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Sharon D. White, BSN,RN,CWOCN University of Alabama - Birmingham.

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Presentation on theme: "Sharon D. White, BSN,RN,CWOCN University of Alabama - Birmingham."— Presentation transcript:

1 Sharon D. White, BSN,RN,CWOCN University of Alabama - Birmingham

2 1. Identify different types of lower leg ulcers 2. Describe at least 3 major risk factors that may contribute to arterial, venous and diabetic ulcers 3. Identify the characteristics of arterial, venous and diabetic ulcer 4. List at least 2 interventions for treating arterial, venous and diabetic ulcers

3  PVD (peripheral vascular disease) ~ 2 million American  Venous stasis ulcers affects 500, ,000 people in the US every year.  VLU-cost per patient exceeds $40,000  Total estimated cost to the US health care system is > 1 billion per year (Fletcher 2011)  Diabetes Mellitus (DM) affects ~25.8 million Americans in 2011  15-25% of DM are at risk for developing foot ulcers  $1 in $10 health care dollar in 2010 were attributable to DM (Guffanti 2014)

4  Lower Extremity Arterial Disease (LEAD)  Atherosclerosis in the older adults  Premature atherosclerotic disease or thromboangitis obliterans (Buerger’s Disease)in younger adults

5  Risk Factors  Reversible ▪ Hypertension (controlled) ▪ Diabetes (controlled) ▪ Cigarette smoking ▪ Obesity ▪ Sedentary lifestyle  Irreversible ▪ Male ▪ Strong family history

6  Assessment  Patient history (assessing for risk factors)  Pain ▪ Location ▪ Character ▪ Exacerbating and relieving factors  Ulcer History ▪ Onset ▪ Precipitating factors ▪ Past and Present treatment ▪ Progress/regression

7  Signs and Symptoms  Location ▪ Tips of toes ▪ Pressure Points ▪ Areas of trauma  Wound Bed  Exudate  Wound Edges

8  Management  Diagnostic test Ankle Brachial Index (ABI) The ankle-brachial index (ABI) is the ratio of the systolic blood pressure (SBP) measured at the ankle to that measured at the brachial artery

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10  Surgical  Bypass Grafts  Angioplasty  Pharmacologic  Antithrombotics  Hemorrheologics  Analgesics  Lifestyle Changes  Cessation of Tobacco Use  HBOT  Topical Therapy

11  Lower Extremity Neuropathic Disease (LEND)  LEND is the result of a long history of uncontrolled diabetes  Diabetic foot ulcers result from the simultaneous actions of multiple contributing causes. The major underlying causes are noted to be peripheral neuropathy and ischemia from peripheral vascular disease

12  Risk Factors  Advanced Age  Diabetes  Hansen’s disease  Heredity  Smoking  HIV/AIDS  HTN, Obesity, Raynaud’s disease, scleroderma, hypo/hyperthyroidism, COPD  Spinal Cord Injury, orthopedic procedures  Malabsorption syndrome due to bariatric surgery, celiac disease  History of previous ulcers  History of amputation  Vascular insufficiency

13  Common Location  Plantar Foot  Metatarsal head  Dorsal and distal aspects of toes  Heels  Wound Appearance  Pale, pink, necrosis, eschar  Size  Edges well defined- undermining  Shape- round or oblong  Exudate- small to moderate- odor

14  Surrounding Skin  Color  Fissures, maceration  Callus  Musculo-skeletal/foot deformities  Edema  Tempature  Tinea pedis  Diabetic skin markers

15 Monofilament testing

16  Nails  Dystrophic, hypertrophy, Onychomycosis, paronychia  Complications  Infection  Arterial ischemia  Osteomyelitis  Charcot fracture  Gangrene  Pain  Perfusion

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18  Grade I-A: non-infected, non-ischemic superficial ulceration  Grade I-B: infected, non-ischemic superficial ulceration  Grade I-C: ischemic, non-infected superficial ulceration  Grade I-D: ischemic and infected superficial ulceration   Grade II-A: non-infected, non-ischemic ulcer that penetrates to capsule or bone  Grade II-B: infected, non-ischemic ulcer that penetrates to capsule or bone  Grade II-C: ischemic, non-infected ulcer that penetrates to capsule or bone  Grade II-D: ischemic and infected ulcer that penetrates to capsule or bone   Grade III-A: non-infected, non-ischemic ulcer that penetrates to bone or a deep abscess  Grade III-B: infected, non-ischemic ulcer that penetrates to bone or a deep abscess  Grade III-C: ischemic, non-infected ulcer that penetrates to bone or a deep abscess  Grade III-D: ischemic and infected ulcer that penetrates to bone or a deep abscess

19  Grade 0: No ulcer in a high risk foot.  Grade 1: Superficial ulcer involving the full skin thickness but not underlying tissues.  Grade 2: Deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation.  Grade 3: Deep ulcer with cellulitis or abscess formation, often with osteomyelitis.  Grade 4: Localized gangrene.  Grade 5: Extensive gangrene involving the whole foot.

20  Improve Tissue Perfusion  Prevent Trauma  Offload wounds  Proper Footwear  Use assistive devices for support, balance and additional offloading  Pressure redistribution devices while in bed  Routine professional nails care- Podiatrist  Avoid chemical, thermal, mechanical injury

21  Topical Therapy  Prevent Trauma  Treat Infection  Promote wound healing ▪ Moist wound healing ▪ Debridement ▪ Avoid occlusive dressing  Adjunctive Therapy ▪ HBOT ▪ Skin substitutes ▪ NPWT ▪ Growth factors ▪ Surgery to correct deformities

22 Diabetic Shoes CAM Walker C.R.O.W. Total Contact Casting

23  Lower Extremity Venous Disease (LEVD)  Lower extremity venous leg ulcers are caused by chronic venous hypertension.

24  Risk Factors  Advanced Age  Obesity  Pregnancy  Systemic Inflammation  Venous thromboembolism  Varicose veins  Pulmonary embolus  Sedentary lifestyle  Trauma/leg fractures  Family hx of venous disease  Previous wound  Injection drug user  Impair calf muscle pump  Restricted range of motion of the ankle

25  Location  Malleolus  Medial aspect of leg superior to medial malleolus  Appearance:  Wound depth – usually shallow,  superficial crater  Wound edges – irregular  Wound bed – ruddy red  yellow adherent or loose slough  Amount of exudate – moderate to high

26  Pain – variable; dull aching, heaviness, or cramping  Edema – generalized, often worsens during the day  Skin Conditions  Periwound margin: macerated, crusty  Dermatitis – inflammatory process due to extravasation of proteolytic enzymes and metabolic waste into tissues  Scaling  Hemosiderin staining  Fibrotic tissue  Atrophe blanche, white, fragile tissue with tiny, tortuous blood vessels  Ankle flare  Scarring from previous ulcers

27  Management  Diagnostic Test ▪ Non-Invasive ▪ Capillary Refill- < 3 seconds ▪ Venous Refill- < 20 seconds ▪ ABI – within normal limits ( ) ▪ Sensory/neuropathy ▪ Vascular Studies ▪ Venous duplex imaging ▪ Doppler Ultrasound ▪ Photoplethysmography, ▪ Venography ▪ Labs

28  Debridement  Compression Therapy  mmHg –ABI > 0.8  mmHg- ABI < 0.8  Do NOT apply compression if ABI < 0.5 ▪ Short stretch bandages (e.g. Setopress, Surepress, Comprilan) ▪ Unna’s Boot ▪ Multi-layer- 2 or 4 layer wraps ▪ Intermittent pneumatic compression  Surgical  Obliterate damaged vein  Subfascial endoscopic perforator surgery (SEPS)  Topical Therapy  Treat infection  Topical steroids  Topical emollients  Topical analgesics

29  Patient Education  Prevention is critical to manage re-occurrence  Re-occurrence rates 26% to 69% following ulcer healing*  Principles of Venous Leg Ulcer Prevention  Wear bandages or stockings  Elevate legs for 15+ minutes several times a day  Exercise – walk, cycle  Avoid standing in one position  Don’t wear constricting clothing  Protect legs from trauma  Pay attention to legs

30 UNNA’s BOOT 2- LAYER WRAP 4- LAYER WRAP

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32  https://youtu.be/FqKjBE6_0AU https://youtu.be/FqKjBE6_0AU  https://youtu.be/l0iuNjZ0SmQ https://youtu.be/l0iuNjZ0SmQ

33 Venous Diabetic Arterial

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36  achial_Index_Quick_R.pdf achial_Index_Quick_R.pdf   Fletcher, S.,2011. Successful treatment of venous stasis ulcers with combination compression therapy and pulsed radio frequency energy in a patient scheduled for amputation. Journal of Wound, Ostomy, Continence Nursing. 38(1): Guffanti, A., Negative pressure wound therapy in the treatment of diabetic foot ulcers: A systematic review of the literature. Journal of Wound, Ostomy, Continence Nursing: May-June (41) 3: 233–237. doi: /WON

37  COMPRESSION THERAPY


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