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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 arterial/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 (in calves, buttocks or thighs especially with walking and/or with elevation of leg above level of heart)
  • Where patient sleeps at night (e.g. if patient sleeps upright in chair at night, could indicate pain if leg elevated in bed)
  • 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

All clinicians involved in the management of patients with lower limb ulcers should have direct access to an 8 MHz hand held Doppler device. This should not be considered a special investigation limited to vascular laboratory1.

Assess for the following:

  • ABPI/TPBI completed within last 3 months and results documented
  • If unable to obtain ABPI/TPBI, referral to vascular surgeon is recommended
  • Assess pulses (popliteal – behind knee, dorsalis pedis – top of foot, posterior tibial – medial ankle)
  • Measurement of edema
  • Assess capillary refill (normal less than 3 seconds)
  • Ankle range of motion (ROM)
  • Foot deformities
  • Ankle flare
  • Skin temperature (compare both legs)
  • Skin colour (dependent and on elevation)
  • Presence of pain
  • Nail changes
  • Presence of hair on lower leg, feet and toes
  • Presence of varicosities (varicose veins)
  • Dermatological changes due to impaired blood flow
  • Repeat ABPI/TPBI assessment every 3 months if healing is not progressing
Acute arterial occlusion is a life and limb-threatening situation which requires immediate emergency intervention

Signs and symptoms that may become severe may be 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



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))


4 P’s of Arterial Ulcers
  • Pale wound base
  • Punched-out appearance
  • Painful
  • Parched (low to no exudate)

A comprehensive wound assessment should include observation and documentation of the following:2 3

  • Location: Arterial leg ulcers are usually situated on the lateral malleolus, mid tibia, phalangeal heads, toe tips or web spaces
  • 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. Arterial wounds usually have low to no exudate
  • Pain: Usually more painful than expected
  • Wound bed appearance: colour and type of tissue present (fibrin, granulation or epithelial tissue) and presence of eschar or slough. Arterial ulcers generally have a pale wound base and a ‘punched-out’ appearance
  • Condition of peri-wound (surrounding skin) and wound edges
  • Document percentage of healing since last visit
  • Obtain photos following best practice


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


Table 3 - Venous / Arterial / Mixed4 5 6 7

  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

Surrounding Skin: Venous dermatitis; hemosiderin; lipodermatosclerosis; atrophy blanche

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

Temperature: normal; warm to touch

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

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

Nails: Dystrophic

Temperature: decreased/cold

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

Edema: variable

Nails: Thickened toenails

Infection: Can have signs and symptoms of both venous and arterial disease
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 disease8.


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 recommended11.

ABPI 0.5 to 0.8 TBPI 0.64 to 0.7
Suggest Transcutaneous Oxygen Pressure(TcPO2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies
ABPI <0.5 TBPI <0.64
Urgent vascular surgical consult needed


Referrals to vascular lab may be required for the following investigations12:

Transcutaneous oxygen (TcPO2)

  • Measures partial pressure in adjacent areas of the wound
  • Considered reliable method to measure the viability of tissue except where acute edema or inflammation is present
  • Tissue hypoxia results TcPO2 <40 mmHg
  • Critical ischemia TcPO2 <30 mmHg

Laser Doppler Flowmetry

  • Useful in cases where false readings obtained in TcPO2 (where acute edema or inflammation is present)

Doppler Arterial Waveforms

  • Non-invasive
  • Demonstrates the normal tri-phasic signal of the pulse

Segmental Doppler Pressures

  • Determines location of vascular lesion
  • Pressures measured at thigh, above knee, calf and ankles
  • Results compared with each other and with other leg

Imaging Studies (Angiography)

  • Determines location and extent of disease
  • Used by surgeon to provide roadmap in deciding and planning revascularization of the limb


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-life13

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


Nutritional Supplementation

Nutritional supplementation should be provided to a patient only after a thorough nutritional assessment has been completed and the reason for malnutrition has been identified14.


Macronutrients

Macronutrients such as carbohydrates, proteins and lipids (fats) are required in adequate amounts to provide the body with total energy needs. Caloric intake of 30-35 kcal/kg of body weight is recommended for patients with chronic wounds. Patients that are underweight may require a caloric intake of 35-40% kcal/kg of body weight15.

These macronutrients should be consumed daily in the following amounts:

  • Carbohydrates 45-60%
  • Fat 25-30%
  • Protein 15-20% (1.25-1.5 g/kg of body weight)16

Protein needs are increased in order for healing to occur. Diets that include inadequate amounts of protein can be blamed for “increased skin fragility, decreased immune function, poorer healing and longer recuperation after illness”17. Caution should be taken when administering protein to patients with liver or kidney failure. Consultation with a Registered Dietician is recommended with this patient population.

Arginine and Glutamine are amino acids that are needed in the production of collagen. Collagen is required for healing to occur. Although supplementation of Glutamine is controversial, it is believed to be helpful in those patients where malnutrition and chronic wound healing are being addressed. Arginine is required by the body when under metabolic stress. Supplementation of Arginine has been shown to improve healing. It is important to note that both Arginine and Glutamine require adequate protein intake to be of any value18.

Fats are an integral part of a healthy diet required for healing to occur. Omega 3 fatty acids are antithrombotic, vasodilators and anti-inflammatory. Omega 6 fatty acids are responsible for platelet aggregation, inflammation and vasoconstrictors. Further research is required before supplementation of Omega 3 or Omega 6 should be recommended19.


Micronutrients20

Zinc

  • Should only be supplemented if deficiency is determined
  • Recommended dose: 40mg of elemental zinc/day (176 mg zinc sulfate) for up to 10 days to enhance wound healing

Ascorbic Acid (Vitamin C)

  • Recommended dose: 500 to 1000 mg daily in divided doses

Vitamin A

  • Recommended in patients taking corticosteroids
  • Recommended dose: 10,000-25,000 IU daily for 10-14 days
  • Use with caution in patients with protein deficiencies or liver failure


Optimize Medical Therapy
  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. Registered Nurses Association of Ontario. Nursing Best Practice Guideline: Assessment and Management of Venous Leg Ulcers. March 2004.
  3. Registered Nurses Association of Ontario. Nursing Best Practice Guideline Supplement: Assessment and Management of Venous Leg Ulcers. March 2007.
  4. WOCN Clinical Fact Sheet Quick Assessment of Leg Ulcers (November 2009) by CarePartners (2014)
  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. Photos courtesy of:http://www.medetec.co.uk
  8. Hirsch AT, Criqui MH, et al. Peripheral Arterial Disease Detection Awareness and Treatment in Primary Care. JAMA, 2001. September 19:286 (11):1317-24.
  9. Burrows C, Miller R, et al. Best Practice Recommendations for the Prevention and Treatment of Venous Leg Ulcers: Update 2006. Wound Care Canada. 2006;4(1).
  10. Jahromi Afshin, Vascular Surgeon, Guelph General Hospital 2015.
  11. Registered Nurses Association of Ontario. Nursing Best Practice Guideline Supplement: Assessment and Management of Venous Leg Ulcers. March 2007.
  12. 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.
  13. Despatis,M.,Shapera,L.,Parslow,N.Woo,K.(2008) Complex Wounds Wound Care Canada 8(2):24‐25.
  14. Molnar J.A, Underdown M.J, Clark W.A. Nutrition and Chronic Wounds. Advances in Wound Care. Volume 3 Number 11. 2014.
  15. Molnar J.A, Underdown M.J, Clark W.A. Nutrition and Chronic Wounds. Advances in Wound Care. Volume 3 Number 11. 2014.
  16. Molnar J.A, Underdown M.J, Clark W.A. Nutrition and Chronic Wounds. Advances in Wound Care. Volume 3 Number 11. 2014.
  17. Molnar J.A, Underdown M.J, Clark W.A. Nutrition and Chronic Wounds. Advances in Wound Care. Volume 3 Number 11. 2014.
  18. Molnar J.A, Underdown M.J, Clark W.A. Nutrition and Chronic Wounds. Advances in Wound Care. Volume 3 Number 11. 2014.
  19. Molnar J.A, Underdown M.J, Clark W.A. Nutrition and Chronic Wounds. Advances in Wound Care. Volume 3 Number 11. 2014.
  20. Molnar J.A, Underdown M.J, Clark W.A. Nutrition and Chronic Wounds. Advances in Wound Care. Volume 3 Number 11. 2014.

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