Arterial Leg Ulcer Clinical Pathway

Transcription

1 Waterloo Wellington Integrated Wound Care Program Evidence-Based Wound Care Arterial Leg Ulcer Clinical Pathway 0-7 Days Expected Outcomes Notes Patient admitted to service/facility Most Responsible Physician(MRP)/Nurse Practitioner (NP) identified/informed Medical/surgical history and co-morbidity management considered within care plan Current ongoing adjunctive therapies integrated into care plan Refer patient to Care Connects if no responsible practioner currently involved with patient Determine if MRP/NP is part of family health team (FHT) or community health centre (CHC) and consider additional supports available Risk factors include: Chronic renal disease Smoking Congestive heart failure Diabetes mellitus Impaired liver function Hyperlipidemia Use of systemic steroids, Hypertension immunosuppressives and chemotherapy Poor nutrition >70 years of age Low hemoglobin Age years with history of diabetes Obesity or smoking Decreased thyroid function < 50 years with diabetes and one other Coronary artery disease atherosclerotic factor Psoriasis History of vascular surgery or deep vein History of cerebral vascular accident thrombosis (CVA) Bleeding disorders Autoimmune diseases Family history of arterial disease Medication reconciliation and their impact on wound healing reviewed Recent blood work and other diagnostic test results reviewed and implictions for wound healing considered Physical examination performed Prescription, non-prescription, naturopathic and illicit drug use (including e-cigarettes, inhaled substances and nicotine replacement therapy) Medications that can affect healing include: chemotherapy, anticoagulants, antiplatelets, corticosteroids, vasoconstrictors, antihypertensives, diuretics and immunosepressive drugs Other medications used to treat acute episodic illnesses may affect healing (eg. antibiotics, colchicine, anti-rheumatoid arthritics) Vitamin and mineral supplementation Determine bloodwork and other diagnostic tests required Waterloo Wellington Integrated Wound Care Program Arterial Pathway May

2 Bilateral lower leg assessment completed Signs and symptoms of Peripheral Arterial Disease could include: Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication) Dependent rubor in lower legs and feet Pallor in feet on elevation Dry, shiny skin on lower legs Edema subsequent to leg being dependent Thick or flaking toe nails Hairless lower legs and feet Weak or absent pulses Intense hyperesthesia (sensitive to light touch) Limb muscle may appear wasted from ischemic atrophy Delayed capillary refill Distal gangrene Erectile dysfunction in men Non-healing wound ABPI 0.5 to 0.8 TBPI 0.64 to 0.7 Suggest Transcutaneous Oxygen Pressure(TcPo 2 ), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies ABPI <0.5 TBPI <0.64 Urgent vascular surgical consult needed ABPI/TPBI completed within last 3 mths 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) Leg measurements (foot, ankle, calf, thigh) 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 Wound Assessment completed Complete: Bates-Jensen Wound Assessment Tool (BWAT) OR 4 P s of Arterial Ulcers Leg Ulcer Measurement Tool (LUMT) Pale wound base Determine wound etiology Punched-out appearance Arterial ulcers are typically pale at base of wound, have punched out appearance, are more painful than expected and have low to no exudate Painful Results of LLA and ABPI/TPBI Parched (low to no exudate) Document percentage of healing since last visit Assessment for infection (NERDS and STONEES) Obtain photos following best practice as per framework for individual organization policies and procedures. Suggest following publication as guideline: Waterloo Wellington Integrated Wound Care Program Arterial Pathway May

3 Compression therapy history documented and considered in plan Compression is typically contraindicated in the presence of peripheral arterial disease. In some circumstances light compression may be beneficial, but only if arterial supply is sufficient. Sufficient arterial supply should be objectively evidenced by diagnostic tests. In such cases, compression should be ordered by an advanced wound care physician or nurse practitioner only! Pain management initiated Arterial pain is typically described as: Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication) History of: Previous compression garments Age of compression garments Adherence Application and removal of compression in past Finances Reason compression treatment plan has changed if applicable Complete: Brief Pain Inventory Short Form (BPI-SF) Obtain physician/nurse practitioner orders for analgesics (opioids and non-opioids) Patient s nutritional status optimized Review blood work results Calculate Body Mass Index (BMI) Determine recent weight loss/gain Complete Mini Nutritional Assessment (MNA) If screening section results < 11 = complete assessment section If Assessment section results< 24 = Registered Dietician referral required Wound etiology and appropriate pathway established Patient and caregiver concerns and goals integrated into the care plan and shared with care team Wound treatment plan determined in accordance to treatment goal (healable, maintenance or non-healable) Caution: USE DRY WOUND HEALING 1. Keep eschar dry 2. No occlusive dressings 3. Do NOT debride 4. Avoid tourniquet effect when securing dressings 5. If eschar becomes wet/boggy URGENT referral to advanced wound care specialist is recommended Complete: Cardiff Wound Impact Questionnaire OR World Health Organization Quality of Life (WHOQOL) form Arrange for physician/nurse practitioner orders as required to begin plan of care including agreeance to professional referral recommendations Identify any potential barriers to wound treatment plan Utilize toolkit to determine wound cleansing, debridement and dressing selection (South West Region Wound Care Program: Wound Cleansing Table and Dressing Selection and Cleansing enablers and CAWC Product Picker chart) Waterloo Wellington Integrated Wound Care Program Arterial Pathway May

4 Patient counselled on the benefit of activity rest and head elevation in moderation (balancing need for pressure relief) for comfort measures and wound healing Recent changes in overall activity level Daily routine Personal assistance available to perform activities of daily living Ankle range of motion allowing for calf muscle pump to function Determine where patient sleeps at night Patient/caregiver educational plan initiated Emergency signs and symptoms of Peripheral Arterial Disease that require immediate medical attention (refer to lower leg assessment section) Compression is typically contraindicated in the presence of peripheral arterial disease. In some circumstances light compression may be beneficial. In such cases, compression should be ordered by an advanced wound care physician or nurse practitioner only! See algorithm in guidelines. Risks of compression Smoking cessation including e-cigarettes and nicotene replacement Appropriate footwear as discussed with foot care specialist (encourage use of white socks) Skin care Nail care (suggest use of foot care specialist) Wound self care Pain management Encourage patient to sleep in bed with no lower limb elevation (most arterial pain increases when feet elevated above heart level) Mobility and dexterity aids currently being used Safety of transfers Recommendations for exercise Consider Occupational Therapist referral for comfort measures Diagnostic testing Dietary Rest/Activity Prevention of injury avoid extremes (hot/cold, loose/tight) When to call primary care giver (eg. signs and symptoms of infection, deep vein thrombosis, cellulitis, impaired blood flow, difficulties with compression) Self lower-leg assessment Community support groups (i.e. walking groups) Other Ability to self-manage optimized Barriers to participate (transportation, socioeconomic, social environment, other co-morbidities) Cognitive ability Review importance and potential barriers to smoking cessation at every visit Hygeine Waterloo Wellington Integrated Wound Care Program Arterial Pathway May Foot inspection (including bottom of foot and between toes) Enviroment Wound care Compression application and removal if prescribed Coping strategies implemented into plan of care Patient s concerns and fears Signs of anxiety or other mental health issues (eg. delusions, hallucinations, paranoid behaviour) Depression screen using Geriatric Depression Scale assessment form GDS15 Suicide assessment if applicable ETOH and illicit /recreational drug use

5 Family and caregiver support identified and incorporated into plan Family/caregiver actively able to participate in treatment plan of care Social supports/community resources currently utilized is integrated Family support into plan of care Funding Community resources Caregiver conflicts Long or short term placement Assistance provided for financial concerns patient is experiencing Determine: Private insurance availability Eligibility for Assistive Devices Program (ADP [lymphedema only], ODSP, High-needs fund, Veterans Affairs Canada or Aborignal Services) Professional referrals are initiated Primary Care Physician Pharmacist Advanced Wound Specialist Occupational Therapist Nurse Practitioner Physiotherapy Infectious Disease Specialist Chiropodist Vascular Surgeon Certified Pedorothist Dermatologist Certified Orthotist Plastic surgeon Certified Prosthetist Internist/Endocrinologist Podiatrist Mental Health Specialist Lymphatic Massage Psychologists Compression Stocking Fitter Social work Other: Registered Dietitian Physician/nurse practitioner orders received as required to change plan of care including agreeance to professional referral recommendations Appropriate documents shared Identify need to reassess ABPI/TPBI in 6 months Acute care Lower leg assessment Complex Continuing Care/Rehab Recent vascular study results (eg. ABPI, TPBI, Transcutaneous Oxygen Pressure(TcPo 2 ), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies) Long-term care Community care Primary care physician/nurse Practioner Professionals referred to Relevant consultation notes Other Diagnostic results Current treatment plan If wound closed or eschar is stable send discharge summary outlining outstanding issues and teaching completed to: Referral source and most responsible physician (MRP)/nurse Waterloo Wellington Integrated Wound Care Program Arterial Pathway May

6 practitioner (NP) 8-21 Days Expected Outcomes Notes Most Responsible Physician(MRP)/Nurse Practitioner (NP) identified/informed Assessment of wound performed and percentage of healing documented 4 P s of Arterial Ulcers Pale wound base Punched-out appearance Painful Parched (low to no exudate) Wound treatment/compression plan is being followed Communication with primary care physician and/or Nurse Practioner to update on any significant changes in patient s condition. Refer patient to Care Connects if no responsible practioner currently involved with patient Determine if MRP/NP is part of family health team (FHT) or community health centre (CHC) and consider additional supports available Complete: Bates-Jensen Wound Assessment Tool (BWAT) OR Leg Ulcer Measurement Tool (LUMT) Determine wound etiology Arterial ulcers are typically pale at base of wound, have punched out appearance, are more painful than expected and have low to no exudate Results of LLA and ABPI/TPBI Document percentage of healing since admission Assessment for infection (NERDS and STONEES) Potential need for wound care specialist considered if wound healing is not progressing and infection is absent Obtain photos following best practice as per framework for individual organization policies and procedures. Suggest following publication as guideline: Review: Adherence to plan Real or potential barriers to wound treatment plan Caution: USE DRY WOUND HEALING 1. Keep eschar dry 2. No occlusive dressings 3. Do NOT debride 4. Avoid tourniquet effect when securing dressings 5. If eschar becomes wet/boggy URGENT referral to algorithm in guidelines. Waterloo Wellington advanced wound Integrated care specialist Wound Care is recommended Program Arterial Pathway May Compression is typically contraindicated in the presence of peripheral arterial disease. In some circumstances light compression may be beneficial. In such cases, compression should be ordered by an advanced wound care physician or nurse practitioner only! See

7 Pain management reviewed Arterial pain is typically described as: Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication) Medical/surgical history and co-morbidity management considered within care plan Medication reconciliation and their impact on wound healing reviewed Review for changes Brief Pain Inventory Short Form (BPI-SF) Obtain physician/nurse practitioner orders for analgesics required (opioids and nonopioids) Review for changes Review for changes: Prescription, non-prescription, naturopathic and illicit drug use Recent blood work and other diagnostic test results reviewed and implictions for wound healing considered Determine bloodwork and other diagnostic tests required Bilateral lower leg assessment completed Signs and symptoms of Peripheral Arterial Disease could include: Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication) Dependent rubor in lower legs and feet Pallor in feet on elevation Dry, shiny skin on lower legs Edema subsequent to leg being dependent Thick or flaking toe nails Hairless lower legs and feet Weak or absent pulses Intense hyperesthesia (sensitive to light touch) Limb muscle may appear wasted from ischemic atrophy Delayed capillary refill Distal gangrene Erectile dysfunction in men Non-healing wound ABPI/TPBI completed within last 3 mths 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) Leg measurements (foot, ankle, calf, thigh) 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 ABPI 0.5 to 0.8 TBPI 0.64 to 0.7 Suggest Transcutaneous Oxygen Pressure(TcPo 2 ), Laser Doppler Acute arterial occlusion is a life and limb-threatening situation which requires Flowmetry, Doppler Arterial Waveforms immediate emergency intervention or Segmental Doppler Pressure studies Signs and symptoms that may become severe may be associated with the following: Waterloo be Wellington performed Integrated Wound Care Program Arterial Pathway May Pale or blue skin 7 ABPI <0.5 TBPI <0.64 Skin cold to the touch Urgent vascular surgical consult needed Sudden decrease in mobility

8 Patient s nutritional status optimized Review: Recent blood work results Significant weight changes Adherence to diet plan Identify barriers to good nutrition Patient and caregiver concerns and goals integrated into the care Review for changes: plan and shared with care team Cardiff Wound Impact Questionnaire OR World Health Organization Quality of Life (WHOQOL) form Patient counselled on the benefit of activity rest and head elevation Review for changes: Encourage patient to sleep in bed with in moderation (balancing need for pressure relief) for comfort Recent changes in overall activity level no lower limb elevation (most arterial measures and wound healing Daily routine pain increases when feet elevated Personal assistance available to above heart level) perform activities of daily living Mobility and dexterity aids currently Ankle range of motion allowing for calf being used muscle pump to function Safety of transfers Determine where patient sleeps at Recommendations for exercise night Consider Occupational Therapist referral for comfort measures Patient/caregiver educational needs reviewed using teach-back Emergency signs and symptoms of Diagnostic testing method Peripheral Arterial Disease that require Dietary immediate medical attention (refer to Rest/Activity lower leg assessment section) Prevention of injury avoid extremes Risks of compression (hot/cold, loose/tight) Smoking cessation including e- cigarettes and nicotene replacement When to call primary care giver (eg. signs and symptoms of infection, deep Appropriate footwear as discussed with foot care specialist (encourage use of white socks) vein thrombosis, cellulitis, impaired blood flow, difficulties with compression) Skin care Self lower-leg assessment Nail care (suggest use of foot care specialist) Community support groups (i.e. walking groups) Wound self care Other Pain management Ability to self-manage optimized Review for changes: Hygeine Waterloo Wellington Integrated Wound Care Program Arterial Pathway May

9 Coping strategies implemented into plan of care Family and caregiver support identified and incorporated into plan of care Adherence to plan Foot inspection (including bottom of Barriers to participate (transportation, foot and between toes) socioeconomic, social environment, Enviroment other co-morbidities) Wound care Cognitive ability Compression application and removal if Review importance and potential barriers to smoking cessation at every visit prescribed Review for changes Patient s concerns and fears Signs of anxiety or other mental health issues (eg. delusions, hallucinations, paranoid behaviour) Depression screen using Geriatric Depression Scale assessment form GDS15 Suicide assessment if applicable ETOH and illicit /recreational drug use Review: Availability of assistance required Social supports/community resources currently utilized is integrated Family support into plan of care Funding Community resources Caregiver conflicts Long or short term placement Assistance provided for financial concerns patient is experiencing Review: Private insurance availability Eligibility for Assistive Devices Program (ADP [lymphedema only], ODSP, High-needs fund, Veterans Affairs Canada or Aborignal Services) Professional referral status reviewed Primary Care Physician Pharmacist Advanced Wound Specialist Occupational Therapist Nurse Practitioner Physiotherapy Infectious Disease Specialist Chiropodist Vascular Surgeon Certified Pedorothist Dermatologist Certified Orthotist Plastic surgeon Certified Prosthetist Internist/Endocrinologist Podiatrist Mental Health Specialist Lymphatic Massage Psychologists Compression Stocking Fitter Social work Other: Registered Dietitian Physician/nurse practitioner orders received as required to change plan of care including agreeance to professional referral Waterloo Wellington Integrated Wound Care Program Arterial Pathway May

10 recommendations Appropriate documents shared Identify need to reassess ABPI/TPBI in 6 months Lower leg assessment Recent vascular study results (eg. ABPI, TPBI, Transcutaneous Oxygen Pressure(TcPo 2 ), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies) Relevant consultation notes Diagnostic results Current treatment plan Acute care Complex Continuing Care/Rehab Long-term care Community care Primary care physician/nurse Practioner Professionals referred to Other If wound closed or eschar is stable send discharge summary outlining outstanding issues and teaching completed to: Referral source and most responsible physician (MRP)/nurse practitioner (NP) Waterloo Wellington Integrated Wound Care Program Arterial Pathway May

11 21-28 Days Expected Outcomes Notes Most Responsible Physician(MRP)/Nurse Practitioner (NP) identified/informed Communication with primary care physician and/or Nurse Practioner to update on any significant changes in patient s condition. Refer patient to Care Connects if no responsible practioner currently involved with patient Determine if MRP/NP is part of family health team (FHT) or community health centre (CHC) and consider additional supports available Assessment of wound performed and percentage of healing documented 4 P s of Arterial Ulcers Pale wound base Punched-out appearance Painful Parched (low to no exudate) Arterial ulcers do not follow trajectory healing rate of venous ulcers (30% week 4 & healed at 12 weeks). Further intervention should be considered if conservative treatment does not improve healing in 4-6 weeks Wound treatment/compression plan is being followed Caution: USE DRY WOUND HEALING 1. Keep eschar dry 2. No occlusive dressings 3. Do NOT debride 4. Avoid tourniquet effect when securing dressings 5. If eschar becomes wet/boggy URGENT referral to advanced wound care specialist is recommended Complete: Bates-Jensen Wound Assessment Tool (BWAT) OR Leg Ulcer Measurement Tool (LUMT) Determine wound etiology Arterial ulcers are typically pale at base of wound, have punched out appearance, are more painful than expected and have low to no exudate Results of LLA and ABPI/TPBI Document percentage of healing since admission Assessment for infection (NERDS and STONEES) Potential need for wound care specialist considered if wound healing is not progressing and infection is absent Obtain photos following best practice as per framework for individual organization policies and procedures. Suggest following publication as guideline: Review: Adherence to plan Real or potential barriers to wound treatment plan Compression is typically contraindicated in the presence of peripheral arterial disease. In some circumstances light compression may be beneficial. In such cases, compression should be ordered by an advanced wound care physician or nurse practitioner only! See algorithm in guidelines. Pain management reviewed Review for changes Brief Pain Inventory Short Form (BPI-SF) Arterial pain is typically described as: Obtain physician/nurse practitioner orders for analgesics required (opioids and non-opioids) Waterloo Wellington Integrated Wound Care Program Arterial Pathway May

12 Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication) Medical/surgical history and co-morbidity management considered within care plan Medication reconciliation and their impact on wound healing reviewed Review for changes Review for changes: Prescription, non-prescription, naturopathic and illicit drug use Recent blood work and other diagnostic test results reviewed and implictions for wound healing considered Bilateral lower leg assessment completed Signs and symptoms of Peripheral Arterial Disease could include: Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication) Dependent rubor in lower legs and feet Pallor in feet on elevation Dry, shiny skin on lower legs Edema subsequent to leg being dependent Thick or flaking toe nails Hairless lower legs and feet Weak or absent pulses Intense hyperesthesia (sensitive to light touch) Limb muscle may appear wasted from ischemic atrophy Delayed capillary refill Distal gangrene Erectile dysfunction in men Non-healing wound Determine bloodwork and other diagnostic tests required ABPI/TPBI completed within last 3 mths 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) Leg measurements (foot, ankle, calf, thigh) 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 ABPI 0.5 to 0.8 TBPI 0.64 to 0.7 Suggest Transcutaneous Oxygen Pressure(TcPo 2 ), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies ABPI <0.5 TBPI <0.64 Urgent vascular surgical consult needed 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 Waterloo Wellington Integrated Wound Care Program Arterial Pathway May

13 Patient s nutritional status optimized Patient and caregiver concerns and goals integrated into the care plan and shared with care team Patient counselled on the benefit of activity rest and head elevation in moderation (balancing need for pressure relief) for comfort measures and wound healing Patient/caregiver educational needs reviewed using teach-back method Ability to self-manage optimized Review: Recent blood work results Significant weight changes Adherence to diet plan Identify barriers to good nutrition Review for changes: Cardiff Wound Impact Questionnaire OR World Health Organization Quality of Life (WHOQOL) form Review for changes: Encourage patient to sleep in bed with Recent changes in overall activity level no lower limb elevation (most arterial Daily routine pain increases when feet elevated Personal assistance available to perform above heart level) activities of daily living Mobility and dexterity aids currently Ankle range of motion allowing for calf being used muscle pump to function Safety of transfers Determine where patient sleeps at night Recommendations for exercise Consider Occupational Therapist referral for comfort measures Emergency signs and symptoms of Pain management Peripheral Arterial Disease that require Diagnostic testing immediate medical attention (refer to Dietary lower leg assessment section) Rest/Activity Risks of compression Prevention of injury avoid extremes Smoking cessation including e-cigarettes (hot/cold, loose/tight) and nicotene replacement When to call primary care giver (eg. Appropriate footwear as discussed with signs and symptoms of infection, deep foot care specialist (encourage use of vein thrombosis, cellulitis, impaired white socks) blood flow, difficulties with Skin care compression) Nail care (suggest use of foot care Self lower-leg assessment specialist) Community support groups (i.e. walking Wound self care groups) Other Review for changes: Adherence to plan Barriers to participate (transportation, socioeconomic, social environment, other comorbidities) Cognitive ability Review importance and potential barriers to smoking cessation at every visit Waterloo Wellington Integrated Wound Care Program Arterial Pathway May

14 Coping strategies implemented into plan of care Family and caregiver support identified and incorporated into plan of care Hygeine Foot inspection (including bottom of foot and between toes) Enviroment Wound care Compression application and removal if prescribed Review for changes Patient s concerns and fears Signs of anxiety or other mental health issues (eg. delusions, hallucinations, paranoid behaviour) Depression screen using Geriatric Depression Scale assessment form GDS15 Suicide assessment if applicable ETOH and illicit /recreational drug use Review: Availability of assistance required Social supports/community resources currently utilized is Family support integrated into plan of care Funding Community resources Caregiver conflicts Long or short term placement Assistance provided for financial concerns patient is experiencing Review: Private insurance availability Eligibility for Assistive Devices Program (ADP [lymphedema only], ODSP, High-needs fund, Veterans Affairs Canada or Aborignal Services) Professional referral status reviewed Primary Care Physician Pharmacist Advanced Wound Specialist Occupational Therapist Nurse Practitioner Physiotherapy Infectious Disease Specialist Chiropodist Vascular Surgeon Certified Pedorothist Dermatologist Certified Orthotist Plastic surgeon Certified Prosthetist Internist/Endocrinologist Podiatrist Mental Health Specialist Lymphatic Massage Psychologists Compression Stocking Fitter Social work Other: Registered Dietitian Physician/nurse practitioner orders received as required to change plan of care including agreeance to professional referral recommendations Appropriate documents shared Waterloo Wellington Integrated Wound Care Program Arterial Pathway May

15 Identify need to reassess ABPI/TPBI in 6 months Lower leg assessment Recent vascular study results (eg. ABPI, TPBI, Transcutaneous Oxygen Pressure(TcPo 2 ), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies) Relevant consultation notes Diagnostic results Current treatment plan Acute care Complex Continuing Care/Rehab Long-term care Community care Primary care physician/nurse Practioner Professionals referred to Other If wound closed or eschar is stable send discharge summary outlining outstanding issues and teaching completed to: Referral source and most responsible physician (MRP)/nurse practitioner (NP) Collaborative team/patient conference arranged to discuss barriers to healing and care plan if progression to healing is stalled Arrange a Collaborative team/patient meeting to discuss barriers to healing and care plan Waterloo Wellington Integrated Wound Care Program Arterial Pathway May

16 77-84 Days Expected Outcomes Notes Most Responsible Physician(MRP)/Nurse Practitioner (NP) identified/informed Assessment of wound performed and percentage of healing documented Wound treatment/compression plan is being followed Pain management reviewed 4 P s of Arterial Ulcers Pale wound base Punched-out appearance Painful Parched (low to no exudate) Arterial ulcers do not follow trajectory healing rate of venous ulcers (30% week 4 & healed at 12 weeks). Further intervention should be considered if conservative treatment does not improve healing in 4-6 weeks Caution: USE DRY WOUND HEALING 1. Keep eschar dry 2. No occlusive dressings 3. Do NOT debride 4. Avoid tourniquet effect when securing dressings 5. If eschar becomes wet/boggy URGENT referral to advanced wound care specialist is recommended Arterial pain is typically described as: Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication) Medical/surgical history and co-morbidity management considered within care plan Communication with primary care physician and/or Nurse Practioner to update on any significant changes in patient s condition. Refer patient to Care Connects if no responsible practioner currently involved with patient Determine if MRP/NP is part of family health team (FHT) or community health centre (CHC) and consider additional supports available Complete: Bates-Jensen Wound Assessment Tool (BWAT) OR Leg Ulcer Measurement Tool (LUMT) Determine wound etiology Arterial ulcers are typically pale at base of wound, have punched out appearance, are more painful than expected and have low to no exudate Results of LLA and ABPI/TPBI Document percentage of healing since admission Assessment for infection (NERDS and STONEES) Potential need for wound care specialist considered if wound healing is not progressing and infection is absent Obtain photos following best practice as per framework for individual organization policies and procedures. Suggest following publication as guideline: Adherence to plan Real or potential barriers to wound treatment plan Compression is typically contraindicated in the presence of peripheral arterial disease. In some circumstances light compression may be beneficial. In such cases, compression should be ordered by an advanced wound care physician or nurse practitioner only! See algorithm in guidelines. Brief Pain Inventory Short Form (BPI-SF) Obtain physician/nurse practitioner orders for analgesics required (opioids and non-opioids) Waterloo Wellington Integrated Wound Care Program Arterial Pathway May

17 Medication reconciliation and their impact on wound healing reviewed Prescription, non-prescription, naturopathic and illicit drug use Recent blood work and other diagnostic test results reviewed and implictions for wound healing considered Bilateral lower leg assessment completed Signs and symptoms of Peripheral Arterial Disease could include: Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication) Dependent rubor in lower legs and feet Pallor in feet on elevation Dry, shiny skin on lower legs Edema subsequent to leg being dependent Thick or flaking toe nails Hairless lower legs and feet Weak or absent pulses Intense hyperesthesia (sensitive to light touch) Limb muscle may appear wasted from ischemic atrophy Delayed capillary refill Distal gangrene Erectile dysfunction in men Non-healing wound Determine bloodwork and other diagnostic tests required ABPI/TPBI completed within last 3 mths 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) Leg measurements (foot, ankle, calf, thigh) 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 ABPI 0.5 to 0.8 TBPI 0.64 to 0.7 Suggest Transcutaneous Oxygen Pressure(TcPo 2 ), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies ABPI <0.5 TBPI <0.64 Urgent vascular surgical consult needed 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 Patient s nutritional status optimized Recent blood work results Significant weight changes Adherence to diet plan Identify barriers to good nutrition Waterloo Wellington Integrated Wound Care Program Arterial Pathway May

18 Patient and caregiver concerns and goals integrated into the care plan and shared with care team Patient counselled on the benefit of activity rest and head elevation in moderation (balancing need for pressure relief) for comfort measures and wound healing Patient/caregiver educational needs reviewed using teach-back method Cardiff Wound Impact Questionnaire OR World Health Organization Quality of Life (WHOQOL) form Encourage patient to sleep in bed with Recent changes in overall activity level no lower limb elevation (most arterial Daily routine pain increases when feet elevated Personal assistance available to perform above heart level) activities of daily living Mobility and dexterity aids currently Ankle range of motion allowing for calf being used muscle pump to function Safety of transfers Determine where patient sleeps at night Recommendations for exercise Consider Occupational Therapist referral for comfort measures Emergency signs and symptoms of Pain management Peripheral Arterial Disease that require Diagnostic testing immediate medical attention (refer to Dietary lower leg assessment section) Rest/Activity Risks of compression Prevention of injury avoid extremes Smoking cessation including e-cigarettes (hot/cold, loose/tight) and nicotene replacement When to call primary care giver (eg. Appropriate footwear as discussed with signs and symptoms of infection, deep foot care specialist (encourage use of vein thrombosis, cellulitis, impaired white socks) blood flow, difficulties with Skin care compression) Nail care (suggest use of foot care Self lower-leg assessment specialist) Community support groups (i.e. walking Wound self care groups) Other Ability to self-manage optimized Hygeine Adherence to plan Foot inspection (including bottom of Barriers to participate (transportation, foot and between toes) socioeconomic, social environment, Enviroment other co-morbidities) Wound care Cognitive ability Compression application and removal if Review importance and potential prescribed barriers to smoking cessation at every visit Coping strategies implemented into plan of care Patient s concerns and fears Signs of anxiety or other mental health issues (eg. delusions, hallucinations, paranoid Waterloo Wellington Integrated Wound Care Program Arterial Pathway May

19 Family and caregiver support identified and incorporated into plan of care behaviour) Depression screen using Geriatric Depression Scale assessment form GDS15 Suicide assessment if applicable ETOH and illicit /recreational drug use Availability of assistance required Social supports/community resources currently utilized is integrated into plan of care Family support Funding Community resources Caregiver conflicts Long or short term placement Assistance provided for financial concerns patient is experiencing Private insurance availability Eligibility for Assistive Devices Program (ADP [lymphedema only], ODSP, High-needs fund, Veterans Affairs Canada or Aborignal Services) Professional referral status reviewed Primary Care Physician Pharmacist Advanced Wound Specialist Occupational Therapist Nurse Practitioner Physiotherapy Infectious Disease Specialist Chiropodist Vascular Surgeon Certified Pedorothist Dermatologist Certified Orthotist Plastic surgeon Certified Prosthetist Internist/Endocrinologist Podiatrist Mental Health Specialist Lymphatic Massage Psychologists Compression Stocking Fitter Social work Other: Registered Dietitian Physician/nurse practitioner orders received as required to change plan of care including agreeance to professional referral recommendations Appropriate documents shared Identify need to reassess ABPI/TPBI in 6 months Lower leg assessment Recent vascular study results (eg. ABPI, TPBI, Transcutaneous Oxygen Pressure(TcPo 2 ), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies) Relevant consultation notes Acute care Complex Continuing Care/Rehab Long-term care Community care Primary care physician/nurse Practioner Professionals referred to Other Waterloo Wellington Integrated Wound Care Program Arterial Pathway May

20 Diagnostic results Current treatment plan If wound closed or eschar is stable send discharge summary outlining outstanding issues and teaching completed to: Referral source and most responsible physician (MRP)/nurse practitioner (NP) Collaborative team/patient conference arranged to discuss barriers to healing and care plan if progression to healing is stalled Arrange a Collaborative team/patient meeting to discuss barriers to healing and care plan Waterloo Wellington Integrated Wound Care Program Arterial Pathway May

21 91-98 Days Expected Outcomes Notes Most Responsible Physician(MRP)/Nurse Practitioner (NP) identified/informed Assessment of wound performed and percentage of healing documented 4 P s of Arterial Ulcers Pale wound base Punched-out appearance Painful Parched (low to no exudate) Arterial ulcers do not follow trajectory healing rate of venous ulcers (30% week 4 & healed at 12 weeks). Further intervention should be considered if conservative treatment does not improve healing in 4-6 weeks Wound treatment/compression plan is being followed Caution: USE DRY WOUND HEALING 1. Keep eschar dry 2. No occlusive dressings 3. Do NOT debride 4. Avoid tourniquet effect when securing dressings 5. If eschar becomes wet/boggy URGENT referral to advanced wound care specialist is recommended Pain management reviewed Arterial pain is typically described as: Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication) Medical/surgical history and co-morbidity management considered within care plan Medication reconciliation and their impact on wound healing Communication with primary care physician and/or Nurse Practioner to update on any significant changes in patient s condition. Refer patient to Care Connects if no responsible practioner currently involved with patient Determine if MRP/NP is part of family health team (FHT) or community health centre (CHC) and consider additional supports available Complete: Bates-Jensen Wound Assessment Tool (BWAT) OR Leg Ulcer Measurement Tool (LUMT) Determine wound etiology Arterial ulcers are typically pale at base of wound, have punched out appearance, are more painful than expected and have low to no exudate Results of LLA and ABPI/TPBI Document percentage of healing since admission Assessment for infection (NERDS and STONEES) Potential need for wound care specialist considered if wound healing is not progressing and infection is absent Obtain photos following best practice as per framework for individual organization policies and procedures. Suggest following publication as guideline: Adherence to plan Real or potential barriers to wound treatment plan Compression is typically contraindicated in the presence of peripheral arterial disease. In some circumstances light compression may be beneficial. In such cases, compression should be ordered by an advanced wound care physician or nurse practitioner only! See algorithm in guidelines. Brief Pain Inventory Short Form (BPI-SF) Obtain physician/nurse practitioner orders for analgesics required (opioids and non-opioids) Waterloo Wellington Integrated Wound Care Program Arterial Pathway May

22 reviewed Prescription, non-prescription, naturopathic and illicit drug use Recent blood work and other diagnostic test results reviewed and implictions for wound healing considered Determine bloodwork and other diagnostic tests required Bilateral lower leg assessment completed Signs and symptoms of Peripheral Arterial Disease could include: Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication) Dependent rubor in lower legs and feet Pallor in feet on elevation Dry, shiny skin on lower legs Edema subsequent to leg being dependent Thick or flaking toe nails Hairless lower legs and feet Weak or absent pulses Intense hyperesthesia (sensitive to light touch) Limb muscle may appear wasted from ischemic atrophy Delayed capillary refill Distal gangrene Erectile dysfunction in men Non-healing wound ABPI 0.5 to 0.8 TBPI 0.64 to 0.7 Suggest Transcutaneous Oxygen Pressure(TcPo 2 ), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies ABPI <0.5 TBPI <0.64 Urgent vascular surgical consult needed ABPI/TPBI completed within last 3 mths 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) Leg measurements (foot, ankle, calf, thigh) 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 Patient s nutritional status optimized Recent blood work results Significant weight changes Adherence to diet plan Identify barriers to good nutrition Patient and caregiver concerns and goals integrated into the care plan and shared with care team Cardiff Wound Impact Questionnaire Waterloo Wellington Integrated Wound Care Program Arterial Pathway May

23 Patient counselled on the benefit of activity rest and head elevation in moderation (balancing need for pressure relief) for comfort measures and wound healing Patient/caregiver educational needs reviewed using teach-back method OR World Health Organization Quality of Life (WHOQOL) form Encourage patient to sleep in bed with Recent changes in overall activity level no lower limb elevation (most arterial Daily routine pain increases when feet elevated Personal assistance available to perform above heart level) activities of daily living Mobility and dexterity aids currently Ankle range of motion allowing for calf being used muscle pump to function Safety of transfers Determine where patient sleeps at night Recommendations for exercise Consider Occupational Therapist referral for comfort measures Emergency signs and symptoms of Pain management Peripheral Arterial Disease that require Diagnostic testing immediate medical attention (refer to Dietary lower leg assessment section) Rest/Activity Risks of compression Prevention of injury avoid extremes Smoking cessation including e-cigarettes (hot/cold, loose/tight) and nicotene replacement When to call primary care giver (eg. Appropriate footwear as discussed with signs and symptoms of infection, deep foot care specialist (encourage use of vein thrombosis, cellulitis, impaired white socks) blood flow, difficulties with Skin care compression) Nail care (suggest use of foot care Self lower-leg assessment specialist) Community support groups (i.e. walking Wound self care groups) Other Ability to self-manage optimized Hygeine Adherence to plan Foot inspection (including bottom of Barriers to participate (transportation, foot and between toes) socioeconomic, social environment, Enviroment other co-morbidities) Wound care Cognitive ability Compression application and removal if Review importance and potential prescribed barriers to smoking cessation at every visit Coping strategies implemented into plan of care Patient s concerns and fears Signs of anxiety or other mental health issues (eg. delusions, hallucinations, paranoid behaviour) Depression screen using Geriatric Depression Scale assessment form GDS15 Waterloo Wellington Integrated Wound Care Program Arterial Pathway May

24 Suicide assessment if applicable ETOH and illicit /recreational drug use Family and caregiver support identified and incorporated into plan of care Availability of assistance required Social supports/community resources currently utilized is integrated into plan of care Family support Funding Community resources Caregiver conflicts Long or short term placement Assistance provided for financial concerns patient is experiencing Private insurance availability Eligibility for Assistive Devices Program (ADP [lymphedema only], ODSP, High-needs fund, Veterans Affairs Canada or Aborignal Services) Professional referral status reviewed Primary Care Physician Pharmacist Advanced Wound Specialist Occupational Therapist Nurse Practitioner Physiotherapy Infectious Disease Specialist Chiropodist Vascular Surgeon Certified Pedorothist Dermatologist Certified Orthotist Plastic surgeon Certified Prosthetist Internist/Endocrinologist Podiatrist Mental Health Specialist Lymphatic Massage Psychologists Compression Stocking Fitter Social work Other: Registered Dietitian Physician/nurse practitioner orders received as required to change plan of care including agreeance to professional referral recommendations Appropriate documents shared Identify need to reassess ABPI/TPBI in 6 months Lower leg assessment Recent vascular study results (eg. ABPI, TPBI, Transcutaneous Oxygen Pressure(TcPo 2 ), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies) Relevant consultation notes Diagnostic results Current treatment plan Acute care Complex Continuing Care/Rehab Long-term care Community care Primary care physician/nurse Practioner Professionals referred to Other Waterloo Wellington Integrated Wound Care Program Arterial Pathway May