1. Arterial and Venous Ulcers Presented by Amelia E. Quiz Emory University

2. Objectives Define arterial and venous ulcer through:  Disease etiology  Patient’s history  Clinical presentation Discuss assessment and diagnostic components. Determine management or treatment strategies.

3. ARTERIAL ULCERS  Ulcers resulting from peripheral arterial disease (PAD).

4. VENOUS ULCERS  Ulcers resulting from venous insufficiency or venous HTN.

5. DISEASE EPIDEMIOLOGY: ARTERIAL ULCERS  Increases with age  Greater among men (CDC, 2002)

6. 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).

7. Impact on the Quality of Life Affects lifestyle Inability to work Social isolation Frequent hospitalizations or clinic visits Feelings of anger and resentment

8. 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

9. 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

10. 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

11. Clinical Presentation of Arterial Ulcers (cont’d)

12. 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)

13. Clinical Presentation of Venous Ulcers (cont’d)

14. ASSESSMENT AND DIAGNOSTICS PHYSICAL EXAM  Vascular Assessment  Sensorimotor Assessment  Ulcer Assessment

15. Vascular Assessment  Color/response to elevation and dependency  Temp./warmth  Status of skin/hair/nails

16. Vascular Assessment (cont’d)  Pulses – venous and capillary refill  Edema

17. Vascular Assessment (cont’d)  ABI

18. Sensorimotor Assessment  Response to 5.07 monofilament  Vibratory response  Position sense

19. Sensorimotor Assessment (cont’d)  Toe/Foot deformities  Gait/Wear patterns of footwear

20. Ulcer Assessment Location Dimensions & depth Appearance/color or wound bed Status of wound edges Volume of exudate Status of surrounding tissue

21. DIAGNOSTICS LAB WORK-UP  CBC  ESR  FBS  Serum Albumin & transferrin levels

22. DIAGNOSTICS (cont’d) Arterial Ulcers  Arterial duplex ultrasound

23. DIAGNOSTICS (cont’d) Arterial Ulcers  Plethysmography  Transcutaneous pressure of oxygen (TcPO2)

24. DIAGNOSTICS (cont’d) Venous Ulcers  Color duplex ultrasound scanning

25. Guidelines for Management (Etiology, Systemic Factors & Topical Treatment) ARTERIAL ULCERS Surgical options Hyperbaric O2 Tx Pharmacologic Tx

26. Guidelines for Management (Etiology, Systemic Factors & Topical Treatment) cont’d ARTERIAL ULCERS Behavioral strategies

27. Guidelines for Management (Etiology, Systemic Factors & Topical Treatment) cont’d ARTERIAL ULCERS Topical Therapy

28. Guidelines for Management (Etiology, Systemic Factors & Topical Treatment) VENOUS ULCERS Surgical options Limb elevation Pharmacologic Therapy

29. Guidelines for Management (Etiology, Systemic Factors & Topical Treatment) cont’d VENOUS ULCERS Compression Therapy

30. Guidelines for Management (Etiology, Systemic Factors & Topical Treatment) cont’d VENOUS ULCERS Topical Therapy

31. Guidelines for Management (Etiology, Systemic Factors & Topical Treatment) cont’d VENOUS ULCERS Bioengineered Tissue

32. 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

33. 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

34. References  (1)Bryant, R. (2000). Acute and chronic wounds. Nursing management. (2 nd ed.) St. Louis, MO: Mosby.  (2) CDC Data & Trends (2005). Retrieved April 5, 2007 from http://www.cdc.gov/diabetes/statistics/hosplea/fig4.htm 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.

35. That’s all folks!!!