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Identify and Treat the Cause - Assessment


Identify Risk Factors and Etiology of Arterial Leg Ulcers (ALUs)1 2

History of:

  • Smoking
  • Diabetes mellitus
  • Hyperlipidemia
  • Hypertension
  • Poor nutrition
  • Low hemoglobin
  • Obesity
  • Decreased thyroid function
  • History of vascular surgery or deep vein thrombosis
  • Bleeding disorders
  • History of cerebral vascular accident (CVA)
  • Autoimmune diseases
  • Chronic renal disease
  • Congestive heart failure
  • Impaired liver function
  • Coronary artery disease (CAD)
  • Psoriasis
  • Use of systemic steroids, immunosuppressives and chemotherapy
  • Family history of arterial disease
  • >70 years of age
  • Age 50-69 years with history of diabetes or smoking
  • < 50 years with diabetes and one other atherosclerotic factor

Odds Ratio of Arterial Leg Ulcer NOT Healing in 24 Weeks3 4

Research demonstrates that several factors will influence whether the ulcer is going to heal, which include the initial size of the ulcer and the length of time that the ulcer has been present. These ulcers often do not follow the trajectory of venous ulcers (venous ulcers should be 30% smaller at week 4 and should be closed by week 12). Further consultation with a wound care specialist and/or vascular surgeon should be considered if healing is not improving with conservative treatment in 4 to 6 weeks 5 6.

Factors that may affect healing potential

Local
  • Presence of necrosis, foreign body and/or infection
  • Disruption of microvascular supply
  • Cytotoxic (toxic to cells) agents
Host
  • Co-morbidities (i.e. inflammatory conditions, nutritional insufficiencies, peripheral vascular or coronary artery disease)
  • Adherence to plan of care by patient and caregivers
  • Cultural and personal belief systems
Environment
  • Access to care
  • Family support
  • Healthcare sector
  • Geographic
  • Socioeconomic status
Predictors of delayed healing
  • ABPI < 0.8
  • Fixed ankle joint
  • Wound base has more than 50% yellow fibrin
  • Wound has been present longer than 6 months
  • Wound is larger than 5cm² (L x W=>5cm²)
  • Patient had previous hip or knee surgery
  • Patient has history of vein ligation or stripping

Common Signs and Symptoms of Peripheral Arterial Disease (PAD)7

Peripheral vascular disease (PVD) is any disease that affects the blood flow through veins and arteries distal to the heart. Peripheral arterial disease affects the arteries only8. Peripheral arterial disease (PAD) is a life-threatening condition which results from the narrowing of the blood vessels9

The following are common signs and symptoms of PAD

  • Pain or cramping with elevation of lower limbs usually described as gnawing, aching, throbbing or tenderness (nociceptive pain)
  • Rest pain (pain present without exercise) is indicative of advanced PAD (90% occlusion)
  • Nocturnal Pain: Sleep in a recumbent position (legs at same level as the heart) causes the blood pressure in the legs to drop, therefore perfusion to the extremities in decreased causing ischemic neuritis (patients often dangle affected leg over side of bed or sleep sitting up in chair)
  • Intermittent Claudication: the patient has enough blood flow to meet needs at rest, but exercise causes an increase in metabolic demands and the calf muscle becomes ischemic. Patients may complain of pain or cramping in legs when walking with early disease. This indicates mild to moderate PAD
  • Pain may not be experienced or may be described as burning, stabbing, stinging or shooting (neuropathic pain) if extensive sensory neuropathy is present
  • Intense hyperesthesia (cannot tolerate light touch)
  • Limb muscle may appear wasted from ischemic atrophy
  • Pulselessness (weak or absent)
  • Delayed capillary refill (normal refill time is less than 3 seconds)
  • Temperature difference between legs
  • Dependent rubor (redness) in lower legs and feet
  • Pallor in feet on elevation
  • Thick, yellow or flaking toenails (onychogryphosis)
  • Dry, shiny skin on lower legs
  • Hairless lower legs and feet
  • Edema subsequent to leg being dependent
  • Distal gangrene of toes with palpable pulse and/or adequate circulation may indicate microemboli from proximal atheromatous plaques (small pieces of debris or lipids on the innermost portion of an artery)
  • Erectile dysfunction in men
  • Non-healing wound

Arterial Leg Ulcers occur due to insufficient arterial blood supply (APBI<0.8 or TBPI <0.7) resulting in the following:

  • A lack of oxygenated blood reaching the tissue especially in the lower limbs
  • Tissue ischemia and necrosis
  • Need increased blood supply for healing to occur
  • Diagnostic studies are needed to identify the cause

Table 2 - "Time is Tissue"10

Acute arterial occlusion is a life and limb-threatening situation
which requires immediate emergency intervention

Signs and symptoms include sudden pain in the leg or foot that may become severe associated with the following:

  • Pale or blue skin
  • Skin cold to the touch
  • Sudden decrease in mobility
  • No pulse where one was present prior to this
  • Sudden and severe pain
Hairless
  • Little or no hair on the lower legs or feet
11
Thin skin
  • Skin appears thin and fragile and shiny on legs and feet
  • May be pale in colour unless dependent rubor is present
12
Dependent rubor
  • Occurs in the presence of arterial compromise and can mimic cellulitis
  • Disappears when the foot is elevated, which would not happen with cellulitis
  • Can be bilateral
13
Blanching on elevation
  • Occurs in the presence of arterial compromise and represents decrease in arterial flow without the gravitational effect of having the foot below the level of the heart
  • Can be bilateral
14
Feet cool/cold/blue:
  • Often just involving one leg or foot in comparison to the other, but both can be involved to some degree
Toes cool/cold/blue:
  • Blue toes may be caused by mechanical obstruction (secondary to emboli or atherosclerosis) or mechanical damage to blood vessels
15
Lower temperature in one leg compared to other
  • Occurs in the presence of arterial compromise and represents decrease in arterial flow without the gravitational effect of having the foot below the level of the heart
  • One leg feels cooler than the corresponding area on the other leg – this generally suggests the presence of PAD in the cooler leg, but can also be from increased temperature in a leg with infection or cellulitis
16
Capillary refill time: > 3 seconds
  • Delayed capillary refill time (CFT) is suggestive of peripheral arterial disease
  • Normal CFT is less than 3 seconds
Ulcer located on foot
  • Heels and malleoli
  • Tips of toes
  • Between the toes where the toes rub against one another
  • Any area where bony prominences rub against bed sheets, socks or shoes
  • Toes where the toenail cuts into the skin
  • Aggressive toe nail trimming/removal of an ingrown toenail
17
Ulcer located on leg
  • usually associated with trauma (fall, car door, shopping cart, wheelchair)
18
Ulcer base pale & dry and/or contains eschar
  • Yellow, brown, grey, pale pink or black color
  • Usually does not bleed
  • Minimal exudate unless edema and infection are present
  • May initially have grey or purplish tissue that bleeds very little and will turn to eschar if allowed to dry out
19
Ulcer round and punched out in appearance
  • Do not usually have irregular edges and the edges do not slope gently down to the wound bed
  • “punched out” appearance with straight sides to the wound
  • If irritation or infection are present, there may or may not be swelling and redness of the periwound skin
20
Gangrene dry/wet
  • Dry gangrene (ischemia) may start out red in colour and cool to touch, then turn blue or brownish and then becomes black and will dessicate if allowed to dry
  • Wet gangrene (infection causing ischemia) starts out with swelling and putrifies, may have foul smelling exudate, fever
  • If irritation or infection are present, there may or may not be swelling and redness of the periwound skin
21 22


Identify and Treat the Cause - Obtain a Comprehensive Patient History and Perform a Physical Assessment
  1. Weir G.R, Hiske S, Marle J.V, Cronje F.J. Arterial Disease Ulcers, Part 1: Clinical Diagnosis and Investigation. Advances in Skin and Wound Care: September 2014.
  2. Weir G.R, Hiske S, Marle J.V, Cronje F.J, Sibbald R.G. Arterial Disease Ulcers, Part 2: Treatment. Advances in Skin and Wound Care: September 2014.
  3. Registered Nurses Association of Ontario. Nursing Best Practice Guideline: Assessment and Management of Venous Leg Ulcers. March 2004.
  4. Registered Nurses Association of Ontario. Nursing Best Practice Guideline Supplement: Assessment and Management of Venous Leg Ulcers. March 2007.
  5. Registered Nurses Association of Ontario. Nursing Best Practice Guideline: Assessment and Management of Venous Leg Ulcers. March 2004.
  6. Registered Nurses Association of Ontario. Nursing Best Practice Guideline Supplement: Assessment and Management of Venous Leg Ulcers. March 2007.
  7. Weir G.R, Hiske S, Marle J.V, Cronje F.J. Arterial Disease Ulcers, Part 1: Clinical Diagnosis and Investigation. Advances in Skin and Wound Care: September 2014.
  8. Miller-Keane. Encyclopedia and Dictionary of Medicine, Nursing and Allied Health – Seventh edition. Saunders Publishing 2003.
  9. Weir G.R, Hiske S, Marle J.V, Cronje F.J. Arterial Disease Ulcers, Part 1: Clinical Diagnosis and Investigation. Advances in Skin and Wound Care: September 2014.
  10. Weir G.R, Hiske S, Marle J.V, Cronje F.J, Sibbald R.G. Arterial Disease Ulcers, Part 2: Treatment. Advances in Skin and Wound Care: September 2014.
  11. http://www.medetec.co.uk/slide%20scans/leg-ulcer-images/target66.html.
  12. http://www.medetec.co.uk/slide%20scans/leg-ulcer-images-2/target32.html.
  13. Photo courtesy of: Mavis Hicknell.
  14. Photo courtesy of: Mavis Hicknell.
  15. Photo courtesy of: Ido Weinberg http://www.angiologist.com/
  16. Photo courtesy of: Laura Rowbotham.
  17. http://www.medetec.co.uk/slide%20scans/foot-ulcers/target21.html.
  18. http://www.medetec.co.uk/slide%20scans/leg-ulcer-images/target45.html.
  19. http://www.medetec.co.uk/slide%20scans/leg-ulcer-images-2/target5.html.
  20. http://www.medetec.co.uk/slide%20scans/leg-ulcer-images/target19.html.
  21. http://www.medetec.co.uk/slide%20scans/toes/target8.html.
  22. http://www.medetec.co.uk/slide%20scans/toes/target4.html.

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