common lower extremity wounds: what about compression
TRANSCRIPT
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Differential Assessment of Lower Extremity Wounds Presented by: Lynn Peterson RN, BSN, CWOCN 3M Health Care November 3, 2015
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Disclosure Statement
Lynn Peterson is employed by 3M Health Care, Critical & Chronic Care Solutions Division
as a Product Service Specialist
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Program Objectives
• Differentiate between arterial, neuropathic and venous leg ulcerations
• Identify key risk factors for lower extremity ulcerations • List five key wound assessment parameters • Describe appropriate methods of treating lower extremity
ulcerations
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Etiology – leg ulcers treated
72% 8% 14% 6% venous arterial combined other
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Do you know the difference?
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Comprehensive bilateral lower-extremity assessment General appearance • Trophic changes 9 Thin & shiny epidermis, loss of hair growth, thickened nails (LEAD) 9 Edema, hyperpigmentation, scaly, eczematous skin (LEVD) 9 Dryness, fissures, cracks, foot deformities (LEND)
• Hair, nail, skin patterns • Veins • Skin color, shape, texture, integrity • Edema
Ermer-Seltun J. Lower Extremity Assessment. In: Bryant BA, Nix DP. In: Acute & Chronic Wounds; Current Management Concepts, 4th ED. St. Louis, MO: Elsevier Mosby; 2012:169-177.
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Comprehensive bilateral lower-extremity assessment Functional-sensory status • Gait and mobility • Range of motion of ankle joint • Pain Perfusion • Elevational pallor or dependent rubor • Skin temperature • Blood flow (bruit/thrill) • Capillary refill • Pulses • Ankle-brachial index Ermer-Seltun J. Lower Extremity Assessment. In: Bryant BA, Nix DP. In: Acute & Chronic Wounds; Current Management Concepts, 4th ED. St. Louis, MO: Elsevier Mosby; 2012:169-177.
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Lower Extremity Arterial Insufficiency (LEAD)
& Arterial Ulcers
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Lower Extremity Arterial Disease (LEAD)
Insufficient arterial perfusion from arteriosclerotic changes 9 Peripheral vascular disease (PVD) 9 Peripheral arterial occlusive disease (PAOD) 9 Lower-extremity peripheral arterial disease (PAD)
When arterial flow is diminished: 9 Minor injuries can become non-healing wounds 9 Ulcers occur often at distal locations 9 May progress to gangrene or tissue necrosis → amputation
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LEAD prevalence & significance
• 8-12 million adults ≥ 40yrs. of age • 40% in individuals ≥ 80 yrs. of age • 50-80% individuals undiagnosed, untreated or undertreated
secondary to atypical symptoms • $21 billion – US cost of treatment • $4.37 billion - US hospitalization costs Medicare eligible patients
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Risk Factors
• Atherosclerosis • Diabetes • Smoking • Age • Hyperlipidemia • Genetics • Hypertension
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Characteristics of arterial insufficiency
• Dependent rubor/pallor with elevation • Peripheral pulses – absent or diminished • ABI < 0.9 • Ischemic pain • Skin – cool or cold, thin, dry, shiny epidermis
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Characteristics of arterial insufficiency (continued) • Atrophy of skin • Shiny, thin, taut, dry • Hair loss on lower extremity • Localized edema • Dystrophic nails
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Ischemic pain
Intermittent claudication – cramping, aching, fatigue, weakness or calf pain • Pain with moderate to heavy exercise • Relieved by 10 minutes of rest • Vessel ~ 50% occluded Nocturnal pain • Pain at rest in bed, feet elevated • Relieved by lowering legs Rest Pain • Pain at rest • Legs dependent • Advanced occlusive disease Doughty D. Arterial Ulcers. In: Bryant BA, Nix DP. In: Acute & Chronic Wounds; Current Management Concepts, 4th ED. St. Louis, MO: Elsevier Mosby; 2012:p.182.
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Arterial Ulcer: Clinical presentation
• Base: pale, minimal granulation tissue, necrosis, eschar
• Exudate: minimal exudate • Size: Variable, often small • Margins: Punched out appearance,
rolled edges, smooth, undermined • Ischemic toes • Pain: common • Infection: frequent, may be subtle
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Common locations for Arterial Ulcer
• Tips of toes and web spaces • Phalangeal heads • Over lateral malleolus • Areas exposed to repetitive
pressure or repetitive trauma • Mid-tibia (shin)
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Interventions
• Vascular consult – Re-establish perfusion • Diagnostic evaluations 9 Ankle-brachial pressure (ABI) 9 Toe Pressure (TP) measurements – patients with diabetes and suspected
LEAD (indicated for ABI >1.3) 9 Transcutaneous Oxygen (TcPO2) 9 Angiography or Arteriography may be ordered
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Interventions (continued)
• Surgical intervention – bypass/ angioplasty, skin grafts, amputation • Reduce risk factors 9 Smoking cessation 9 Increased activity
• Prevent infection • Pain management: 9 Walking, specialist referral 9 Aspirin, Cilostazol, Prostaglandins?, Pentoxifylline?
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ABPI (ankle-brachial pressure index)
• A method for comparing blood pressure in the arm to blood pressure in the leg
• Reflects the degree of perfusion loss in the leg • Should be a resting pressure obtained with the
patient in a supine position
Interpretation 1.0 – 1.3 Normal range < 0.9 LEAD < 0.6 to 0.8 Borderline perfusion < 0.5 Severe Ischemia, wound healing unlikely unless revascularized
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Nursing management
• Avoid debridement until perfusion is determined • Do NOT debride dry, stable eschar • Determine proper use of antiseptics to assist with maintenance of
stable eschar • Infected, necrotic wounds 9 Refer for surgical debridement and antibiotic therapy 9 Do not rely on topical antibiotics to treat infected, ischemic wounds
• Choose appropriate dressings. May need frequent visualization and inspection of wound
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Nursing management
• Edema - patients with mixed venous and arterial disease, use reduced compression under close supervision 9 ABI >0.5 to <0.8: modified compression, 23 – 30 mm / Hg at the ankle, may
promote healing 9 ABI <0.5: compression should not be used
• Pain management • Nutritional consult • Patient/family education
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Lower Extremity Neuropathic Disease (LEND)
& Diabetic Foot Ulcers
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Lower Extremity Neuropathic Disease (LEND)
LEND Autonomic
dysfunction & loss of
sensation
Lower-extremity
ulcer
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LEND significance
Diabetes – global epidemic • 370 million people globally • 23.6 million people in U.S. • 25% lifetime risk of diabetic foot ulcer development Patients with diabetic neuropathy & wounds: 9 66% rate of relapse over 5 years, 9 12% progress to amputation
US cost of care - $174 billion/yr.
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Risk factors
Diabetes Advanced age Impaired glucose tolerance Family history Smoking Hypertension, obesity, Raynaud’s disease Spinal cord injury Trauma to lower extremity
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Lower Extremity Neuropathic Disease (LEND) Wounds
Mechanism of damage: • Peripheral Neuropathy (loss of protective
sensation) • Peripheral Vascular Disease (decreased
blood perfusion) 9Vascular changes (occlusion & calcification)
• Tissue injury
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Neuropathic damage Progressive due to uncontrolled hyperglycemia
Motor neuropathy 9 Gait, muscle weakness 9 Orthopedic deformities 9 Hammer toes, claw-toes 9 Muscle atrophy
Autonomic neuropathy 9 Decrease sweat and oil
production – dry skin 9 Loss of skin temperature
regulation 9 Abnormal blood flow in soles
of feet 9 Fissures, cracks, callus 9 Rigid arteries – ischemia,
edema
Sensory neuropathy 9 Loss of protective sensation 9 Numbness, burning, tingling
pain/sensation 9 Loss of vibration and
positional sensation, sensory ataxia
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Assessment parameters
Wound status Perfusion 9 ABI (Ankle brachial index) 9 TBI (Toe brachial index) 9 Transcutaneous oxygen (TCP02)
Screening for loss of protective sensation Pain 9 May be superficial, deep, aching, stabbing, dull, sharp, burning, or cool 9 May be worse at night
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Clinical presentation
Location • Plantar surface or areas of exposed
to trauma • Metatarsal heads • Dorsal and distal aspects of toes • Heels Base: pale, pink, necrosis/eschar Size: Varies
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Clinical presentation
Depth: Varies; partial thickness to full thickness with exposed bone Shape: Round or oblong Exudate: small to moderate • Foul odor and purulence indicate infection
Periwound • Callus common • Erythema, induration • May have dry, cracked skin or maceration
Pain • May be superficial, deep, aching, stabbing, dull,
sharp, burning, or cool • May be worse at night
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Diabetes – Common presentation
•NOTE: Neuropathic ulcers Are NOT pressure ulcers! Think of their etiology – NEUROPATHY!
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Diabetic Ulcers – Nursing management
• Wound care 9 Offloading, referral, education & support 9 Provide moist environment for healing 9 Dressing selection – periodic reevaluation 9 Maintain dry stable eschar on noninfected, ischemic wounds
• Observe clinical manifestations of infection – may be subtle due to reduced blood flow
• Optimize healing process through management of blood glucose levels • Pain management • Monitor patients receiving compression therapy due to decreased
sensation of pain • Nutritional support, control of blood glucose
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Patient & family education
• Offloading • Wound care • Routine foot surveillance/daily foot inspection • Appropriate footwear • Pain management • Nutrition/glycemic control • Smoking cessation
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Lower Extremity Venous Disease (LEVD)
& Venous Leg Ulcers
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Lower Extremity Venous Disease (LEVD)
Prevalence • 7 million individuals worldwide, 2-5% of Americans • 3 million progressing to ulceration (VLU) • Account for 80-90% of all leg ulcers • 600,000 new VLU each year • Common in women • More common in aging • $ 1.9 to 3.5 billion/year in US • 26-28% VLU reoccur within 12 months
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When damage occurs to the venous system…
• Incompetent valves • Damaged or dysfunctional veins • Impaired calf muscle pump
Chronic ambulatory venous hypertension occurs which is the
underlying cause of venous ulcers
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Impact on Quality of Life
• Decreased self esteem • Decreased mobility • Decreased functionality of affected limb • Difficulty finding appropriate clothing/shoes • Inability to manage ADL’s • Inability to work, job loss • Adverse effect on finances • Housebound • Depression • Cost to health care system and personal life disruption for repeat
admissions for cellulitis
Sen Chandan, Gordillo Gayle , Roy Sashwat, Kirsner R, et al; Human skin wounds: A major and snowballing threat to public health and the economy Wound Rep Reg (2009) 17 763-771
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Clinical conditions present with LEVD
• Edema • Wound drainage • Pain • Periwound margins • Skin changes • Maceration
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Common characteristics of the venous ulcer
• Warm, palpable pulses • Edema: usually hard, non-pitting • Characteristic location 9 Above medial malleolus 9 Calf to malleolus
• Irregular shape, margins • Dark red (“ruddy”) base • Hemosiderin staining
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Effect of Chronic Edema in Lower Extremities – Clinical Presentation
Maceration
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Dermatitis
Inflammation of the epidermis and dermis • Inside-out problem. “Only way to
heal it is to remove the edema”*
Characteristic: • Scaling • Crusting • Weeping • Erythema • Erosions • Intense itching *Dr. David Keast, Enhancing Wound Healing with Compression Therapy Presentation at Wounds International 2011, Cape Town Africa
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Dermatitis vs. Cellulitits
Dermatitis • Inflammation of epidermis and dermis
Cellulitis • Diffuse acute inflammation and
infection of the skin and subcutaneous tissues that signifies a spreading infectious process
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ABPI (ankle-brachial pressure index)
• A method for comparing blood pressure in the arm to blood pressure in the leg • Reflects the degree of perfusion loss in the leg • Should be a resting pressure obtained with the patient in a supine position
Interpretation > 1.0 Normal > 0.8 LEVD < 0.6 to 0.8 Borderline < 0.5 Severe Ischemia
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Topical therapy goals
• Control edema • Absorb exudate • Prevent trauma/injury • Identify/treat infection • Promote wound healing/maintain moist wound bed • Protect periwound skin • Minimize pain
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Optimal wound bed preparation
• Complete debridement of devitalized and poorly functioning tissue • Restoration of bacterial balance • Maintenance of optimal moisture balance • Control of edema/lymphedema • Protect surrounding skin 9 Alcohol free barrier film, ointment 9 Topical corticosteroids to reduce inflammation 9 Bland emollients for moisturization 9 Avoid fragrances, dyes
• Promote comfort
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Topical therapy
• Choose dressings to manage ulcer characteristics • Protect surrounding skin 9 Non alcohol barrier film, ointment 9 Topical corticosteroids to reduce inflammation 9 Bland emollients for moisturization 9 Avoid fragrances, dyes
• Promote comfort
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Provide Compression
• Most essential component of venous leg ulcer treatment. • Reduce edema/lymphedema by providing resistance against the
calf muscle • Improves speed of blood flow to heart • Decrease exudate/weeping of the leg • Reduces MMP’s and inflammatory cytokines • Improve wound healing • Decreases aching and heaviness of the leg
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Management of edema
In patients with mixed venous and arterial disease, use reduced compression under close supervision • ABI >0.5 to <0.8: modified compression, 23 – 30 mm/Hg • ABI <0.5: compression should not be used
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Thank You
Did I meet the objectives for this session? • Differentiate between arterial, neuropathic and venous leg
ulcerations • Identify key risk factors for lower extremity ulcerations • List five key wound assessment parameters • Describe appropriate methods of treating lower extremity ulcerations Questions ?
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References
• Ermer-Seltun J. Lower Extremity Assessment. In: Bryant BA, Nix DP. In: Acute & Chronic Wounds; Current Management Concepts, 4th ED. St. Louis, MO: Elsevier Mosby; 2012:Chapter 10.
Arterial: • A quick reference guide for lower-extremity wounds: venous, arterial, and neuropathic. www.wocn.org • Doughty D. Arterial Ulcers. In: Bryant BA, Nix DP. In: Acute & Chronic Wounds; Current Management Concepts, 4th ED. St. Louis, MO: Elsevier Mosby; 2012:
Chapter 11. • Wound, Ostomy and Continence Nurses Society. (2014). Guideline for the Management of Wounds in Patients with Lower-Extremity Arterial Disease. WOCN
clinical practice guideline series 1. Mt. Laurel: NJ. Author.
Neuropathic: • Driver VR, LeBretton Jm, et al. Neuropathic Wounds: The Diabetic Wound. In: Bryant BA, Nix DP. In: Acute & Chronic Wounds; Current Management Concepts,
4th ED. St. Louis, MO: Elsevier Mosby; 2012: Chapter 14. • Wound, Ostomy and Continence Nurses Society. (2012). Guideline for the Management of Wounds in Patients with Lower-Extremity Neuropathic Disease. WOCN
clinical practice guideline series 3. Mt. Laurel: NJ. Author.
Venous • A quick reference guide for lower-extremity wounds: venous, arterial, and neuropathic. www.wocn.org • Carmel JE. Venous Ulcers. In: Bryant BA, Nix DP. In: Acute & Chronic Wounds; Current Management Concepts, 4th ED. St. Louis, MO: Elsevier Mosby; 2012:
Chapter 12. • Wound, Ostomy and Continence Nurses Society. (2011). Guideline for the Management of Wounds in Patients with Lower-Extremity Venous Disease. WOCN
clinical practice guideline series 4. Mt. Laurel: NJ. Author.