt about etiology so they buy into adherence, connect why their condition has led to current state, risk factors etc.

What is the physiology of compression?

reduce diameter of veins, increases cardiac preload and after load (careful with CHF) decreases edema

What are important components about process of compression?

must be graduated, adequate, sustained, most compression at foot least at knee Ankle circumference must be less than calf

What are contraindications to compression?

ABI less than 0.7, infxn, pulm edema, uncontrolled CHF, active DVT

What are three types of compression?

elastic systems- long stretch inelastic- short stretch, unna boot multilayer

What are lower extremity compression standards?

``` class 0- less than 20 mmHG, non-ambulatory pts class 1- 20-30 mmHG- mild venous class 2- 30-40 mmHG mod venous class 3- 40-50 mmHG severe venous class 4- over 50 mmHG severe ```

What should pressure of compression be at ankle?

30-40 mmHG

For four layer compression what is inner layer for?

absorbs excess wound drainage, provides padding

For four layer what is middle layer for?

absorbs drainage

For four layer what are outer two layers for?

increased compression and can be re used

When is the best time to put on compression?

in the morning and have pts elevate legs prior to wrapping

What is the average healing time for an ulcer using a four layer bandage?

70-110 days

What is the pressure of TEDS?

usually 20-55 mmHG

What is an important concept to remember about compression?

ideally you should use lowest effective level of compression usually leads to better compliance

Will a stocking prevent edema from occuring with patients who have CVI?

No but it will help them maintain current level of edema