Common Lower Extremity Wounds: What about Compression

10/9/2015

Differential Assessment of Lower Extremity Wounds Presented by: Lynn Peterson RN, BSN, CWOCN 3M Health Care November 3, 2015

Disclosure Statement

Lynn Peterson is employed by 3M Health Care, Critical & Chronic Care Solutions Division

as a Product Service Specialist

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

10/9/2015

Etiology – leg ulcers treated

72% 8% 14% 6% venous arterial combined other

Do you know the difference?

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.

10/9/2015

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.

Lower Extremity Arterial Insufficiency (LEAD)

& Arterial Ulcers

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

10/9/2015

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

Risk Factors

• Atherosclerosis • Diabetes • Smoking • Age • Hyperlipidemia • Genetics • Hypertension

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

10/9/2015

Characteristics of arterial insufficiency (continued) • Atrophy of skin • Shiny, thin, taut, dry • Hair loss on lower extremity • Localized edema • Dystrophic nails

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.

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

10/9/2015

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)

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

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?

10/9/2015

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

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

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

10/9/2015

Lower Extremity Neuropathic Disease (LEND)

& Diabetic Foot Ulcers

Lower Extremity Neuropathic Disease (LEND)

LEND Autonomic

dysfunction & loss of

sensation

Lower-extremity

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.

10/9/2015

Risk factors

Diabetes Advanced age Impaired glucose tolerance Family history Smoking Hypertension, obesity, Raynaud’s disease Spinal cord injury Trauma to lower extremity

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

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,

Sensory neuropathy 9 Loss of protective sensation 9 Numbness, burning, tingling

pain/sensation 9 Loss of vibration and

positional sensation, sensory ataxia

10/9/2015

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

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

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!

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

Patient & family education

• Offloading • Wound care • Routine foot surveillance/daily foot inspection • Appropriate footwear • Pain management • Nutrition/glycemic control • Smoking cessation

10/9/2015

Lower Extremity Venous Disease (LEVD)

& Venous Leg Ulcers

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

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

10/9/2015

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

Clinical conditions present with LEVD

• Edema • Wound drainage • Pain • Periwound margins • Skin changes • Maceration

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

10/9/2015

Effect of Chronic Edema in Lower Extremities – Clinical Presentation

Maceration

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

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

10/9/2015

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

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

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

10/9/2015

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

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

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

10/9/2015

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 ?

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

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

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