arterial and venous ulcers presented by amelia e. quiz emory university
TRANSCRIPT
Arterial and Venous Ulcers
Presented by Amelia E. Quiz
Emory University
Objectives
Define arterial and venous ulcer through: Disease etiology Patient’s history Clinical presentation
Discuss assessment and diagnostic components.
Determine management or treatment strategies.
ARTERIAL ULCERS Ulcers resulting from
peripheral arterial disease (PAD).
VENOUS ULCERS Ulcers resulting
from venous insufficiency or venous HTN.
DISEASE EPIDEMIOLOGY:ARTERIAL ULCERS
Increases with age Greater among men
(CDC, 2002)
DISEASE EPIDEMIOLOGY: VENOUS ULCERS
Incidence and prevalence have not been well established (5).
The prevalence of venous ulcer varies greatly (4).
Unhealed venous ulcer is approximately 0.3%,
i.e. about 1 in 350 adults (2).
70% of chronic ulcers of the lower limbs (2).
Greater among women (2). Increases with age (65 & older) (5).
Impact on the Quality of Life
Affects lifestyle Inability to work Social isolation Frequent hospitalizations or clinic
visits Feelings of anger and resentment
DISEASE ETIOLOGY: Risk factors
ARTERIAL ULCERS Atherosclerosis Hx of MI or CVA Hyperlipidemia DM Tobacco use Hypertension Hyper-
homocystinemia
VENOUS ULCERS DVT Obesity Multiple
pregnancies Limited ROM ankle
joint Sedentary lifestyle Thrombophilia
Pt’s. history, Focused PE, Symptoms and Complaints
Ulcer History Onset Duration Prior treatment Response to
treatment
Pain History Severity Description Exacerbating
factors Relieving factors Location
Clinical Presentation of Arterial Ulcers
Location –distal aspect of extremity, pressure points of the foot, area of trauma
Wound size & shape – small craters; well-defined borders (punched out)
Wound bed – pale or necrotic
Exudate – minimal or dry, no edema
Surrounding skin – faint halo of erythema or slight fluctuance. Gangrene, necrosis or infection is common
Increased pain & tenderness
Clinical Presentation of Arterial Ulcers (cont’d)
Clinical Presentation of Venous Ulcers
Location – gaiter area, particularly medial malleolus
Wound edges and depth – irregular edges and shallow
Wound bed – ruddy red; yellow adherent or loose slough; undermining or tunnels uncommon
Exudate – large Surrounding skin –
macerated, crusted, scaling, hemosiderosis, edema, dermatitis
Pain – variable (dull, aching or bursting)
Clinical Presentation of Venous Ulcers (cont’d)
ASSESSMENT AND DIAGNOSTICS
PHYSICAL EXAM Vascular Assessment Sensorimotor Assessment Ulcer Assessment
Vascular Assessment Color/response to
elevation and dependency
Temp./warmth Status of
skin/hair/nails
Vascular Assessment (cont’d) Pulses – venous
and capillary refill Edema
Vascular Assessment (cont’d)
ABI
Sensorimotor Assessment Response to
5.07 monofilament
Vibratory response
Position sense
Sensorimotor Assessment (cont’d)
Toe/Foot deformities Gait/Wear patterns of footwear
Ulcer Assessment
Location Dimensions &
depth Appearance/color
or wound bed Status of wound
edges Volume of exudate Status of
surrounding tissue
DIAGNOSTICS LAB WORK-UP CBC ESR FBS Serum Albumin &
transferrin levels
DIAGNOSTICS (cont’d)
Arterial Ulcers Arterial duplex
ultrasound
DIAGNOSTICS (cont’d) Arterial Ulcers Plethysmography Transcutaneous
pressure of oxygen (TcPO2)
DIAGNOSTICS (cont’d)
Venous Ulcers Color duplex
ultrasound scanning
Guidelines for Management
(Etiology, Systemic Factors & Topical Treatment)
ARTERIAL ULCERS Surgical options Hyperbaric O2 Tx Pharmacologic Tx
Guidelines for Management
(Etiology, Systemic Factors & Topical Treatment) cont’d
ARTERIAL ULCERS Behavioral
strategies
Guidelines for Management
(Etiology, Systemic Factors & Topical Treatment) cont’d
ARTERIAL ULCERS Topical Therapy
Guidelines for Management
(Etiology, Systemic Factors & Topical Treatment)VENOUS ULCERS Surgical options Limb elevation Pharmacologic
Therapy
Guidelines for Management
(Etiology, Systemic Factors & Topical Treatment) cont’d
VENOUS ULCERS Compression
Therapy
Guidelines for Management
(Etiology, Systemic Factors & Topical Treatment) cont’d
VENOUS ULCERS Topical Therapy
Guidelines for Management(Etiology, Systemic Factors & Topical Treatment) cont’d
VENOUS ULCERS Bioengineered
Tissue
Case studies 65 y/o obese female,
retired nurse H/O multiple
pregnancies, DVT CC –Swelling and
aching pain on bil. Lower ext., pain is worse toward the end of the day. Relieved by elevation.
PE – Lower ext. - Edema, erythema, scaling, hemosiderosis
Diagnostics Treatment plan
Case studies 58 y/o male, auto
mechanic H/O smoking, DM2,
HTN, FH of MI & CVA CC – Before, “pain” on
the lower extremities while walking that is relieved by rest; now pain is present even at rest.
PE – Lower Ext - barely palpable pulse, pain, pallor, poikilothermia (cold), necrosis
Diagnostics Treatment
References (1)Bryant, R. (2000). Acute and chronic wounds. Nursing
management. (2nd ed.) St. Louis, MO: Mosby. (2) CDC Data & Trends (2005). Retrieved April 5, 2007 from
http://www.cdc.gov/diabetes/statistics/hosplea/fig4.htm (3) Fernandes Abbade, Luciana P., & Lastória, Sidnei (2005).
Venous ulcer: epidemiology, physiopathology, diagnosis and treatment International Journal of Dermatology. 44 , 449 –456
(4) Fowkers FGR, Evans CJ, Lee AJ. Prevalence and risk factors of chronic venous insufficiency. Angiology 2001; 52 : S5–S6.
(5) Margolis, DJ., Bilker, W., Santanna, J., Baumgarten, M. (2002). Venous leg ulcer: incidence and prevalence in the elderly. J Am Acad Dermatol. Mar;46(3):381-6.
Donnelly, Richard, Hinwood, David & London, Nick J M (2000). ABC of arterial and venous disease: Non-invasive methods of
arterial and venous assessment. StudentBMJ. August 08:259-302.
That’s all folks!!!