4 - arterial & venous ulcers
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Arterial
and
Venous
Ulcers
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Arterial and Venous Ulcers
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Arterial Ulcer Epidemiology
Leg ulcers occur in approximately 1% of the population at some point in their lives
About 25% of these ulcers are arterial origin
Associated with claudication, rest pain, gangrene and localized ulceration
Located almost exclusively in the distal lower extremity
Ischemia is common especially with smokers, Diabetes and in elderly
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Leg ulcers
Concern of the cost
Pain & suffering
Body image change
Struggle for control, independence
Depression, isolation
Social Issues
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Arterial & Venous Ulcer Goals
Understand the pathogenesis (underlying medical problems)
Accurate assessment – differentiate between venous, arterial, mixed etiologies
Identify and manage risk factors to facilitate prevention and early intervention
Management of ulceration – underlying etiology(cause) & wound
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Arterial UlcersArterial UlcersResult of Reduced Blood Supply due to:Result of Reduced Blood Supply due to:
Emboli - leads to infarction &ischemia
Atherosclerosis(accumulation of plaque) - narrows lumen of artery - diminished arterial blood supply
- decreased delivery of O2 & nutrients
- leads to tissue hypoxia and necrosis
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Arterial Ischemia AssessmentArterial Ischemia Assessment
History of:
Cold feetIntermittent claudication - pain in leg/buttock with walkingRest pain - in toes & forefoot Pain aggravated by elevation & relieved by dependencySmoking, diabetes, hypertension, Hyperlipidemia, CAD, age
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Arterial Insufficiency Ischemia
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Colour – pale Dependent rubor- with - Elevation pallorDecreased capillary refill time
(>15 sec.)Atrophy of subcutaneous fatty
tissueShiny, thin, tightly drawn skinLoss of hair on foot and toes Thick, yellow, brittle nails
Vascular Vascular AssessmentAssessment
InspectionInspection:
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Palpation:
Cool to touch Absence of pedal
pulsesBlanch test
Vascular AssessmentVascular AssessmentDorsalis pedis
Posterior tibial
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PAD – Peripheral Vascular Disease
Non-healing foot ulcers
Due to impaired delivery of: Oxygen Nutrients Antibiotics
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Ankle Brachial Index (ABI)
Monitors systolic pressure of ankle and brachial arteries with use of a doppler monitor
Ankle figure divided by brachial figure for index number
Diabetics may have arteriosclerosis and toe pressures are required as regular ABI's may be lower then indicate
Transcutaneous oxygen levels (TpO2) have proven to determine adequate circulation equal to or better then Toe pressures
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ABIABIIdeally the ABI should be 1.0
Arterial ABI Insufficiency
1.0 - 1.2 none 0.8-1.0 mild0.6 - 0.8 moderate
Below - 0.6 severe
ABI of 0.5 Vascular Consult
re-establishment of an aadequate vascular supply is indicated if feasible
ABI = 0.8 ABI = 0.8 Blood flow in ankleBlood flow in ankle is 80% of that inis 80% of that in the armthe arm
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Vascular Assessment
Vascular Lab: Toe pressures more accurate <25 mmHg represent severe occlusion >30 mmHg needed for healing to
occur >45 mmHg in people with diabetesArteriography (diagnosis of by-passable
conditions- surgery)Transcutaneous oxygen pressures ->30%
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Arterial Ulcer Characteristics
Trauma – most commonprecipitating event
Usually very painful
Circular or punched out appearance
Painful if leg elevated
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Arterial Ulcer CharacteristicsArterial Ulcer Characteristics
Usually on distal areas of foot-toe tip, between digits, over bony prominences or other areas d/t trauma
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Arterial Ulcer CharacteristicsArterial Ulcer Characteristics
Wound bed - necrotic tissue (black or yellow) or pale greyish/pink granulation base
Little exudate, dry and necrotic
Surrounding tissue pale or mottled
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Determine Potential for HealingDetermine Potential for Healing
Assess Patient and Wound for:Assess Patient and Wound for: Blood Supply
Important for wounds of lower extremities
If inadequate:
- moist interactive wound healing is contraindicated
use topical antiseptics
vascular referral to determine if
re-vasculization possible
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Management of Arterial Ulcers
Patient History
Treat the cause
medical consult
surgical consult (vascular)
surgery: restoration of adequate blood supply
Arterial by-pass ( autogenous vein or prosthetic graft)
Angioplasty
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Interventions to MaximizeBlood Flow – Treat the Cause
Smoking cessation (causes vasoconstriction)
Warm environment(socks, avoid drafts)
Exercise (as tolerated)
Pain Management (pain causes vasoconstriction)
Elevation of leg contraindicated
Legs at rest should be in neutral position
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Management of Arterial Ulcers
Avoid treatments that interfere with arterial flow:
whirlpool sharps debridement compression therapy restrictive footwear elevation of limb above heart levelManagement of Co-morbid diseases(diabetes)Optimal nutrition
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Maintain walking with rest periods when pain occurs
Treat for pain around the clock
Manage exudate and odour
Position bed so feet lower then heart
Treat infection – continual assessment for signs of infection – change in pain -change in exudate appearance -change in odour - change in client behaviour withdrawn, decreased appetite, restlessness
Management of Arterial Ulcers
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Management of Client Concerns Communicate Fears – provide support
Family/Client education
Independence with wound care when possible
Maintain self esteem through activity and self care
Understanding in regards to pain
Maintain Mobility
Alternative Therapies -relaxation
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Treat the Wound Goal – Prevent/treat Infections and
Avoid/Delay Amputation
Moist healing only if adequate blood supply
to heal
Keep area clean & dry if not adequate blood supply to heal
Avoid debridement
Use Povidone iodine to paint wound
If wound wet consider a topical antimicrobial
Assess & treat for infection if needed
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Arterial disease Signs of adequate blood supply?
a) Feet warm to touch, pulses presentb) ABI < 0.6c) Colour bluish hued) Hairless legs (culture sensitive) e) all of the above
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Arterial Ulcers are painful when legs hang down?
True
False
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Arterial ulcers characteristics consist of all except
a) punched out in appearance
b) distal extremities
c) wound base deep red colour
d) pain with elevation
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ABI and Toe Pressure assessments determine the amount of venous pressure.
True
False
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Which photo shows a arterial ulcer?
A B C D
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Group Discussion
What have you seen in your practice?
What was the hardest element of treatment?
What was the most difficult element for the patient?
What were the solutions implemented or tried?
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Questions?
??
??
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Venous Leg
Ulcers
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Leg Ulcer Epidemiology
According to the Canadian Medical advisory Secretariat (MAS),2006 as cited by Burrows et al
prevalence of lower limb ulcers 0.12%-0.32% in general population
approximately 50,000 to 500,000 Canadians with leg ulcers
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most people with venous leg ulcers were over the age of 65 and nearly 75% had 3 or more medical conditions (Harrison et al, 2005)
>2/3 had ulcers for many months, ½ affected population had leg ulcer history that spanned 5 – 10 years
estimated cost of 192 people receiving treatment costs $1 million in nursing care and $260,000 in supplies annually
Leg Ulcer Epidemiology
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Venous Leg Ulcers1994 survey of people with venous ulcers
81 % adverse effect on mobility
56% spent up to 8 hours per week on ulcer care
68% negative emotional impact, including fear, social isolation, anger,depression, negative self esteem
cost per patient $40,000 - $90,000
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Venous Hypertension - Etiology
Valve dysfunction (deep,perforators,superficial)Obstruction from complete or partial blockage of
the veins( DVT)Failure of calf muscle pump function ( decreased
activity)Previous varicose vein surgeryPrevious DVTCongenitalIncreased abdominal pressure (morbid obese,
pregnant)
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Venous DrainageVenous Drainage
Deep venous system - under muscle fascia
Superficial venous system - close to skin (greater & lesser saphenous system)
Perforator or communicating veins - join deep venous system & superficial venous system
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Venous DrainageVenous DrainageOne way valve system - prevents backward flow of blood
Calf muscle pump - calf muscles contract & squeeze venous blood upward toward the heart need to walk from heel to toeor flexion and extension of ankle beyond 45 degrees
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Superficial
Perforator
Deep
Normal
Valves
Incompetent
Valves
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Venous Stasis DiseaseRisk Factors
Family History
Obesity
Pregnancy
Occupations that require long hours of standing or sitting
History of: DVT,Leg injury, Varicose Veins or vein
stripping
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Venous Stasis Ulcer Diseaseunderlying etiologic factors
Sustained venous hypertension due toValvular dysfunction
Obstruction
Calf muscle pump failure causes localized ischemia due to edema
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Clinical Features & Diagnosis
Dilated long Saphenous veinEdema (weeping exudate) worse at the end
of the dayStasis Dermatitis (itchy/dry)Hemosiderin & Melanin deposition (brown
skin staining)Lipodermatosclerosis (woody appearance)Atrophic blanche (white scars)Pain or ache (worse with dependency,
relieved by elevation, worse at end of the day)
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Contributing Factors for progression to ulceration
Trauma
Infection
Edema
Malnutrition
Immobility
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Assessment & Diagnosis
Complete history (medical and social)
Wound assessment
Vascular Assessment
Investigations
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HistoryMedical history – cardiac or pulmonary disease
including CABG
Assess history for:
swelling at the end of the day
varicose veins/ vein stripping, abdominal surgeries, DVT
previous ulcers/treatments
lower leg trauma
prolonged standing
compression treatments
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Wound Characteristics
Rapid development
granulating wound base
(may be necrotic initially) red base in colour
Jagged/irregular wound edges – shallow
located above medial or lateral malleoloi
(gaiter area) or on anterior tibial area – lower 1/3 of calf
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Wound CharacteristicsEdema
Exudate is usually copious & serous
Peri- wound skin may have dermatitis, hyperemia, maceration, hyper pigmentation, & thickening
Feet warm with palpable pulses
Pain or ache – relieved by elevation
May be complicated by bacterial infection
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Treat the Cause Treat the Cause Underlying PathologyUnderlying Pathology
Timely identificationTimely identification of people at risk
ElevationElevation - reduces Edema/venous pressure
Maximize mobility Maximize mobility - consult rehabilitation experts
CompressionCompression - the corner stone of treatment
Weight managementWeight management
Skin careSkin care
Calf Muscle Pump ExercisesROM
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Compression
ABI > 0.8 – full compression
ABI 0.6-0.8 – lower (mild to moderate compression) consult advanced wound clinician
ABI, < or = 0.5 no compression – refer to vascular surgeon
Jobst Sigvaris
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Compression
Contraindicated if arterial disease is present
Patients with diabetes may have elevated ABI's due to calcified arteries – toe pressure needed by
vascular lab or subcutaneous oxygen
Compression is not for use in acute CHF, DVT, or infection
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Underlying PathologyManagement
Compression therapy
Compression bandages
Intermittent pneumatic compression devices
Modified compression
Compression garments – once edema controlled
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Clarification of Compression Bandages
Elastic
pressure characteristics example
Low single layer tensors
Moderate single or double Tubigrips
High Long Stretch ProGuide
High Four Layer Profore
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How To Measure Fit
STEP 1: Measure the circumference of your ankle. Measure around the narrowest part of your ankle above the ankle bone. Record this measurement...
STEP ONE
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Measure to Fit
STEP 2: Measure the circumference of your calf. Measure around your calf at it's widest part. Record this measurement...
STEP TWO
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Measure to Fit
STEP 3: Measure the length of your calf. Measure from the floor to the bend in your knee. Record this measurement...
STEP THREE
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Measure to Fit
STEP 4: Measure the circumference of your thigh. Measure around the widest part of your thigh just below your gluteal fold. Record this measurement...
STEP FOUR
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Measure to Fit
STEP 5: Measure the length of your thigh. Measure from the gluteal fold to the floor. Record this measurement...
STEP FIVE
Jobst Stocking Measuring Scale
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STEP 6: Measure around your hips. Locate the widest part of your hips or waist and measure all the way around
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Four-layer bandage for Four-layer bandage for sustained sustained graduatedgraduated compression compression
natural padding bandage light conformable bandage
light compression bandage flexible cohesive bandage
S S
8 S
S = spiral8 = figure 8
•Apply all elastic layers at half-stretch•Change q 7 days
1 2
3 4
Profore LiteProfore Lite
Layers 1,2,4Layers 1,2,4
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T.E.Ds
T.E.D. Anti-embolism stockings are not the same as support stockings or compression hose. Yes, TED Stockings do have graduated compression to speed blood flow. TED stockings are for the non-ambulatory convalescing person to prevent blood clots.
“T.E.Ds are for bed” compression hosiery is for life Samson & Showalter,1996
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Graduated Compression Therapy
Reduces venous hypertension
Improves calf muscle pump
Increases venous return to the heart
Increases removal of Fibrin
Decreases edema
Decreases distension of superficial veins
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Classification of CompressionBandages systems (inelastic)
Pressure Characteristic Example
Low flexible cohesive RoloFlex or Padding Coban & cast
padding
Moderate Zinc Oxide bandage Duke Boot & cohesive Velcro system Circaid
Moderate short stretch system Comprilanto High
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Compression StockingsCompression StockingsPrevention & AftercarePrevention & Aftercare
4 % recurrence in people who wore good compression stockings.
79% recurrence in people who did not wear good compression stockings.
Any level of compression better then no compression
Teaching is the corner stone of adherence May need tools to assist in applying stockings
Compression hosiery for life
(Samson & Showalter, 1996)
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Compression Stockings
Dress support hose – 8.5 mmHg – prominent veins without edema
Class I-20-30 mmHg – treat varicose veins or mild edema
Class II – 30-40 mmHg – recommended to treat more severe varicosities or moderate edema
Class IV - >60 mmHg – for severe venous insufficiency
Level of compression depends on severity of venous hypertension
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Compression Stockings
Devices to assist with application rubber gloves nylon or silk sock zipper inserts in the back
Action compress dilated superficial veins
Useremove stockings & bath at bedtime – moisturise
legs -re apply early in AM
2 pairs of stockings should be purchased
may need replacement every 6 months
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Summary
Some compression is superior to no compression
high compression is superior to low compression in the absence of significant arterial disease
no clear difference in the effectiveness of the different types of compression stockings
Fletcher et al. 1997
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Increased use of correctly applied compression system should be promoted
Elastic systems have an advantage over inelastic systems
Summary
Fletcher et al. 1997
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Patient Education
Reduce weight if necessary
Avoid prolonged standing or sitting
walk/calf muscle pump exercises
Elevate feet above level of heart frequently during the day
Periodic reminders of treatment plan for
prevention
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Patient EducationOptimum treatment of all co-morbid conditions
Avoid tight bands of clothing around legs
Good skin care – use of emollients
Venous ulcer reoccurance = 72%
Wear compression for life
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Treat the WoundIrrigate – 30 ml syringe with cathlon 18 gauge
Support debridement – autolytic/surgical pain management
Rule out or treat infection
Apply dressing that supports moist wound environment
Absorb excess exudate
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Appropriate Dressings
Foams
Calcium alginate
Hydrocolliods
Hydrogels
Transparent adhesive dressing
Zinc oxide bandages are an alternate primary layer for use over the dressing alone or under compression bandage
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If Conservative Therapy Unsuccessful.....
Surgery InterventionGrafting Pinch grafting Split thickness (disadvantage – donor site
painful & difficult to heal) Biological skin substitutes Ligation and Stripping Arterial surgery for mixed & arterial
disease Biopsy to rule out more unusual causes of
ulceration <10% of venous ulceration are refractory
to medical management
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Peripheral Vascular Disease Peripheral Vascular Disease (Ischemia)(Ischemia)
Impairs viability of skin Inhibits/prevents wound healing
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ISCHEMIC FOOT ULCERISCHEMIC FOOT ULCER
This patient has previously had most of the toes of this foot removed because of gangrene but has failed to heal one of the amputation sites due to persistent ischemia which
originated in the calf arteries
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MixedVenous & Arterial
Coexisting illnesses
Optimal Management
ArterialInsufficiency
VenousReflux
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Differential Diagnosis
Venous & arterial insufficiency coexist in about 20% of patients
Prior to the application of compression, an arterial assessment must be done (ABI,Toe Pressures,Transcutaneous Oxygen)
If compression is applied to a limb with impaired arterial blood supply serious damage can result
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Mixed Arterial/Venous UlcerManagement
Address limb threatening disease – maximize flow (surgical consult)
Pain control
Passive control of leg edema position limb at heart level modified compression – Tubigrips
Prevent infection topical antiseptics
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Compression Therapy
Level Etiology Compression
0.8 – 0.9 Venous High
0.5-0.8 Mixed Modified (low)
Less then Arterial None
Guidelines for interpretation of ABI & compression therapy
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Arterial & Venous Ulcer
Treat the cause arterial venous mixedTreat the Wound
moist wound healing (if adequate blood supply to heal)
Treat the patient
pain, compliance, adherence to treatments, nutrition, Life style changes, & follow up
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Type of vascular disease needs to be
known prior to compression?
True
False
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Mixed disease means:
a) venous & arterial flow diminished
b) client has multiple co-morbid illness plus a ulcer
c) a ulcer on the plantar foot surface is present with Hemosiderin staining
d) no pain with elevation or hanging of feet
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Hemosiderin staining is:
a) a large bruise to lower legs from DVT
b) dull woody appearance on lower leg caused by edema
c) white spot on the skin that does not blanche
d) brown staining to lower leg associated with venous disease
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Compression is a treatment option for mixed disease
a) all the time
b) according to ABI
c) only if palpable edema present
d) never
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Diagnosis and why
Potential cause
Treatment recommendation
78 year old male
recent widow, no children
mixed farming
early spring
quit smoking 1 year ago
hauls water – no well
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If lower leg is red but fades with elevation what could this indicate?
a) arterial disease
b) phlebitis
c) Cellulitis
d) vascular disease
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Questions?
??
??