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Integ > Venous and Arterial Insufficiency > Flashcards

Venous and Arterial Insufficiency Flashcards

1
Q

70–90% of all LE ulcers; Managed conservatively Recurrence rate of up to 97%; 91% can be resolved by conservative measures

A

Venous insufficiency ulcers

  • recurrence correlated with patient nonadherence
  • 15-25% of VI is combined with arterial insufficiency
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2
Q

Carries majority of blood back to heart; Located in the calf

A

Deep veins

  • femoral, popliteal, tibial
  • Usually malfunction before superficial veins
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3
Q

connect deep and superficial veins

A

Perforating

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4
Q

Drain skin and subcutaneous tissues; Assist with temperature regulation;More easily damaged

A

Superficial veins

  • grater and lesser saphenous
  • thinner, more flexible and extensible
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5
Q

What does proximal flow of venous blood rely on?

A
  1. Respiratory pump - inspiration – diaphragm descends causing decreased thoracic pressure and increased abdominal pressure, pushes blood from abdominal veins to thoracic veins to right atrium
  2. Calf muscle pump - inspiration – diaphragm descends causing decreased thoracic pressure and increased abdominal pressure, pushes blood from abdominal veins to thoracic veins to right atrium
  3. Valves - prevent retrograde blood flow and increased venous pressure (venous HTN)
  • 90 mmHg downward pressure in standing as compared to 5-15 mmHg upward pressure
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6
Q

What causes venous insufficiency?

A

Sustained venous HTN:

  1. Veins become incompetent and lose elasticity
  2. Damaged valves that cause retrograde blood flow - Damaged by trauma and inflammation
  3. Calf muscle pump is ineffective - Sedentary lifestyles or jobs, deconditioned patients
  • Treat with weight loss, move around more, elevate legs, avoid long periods of sitting and standing
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7
Q

What are risk factors for developing a venous ulcer?

A
  1. Vein/valve dysfunction
  2. Calf muscle pump failure
  3. Trauma
  4. Previous venous ulcer - 97% recurrence rate
  5. Advanced age - 7x increase >65 years
  6. Diabetes - poor control of sugars adverse affect on wound healing
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8
Q

What are the signs of venous disease?

A
  1. Pain, heaviness, fatigue
  2. Varicose veins
  3. Swelling
  4. Hemosiderin staining - reddish brown color stained skin
  5. Lipodermatosclerosis - thick hard tight tissue, fibrin and lipid deposits, characterized by extremely smooth skin that turns brown in color
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9
Q

What are PT tests and measures for VI?

A
  1. Clinical Assessment for DVT - Doppler Ultrasound; Well’s Clinical Prediction Rule
  2. Venous Filling Time
    - need to know pt’s ABI to rule in/out AI
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10
Q

What are the parameters for ABI?

A
  • Normal 0.9-1.1 = Ok for compression
  • Mild AI 0.7-0.9 = Still ok for compression
  • Moderate AI 0.5-0.7 = Only light compression – never multilayer bandage
  • Severe AI <0.5 = Compression totally contraindicated!!
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11
Q

What are the characteristics of venous ulcers?

A
  1. Mild to moderate pain
  2. Pain decreased with elevation or compression
  3. Medial knee to ankle most common
  4. Irregular shape
  5. Beefy red wound bed with little slough
  6. Weepy and wet, copious drainage
  7. Periwound area = Swelling, hemosiderin staining, lipodermatosclerosis
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12
Q

What should compression parameters be at ankle? knee?

A

30-40 mm Hg at ankle
10-15 mm Hg at knee
- If severe VI, can increase up to 50-60 mm Hg
- If mild AI, can decrease to 20–30 mm Hg

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13
Q

What are contraindications to compression?

A
  1. ABI <0.5
  2. Acute infection
  3. Pulmonary edema
  4. Uncontrolled or severe CHF
  5. Active DVT
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14
Q

What are the types of compression?

A
  1. Short stretch bandage
  2. Long stretch or multilayer bandage
  3. CircAid
  4. Compression stockings
  5. Pneumatic pump
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15
Q

Non-elastic; High working pressure, low resting pressure; Use spiral or figure 8; technique; Can be used for VI with moderate AI or if lymphedema is also present; 60% extensibility of original length; Only works with ambulation, works with you

A

Short stretch bandage

- example = unna’s boot

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16
Q

Treatment of choice for venous ulcers; High resting pressure; Continual compression even at rest; 140% extensibility of original length; 40mm Hg graduating to 17mm Hg at knee

A

Long stretch or multilayer bandage

- can’t be used with moderate or severe AI

17
Q

what are the layers of the long stretch/ multilayer bandage?

A

1st layer absorbs excess wound drainage and provides padding - felt
2nd layer absorbs drainage – gauze wrap
3rd layer provides increased compression – ace wrap
4th layer – sticks to itself (coban)

18
Q

Removable, semi-rigid orthotic; Rows of nonelastic Velcro straps that provide sustained compression; Newer versions are easier to customize based on size of leg

A

CircAid

19
Q

Used for long-term management; Off-the-shelf and custom garments; Most garments range from 20–60 mm Hg (at the ankle); Use lowest effective level of compression possible; Most often require donning aids; Wear garments at all times except while sleeping and bathing

A

Compression stockings

20
Q

Bilayered, multichambered sleeve; Slides over extremity and attaches to pump; Sequentially fills and empties; Used if there is also lymphedema

A

Pneumatic pump

21
Q

What are therapeutic exercises used to improve VI?

A
  1. Range of motion exercise - improve calf muscle pump function
  2. Aerobic exercise - improve respiratory pump function and possibly calf m. pump; also weight loss if needed
  3. Gait and mobility training - safety
22
Q

What are surgical interventions for VI?

A
  1. debridement
  2. skin grafting and skin substitutes
  3. vein surgery - vein ligation (tying off), vein stripping (surgical resection of varicosities), sclerotherapy (injection of an agent to scar dysfunctional veins), endoscopic procedures (SEPS and PAPS)
    - Doesn’t work for system wide disease
23
Q

Arterial insufficiency ulcers account for ____% of all LE ulcers. More than 80% of patients with PAD are ______.

A

5-10%; current or former smokers

24
Q

What causes AI?

A

Arterial ulcers are caused by decrease in arterial blood supply:

  1. Arteriosclerosis
  2. Trauma
  3. Acute embolism
  4. Diabetes
  5. Buerger’s disease - similar to arteriosclerosis, young adults who smoke heavily
25
Q

First signs of AI; Discomfort with activity due to local ischemia; Pain stops within 1–5 minutes of ceasing the provocative activity; Pain is described as cramping or burning; ~50% stenosis

A

Intermittent claudication

26
Q

Burning pain ; Exacerbated with elevation and relieved by dependency; ~70% stenosis; AI ulcers more likely

A

Ischemic rest pain

  • represents even more severe AI than intermittent claudication
  • pain during rest
27
Q

What are risk factors for AI?

A
  1. High cholesterol (LDLs) - enhances cholesterol deposition within vessel walls
  2. Diabetes – vessel walls accumulate calcium, hyperglycemia decreases all phases of healing
  3. Systolic HTN more damaging than diastolic – repetitive wave of higher pressure during contraction vs. sustained lower levels
  4. Trauma – (1) Mechanical (excessive pressure from shoes, stubbed toe); (2) Chemical – OTC agents – corn removers; (3) Thermal – c/o cold legs/feet – heating pads or soaking feet in hot water
  5. Age – slower immune and inflammatory response, skin more susceptible to trauma
  6. Smoking
28
Q

What are PT tests and measures for AI?

A
  1. Pulses
  2. Capillary Refill
  3. Ankle-Brachial Index
  4. Rubor of Dependency
  5. Venous Filling Time
29
Q

What are possible vascular interventions for ABI levels of mild, moderate, severe, and rest pain/ gangrene?

A 
.7-.9 = Mild - conservative interventions
.5-.7 = moderate - may perform trial of conservative care; physician may consider revascularizatino
30
Q

What are the characteristics of AI ulcers?

A
  1. Severe pain
  2. Pain increased with elevation
  3. Distal toes, dorsum of feet, and areas of trauma are most common
  4. Regular shape
  5. Pale granulation tissue, black eschar, or gangrene
  6. Little or no drainage
  7. Decreased or absent pedal pulses
  8. Decreased temperature
  9. Periwound thin, shiny skin with no hair
31
Q

What are the interpretations of venous filling time?

A

< 5s = venous insufficiency
5-15s = normal
>20s = arterial insufficiency

32
Q

What are the keys to wound care with AI ulcers?

A
  1. moisture dry skin
  2. avoid adhesives
  3. reduce friction btwn toes
  4. provide padding to protect ischemic tissues

Address wound bed: choose dressings to moisten wound bed; decried necrotic tissue if appropriate

33
Q

What are the steps to do a rubor of dependency test?

A

Step 1: Supine position note color of plantar foot, elevate LE 60 degrees for 1 min., again note color of plantar foot
- Pallor after 30 sec to 1 min. = mild or moderate arterial insufficiency
- Pallor within 25 sec = severe arterial insufficiency
Step 2: Bring foot into dependent position and record how long it takes to return to its original color
- A bright red color (rubor) with step 2 = severe arterial insufficiency

34
Q

What are therapeutic exercises for AI ulcers?

A
  1. Gait and mobility training
  2. Patient positioning
  3. Aerobic exercise
  4. Resistive exercise
  5. Flexibility exercise
35
Q

What are the modalities used for AI?

A
  1. Hydrotherapy/Whirlpool
  2. Therapeutic heat
  3. Ultrasound
  4. Electrical stimulation
  5. Hyperbaric oxygen
  6. Negative pressure wound therapy (VAC)
36
Q

What is healing time for full thickness venous ulcers with appropriate interventions?

A

Avg 8 weeks

  • smaller ulcers = 5-7 weeks
  • larger ulcers = 10-16 weeks
37
Q

What are interventions for patients with VI ulcers

A
  1. treat wound - inflammation control, infection control, absorb drainage, debridement
  2. treat periwound - moisturize, infection control, absorb drainage debridement
  3. healthcare team and pt address co-morbidities
  4. educate pt/ caregiver
  5. treat cause - venous HTN, compression, sx if needed
38
Q

Pressure in the arterial system is ____ mm Hg in the larger vessels, ____ mm Hg as blood passes through capillaries, and ____ mm Hg as returns to right atrium

A

90–100; 25–35; 0

  • Oxygen and nutrients flow via capillaries from the blood into the tissues

Integ (11 decks)

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