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Arterial and Venous Ulcers Presented by Amelia E. Quiz Emory University
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Objectives Define arterial and venous ulcer through: Disease etiology Patient’s history Clinical presentation Discuss assessment and diagnostic components. Determine management or treatment strategies.
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ARTERIAL ULCERS Ulcers resulting from peripheral arterial disease (PAD).
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VENOUS ULCERS Ulcers resulting from venous insufficiency or venous HTN.
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DISEASE EPIDEMIOLOGY: ARTERIAL ULCERS Increases with age Greater among men (CDC, 2002)
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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).
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Impact on the Quality of Life Affects lifestyle Inability to work Social isolation Frequent hospitalizations or clinic visits Feelings of anger and resentment
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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
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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
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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
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Clinical Presentation of Arterial Ulcers (cont’d)
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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)
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Clinical Presentation of Venous Ulcers (cont’d)
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ASSESSMENT AND DIAGNOSTICS PHYSICAL EXAM Vascular Assessment Sensorimotor Assessment Ulcer Assessment
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Vascular Assessment Color/response to elevation and dependency Temp./warmth Status of skin/hair/nails
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Vascular Assessment (cont’d) Pulses – venous and capillary refill Edema
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Vascular Assessment (cont’d) ABI
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Sensorimotor Assessment Response to 5.07 monofilament Vibratory response Position sense
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Sensorimotor Assessment (cont’d) Toe/Foot deformities Gait/Wear patterns of footwear
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Ulcer Assessment Location Dimensions & depth Appearance/color or wound bed Status of wound edges Volume of exudate Status of surrounding tissue
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DIAGNOSTICS LAB WORK-UP CBC ESR FBS Serum Albumin & transferrin levels
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DIAGNOSTICS (cont’d) Arterial Ulcers Arterial duplex ultrasound
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DIAGNOSTICS (cont’d) Arterial Ulcers Plethysmography Transcutaneous pressure of oxygen (TcPO2)
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DIAGNOSTICS (cont’d) Venous Ulcers Color duplex ultrasound scanning
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Guidelines for Management (Etiology, Systemic Factors & Topical Treatment) ARTERIAL ULCERS Surgical options Hyperbaric O2 Tx Pharmacologic Tx
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Guidelines for Management (Etiology, Systemic Factors & Topical Treatment) cont’d ARTERIAL ULCERS Behavioral strategies
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Guidelines for Management (Etiology, Systemic Factors & Topical Treatment) cont’d ARTERIAL ULCERS Topical Therapy
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Guidelines for Management (Etiology, Systemic Factors & Topical Treatment) VENOUS ULCERS Surgical options Limb elevation Pharmacologic Therapy
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Guidelines for Management (Etiology, Systemic Factors & Topical Treatment) cont’d VENOUS ULCERS Compression Therapy
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Guidelines for Management (Etiology, Systemic Factors & Topical Treatment) cont’d VENOUS ULCERS Topical Therapy
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Guidelines for Management (Etiology, Systemic Factors & Topical Treatment) cont’d VENOUS ULCERS Bioengineered Tissue
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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
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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
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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.
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That’s all folks!!!
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