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Identify and Treat the Cause - Obtain a Comprehensive Patient History and Perform a Physical Assessment


RNAO Evidence Level:

Level C
 

Information obtained should be documented in a structured format (see Toolkit item #8 for assessment form) for a patient presenting with either their first or recurrent leg ulcer and should be ongoing thereafter.

Complete a comprehensive patient history including:

  • Medical history including history of venous insufficiency
  • Family history of venous, arterial or mixed ulcers
  • History of deep vein thrombosis (DVT) and/or lower leg injury
  • History of episodes of chest pain, hemoptysis or pulmonary embolus
  • History of heart disease, stroke or transient ischemic attack (TIA)
  • Comorbidities (diabetes, peripheral vascular disease, intermittent claudication, rheumatoid arthritis or Ischemic rest pain)
  • Pain
  • Smoking history
  • History of ulcer and past treatments
  • Current and past medications
  • Nutritional status
  • Allergies
  • Psychosocial status including quality of life
  • Functional, cognitive, emotional status and ability for self-care
  • Lifestyle (activity level, interests, employment, dependents, support system)

Complete a comprehensive physical examination including:

  • Blood Pressure, height, weight, pulses in foot and ankle
  • Review bloodwork that should include the following:
 

Lower Leg Assessment

RNAO Evidence Level:

Level A
 

Perform a BILATERAL lower leg assessment including ABPI/TPBI

Assess for the following:

  • Edema (may be pitting or firm)
  • Skin changes (eczema, lipodermatosclerosis, hyperpigmentation, atrophe blanche)
  • Ankle range of motion (ROM)
  • Foot deformities (hammer toes, prominent metatarsal heads, charcot joint)
  • Ankle flare
  • Skin temperature
  • Presence of pain
  • Nail changes
  • Capillary refill
  • Peripheral pulses (Dorsalis Pedis and Posterior Tibial)
  • Presence of varicosities (varicose veins)
  • Circumference measurements of thighs, ankles and calves

Assess the Wound and Peri-wound

Wound and Peri-wound Assessment is best performed using a validated and reliable wound assessment tool. (See Toolkit item #10a for Bates-Jensen Wound Assessment Tool and #10b Leg Ulcer Measurement Tool (LUMT))

A comprehensive wound assessment should include observation and documentation of the following:

  • Location: Venous leg ulcers are usually situated on the gaiter area of the leg
  • Odour
  • Sinus Tracts (including undermining and tunneling): Measurement can be obtained by gently inserting small probe into sinus tract, marking probe with end of finger and measuring length from end of probe to finger end
  • Exudate: Comment on amount and colour of exudate present
  • Pain:
  • Wound bed appearance: colour and type of tissue present (fibrin, granulation or epithelial tissue) and presence of eschar or slough
  • Condition of peri-wound (surrounding skin) and wound edges
 

Wound Measurements

RNAO Evidence Level:

Level B
 
  • Measure and document the surface areas of ulcers at regular intervals to monitor progress
  • Measure depth of Wound
  • Measure size of wound: Area of wound measured by multiplying length (longest measurement) and width (shortest measurement) of wound

Comparison of Venous versus Arterial versus Mixed Venous/Arterial Leg Ulcers

RNAO Evidence Level:

Level C
 

People who have cardiovascular insufficiency (CVI) can also develop peripheral arterial disease, which can complicate the ability to treat and heal those individuals who develop lower leg ulcers. These wounds are generally called “mixed venous/arterial” leg ulcers. While the principles of treatment fall under those for Venous Leg Ulcers, extra attention and caution must be taken to the selection of a safe level of compression. Because pain with ischemic disease has a neuropathic component, it is essential that adequate pain management be implemented BEFORE compression therapy is started.

 

Table 3 - Venous / Arterial / Mixed1 2

  Venous Disease Arterial Disease and Ischemia Mixed Venous/Arterial
Placeholder Placeholder Placeholder
Wound Appearance Base: ruddy red; yellow adherent or loose slough; granulation tissue may be present

Depth: usually shallow

Margins: irregular

Undermining: is rare. If present, further assessment should be undertaken to rule out other etiologies (i.e. arterial)

Exudate: moderate to heavy

Infection: less common but chronic venous ulcers are prone to biofilms, induration, cellulitis, inflamed, tender blisters

Surrounding Skin: Venous dermatitis, hemosiderosis lipodermatosclerosis; atrophy blanche

Temperature: normal; warm to touch

Edema: pitting or non-pitting; may worsen with prolonged standing or sitting from legs being in a dependent position

Scarring: from previous ulcers, ankle flare, tinea pedis (athlete’s foot)

Nails: Usually normal unless infection present
Base: pale; granulation rarely present; necrosis, eschar, gangrene (wet or dry) may be present

Depth: may be deep

Margins: edges rolled; “punched out” appearance, smooth

Undermining: may be present

Exudate: minimal

Infection: frequent (signs may be subtle); cellulitis,necrosis, eschar, gangrene may be present

Surrounding Skin: Pale or blue feet, pallor on elevation, dependant rubor; Shiny, taut, thin, dry; Hair loss over lower extremities; Atrophy of subcutaneous tissue

Edema: atypical

Temperature: decreased/cold

Nails: Dystrophic
 
Ulcers may have elements of both kinds of disease:
  • Venous shape
  • Yellow/black fibrous base
  • Wound bed may be dry (if no edema or infection)
Surrounding Skin: Possible cool skin, edema, pallor on elevation, dependant rubor

Infection: Can have signs and symptoms of both venous and arterial disease

Edema: variable

Nails: Thickened toenails
Location Ulceration is usually on the medial lower leg superior to malleolus in gaiter region but can be on lateral aspect as well or may encircle the entire ankle or leg

Ulcers occurring above the mid-calf or on the foot likely have other origins, but may be caused by trauma in a leg with existing venous insufficiency
Areas exposed to pressure or repetitive trauma, or rubbing of footwear:
  • Lateral malleolus
  • Mid tibial
  • Phalangeal heads
  • Toe tips or web spaces
Same as venous or ulcer may be circumferential
Pain Described as throbbing, sharp, itchy, sore, tender, heaviness

Worsens with prolonged dependency. Some relief on elevation of limb.
Pain is increased with elevation of limb. Pain may also be incurred with walking. This is usually due to the presence of intermittent claudication which will be relieved with 10 minutes of rest Pain with elevation

Intermittent claudication (early)

Night time rest pain (late disease)
 

Ankle Brachial Pressure Index (ABPI) / Toe Brachial Pressure Index (TBPI)

RNAO Evidence Level:

Level B
 

Perform ABPI/TBPI to rule out the arterial disease. If patient is a diabetic, toe pressures should be obtained.

An Ankle Brachial Pressure Index (ABPI) measurement should be performed by a trained practitioner to rule out the presence of peripheral arterial disease, particularly prior to the application of compression therapy. ABPI measurement offers valuable information as a screening tool for lower extremity peripheral arterial disease3.

Where peripheral arterial disease is suspected, compression therapy treatments designed for venous leg ulcers may be contraindicated. ABPI may also offer prognostic data that are useful to predict limb survival, wound healing and patient survival. The use of ABPI measurement for diagnosis is generally outside of the scope of nursing practice. Furthermore, only those practitioners with the appropriate knowledge, skill and judgment to perform this measurement should do so.

Further Investigation Required

RNAO Evidence Level:

Level C
 

An Ankle Brachial Pressure Index (ABPI) >1.2 and <0.8 warrants referral for further medical assessment. People with abnormally low or abnormally high ABPI should be further investigated for peripheral arterial disease. For example, an ABPI >1.3 is considered indicative of non- compressible vessels that are found in individuals with diabetes, chronic renal failure and who are older than 70 years of age. In these cases, compression therapy may not be recommended4.

If ulceration does not heal or show improvement after 3 months of compression and patient has an Ankle Brachial Pressure Index (ABPI) of > 0.8 to 1.3, a referral to a vascular surgeon to review potential surgical interventions is recommended5.

 

Determine if the wound is "Healable, Maintenance or Non-Healable"

  • Healable: Have sufficient vascular supply, underlying cause can be corrected, & health can be optimized
  • Maintenance: have healing potential, but various patient factors are compromising wound healing at this time
  • Non-healable/Palliative wound: has no ability to heal due to untreatable causes such as terminal disease or end-of-life6

Nutritional Assessment

RNAO Evidence Level:

Level B
 

The following assessments and blood work should be considered when investigating nutritional status of a person with a wound:

In addition to inquiring about recent weight loss, signs of dehydration, and assessing the Braden Scale Nutritional sub-scale, which helps to capture protein intake, there are several signs of micronutrient deficiencies that are easy to detect when you know what to look for.

Signs of micronutrient deficiencies:

  • Reddish tongue with a smooth surface (Vitamin B deficiency)
  • Magenta flank-steak appearing tongue with cracks at corners of the mouth (called angular stomatitis) (Vitamin B2 deficiency )
  • Dementia, diarrhea, dermatitis (pellagra)—crepe paper skin with wrinkles in the skin and flat surfaces between the wrinkles –also associated with bullous pemphigoid and gramuloma annulare (Vitamin B3 deficiency)
  • Prominent “snowflake” exfoliation of the epidermis of the lower legs (Essential Fatty Acid deficiency)
  • Skin and capillary fragility with purpura, skin tears, increase risk of pressure ulcers, severe collagen deficiency so that the skin is like plastic wrap, and extensor tendons and venous plexus is easily seen through the transparent epidermis (Chronic Scurvy/Vitamin C deficiency)
  • Reddish, scaly, itchy skin lesions (Vitamin A, E, and K deficiency)
  • Seborrheic-like rash that is red, flaky seen along the lateral eyebrows, nasal labial folds and chin (Zinc deficiency)
  • Prolonged tenting of the skin in the presence of adequate fluid intake

If the presence of any of these signs of micronutrient deficiencies is noted, a referral should be made to a Registered Dietitian who can work with the primary care provider for screening of dietary deficiencies and treatment.

The Nestle Mini-Nutritional Assessment (MNA) is a screening and assessment tool that identifies individuals age 65 and above who are malnourished or at risk of malnutrition, allowing for earlier intervention to provide adequate nutritional support. It has not been validated for use with younger individuals. The screening tool consists of 6 questions.

Complete the screen by filling in the boxes with the appropriate numbers.
Total the numbers for the screening score.

The screening score (max 14 points):

  • 12 - 14 points = normal nutritional status
  • 8 - 11 points = at risk of malnutrition
  • 0 - 7 points = malnourished


Identify and Treat the Cause - Determine the Cause of Venous Insufficiency Based on Etiology  
  1. Table 3: Adapted from Wound Ostomy and Continence Nurses Society (WOCN) Clinical Fact Sheet Quick Assessment of Leg Ulcers (November 2009) by CarePartners (2014) and Registered Nurses of Ontario. Nursing Best Practice Guidelines: Assessment and Management of Venous Leg Ulcers. March 2004
  2. Photos courtesy of:http://www.medetec.co.uk
  3. Hirsch AT, Criqui MH, et al. Peripheral Arterial Disease Detection Awareness and Treatment in Primary Care. JAMA, 2001. September 19:286 (11):1317-24
  4. Registered Nurses Association of Ontario. Nursing Best Practice Guideline Supplement: Assessment and Management of Venous Leg Ulcers. March 2007
  5. Jahromi Afshin, Vascular Surgeon, Guelph General Hospital 2015
  6. Despatis,M.,Shapera,L.,Parslow,N.Woo,K.(2008) Complex Wounds Wound Care Canada 8(2):24‐25

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