South West Regional Wound Care Toolkit My Arterial Leg Ulcer

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1 16 CALL your nurse or doctor when you notice Fever higher than 38 C (100 F) --- older individuals may have fever at a lower temperature 37 C (99 F) If an ulcer that has been dry starts to: o drain or lift from the edges o feel boggy or o get reddened around This is a change that will need a new treatment plan. There is an increase in pain, swelling, heat or drainage from the wound Your wound appears to be larger Increased pain in your legs or feet when lying in bed Deep pain in your calf muscle CALL 911 RIGHT AWAY when: Your wound begins bleeding and you cannot get it stopped You experience changes in your ability to think or concentrate Your Nursing Agency contact information: This booklet was produced as part of the South West Regional Wound Care Initiative December Adapted from Ready Aim Improve! Surgical Wounds the South West CCAC Wound Care Program Arterial leg Ulcer material Used with permission. This booklet will help you to know more about your kind of wound, and what to do to improve your health. You can help with self-care by: Knowing the signs and symptoms of infection Keeping your dressing clean and dry Eating a healthy, balanced diet Avoiding trauma, pressure or friction to the area (e.g. no tight boots or clothing, no dogs or children jumping at your legs, no rubbing if the area is itchy) STOPPING smoking stopping can improve your symptoms and prevent the arterial disease from getting worse Keeping your pain under control South West Regional Wound Care Toolkit My Arterial Leg Ulcer Keep your blood pressure and cholesterol levels normal Changing the dressings if/ or as instructed by the nurse Closed wounds are not the same as healed wounds, but health care professionals use both words. New skin covering the closed wound will never be as strong as before the injury, even when healing is complete. This can take up to 2 years. It is important to take extra care to prevent the wound from opening again.

2 2 If you need care when at home, and have OHIP, the South West Community Care Access Centre (SWCCAC) may be part of the team with your doctors, nurses and other health care providers. Healthcare Providers who may be involved in healing an arterial ulcer include: Doctor: will oversee your health, and make referrals to other professionals Vascular surgeon: will order tests to see if your circulation can be improved, and will talk to you about surgery if it can help. Nurses: provide wound care, bandaging therapy and information about your condition and improving your health Enterostomal Therapy/ Wound Care Specialist Nurse: These nurses have wound care knowledge beyond the level of the general nurse. Dietitian: can help to choose the proper foods to eat to help you to improve your health Physiotherapist*(PT): Can provide exercises to improve your activity, and sometimes provide other therapies to promote healing in ulcers that are large or older than 6 months Other possible team members are Personal Support Workers and Social Workers *Taking the Pressure Off 2009 Masspro, the Medicare Quality Improvement Organization for Massachusetts sure%20off.8.09.pdf Questions for My Nurse or Doctor: You are doing WELL when: You can help with self-care of your wound You can increase your amount of exercise The pain in your wound becomes less 15

3 14 Personal Plan You should discuss your situation with your nurse and doctor. Here are three key questions that you need to find the answers to: What is my main problem? What do I need to do about it? Why is it important for me to do this? What is an arterial leg ulcer? Arterial ulcers happen because of a poor supply of arterial blood going from your heart and lungs down to your legs and feet. This is called ischemia. The ulcer can start from: trauma such as stubbing your toe dropping something on your foot pressure your toes being pressed together in tight shoes. Poor arterial circulation is caused by hardening or narrowing of the arteries. Blood rich in oxygen and nutrients has trouble getting to your feet and legs. Arterial wounds are very painful. The only way to heal these ulcers is to improve the blood supply. What causes arterial disease? A number of risk factors cause poor arterial circulation: Smoking Being overweight Fatty diet Lifestyle with little exercise Diabetes Heart disease Rheumatoid arthritis Anaemia High blood pressure Stroke Stress High cholesterol Family history of heart disease, strokes or high cholesterol 3

4 4 Symptoms of Arterial Disease in the legs and feet: You may not know that you have arterial disease. Half of people living with arterial disease have no symptoms until the ulcer happens. The most common symptom is pain that happens in one or both calves, thighs, or hips, called claudication. This pain happens when you are walking or climbing stairs and stops when you stop to rest. It can be heavy, cramping or tight pain. Other signs are: cool skin on the foot and leg with blue, red or purple colouring not related to a bruise pain in the feet or toes when in bed or on footstool loss of hair on the lower legs pain in the buttocks tingling or numbness and weakness in the legs and feet thickened toenails pale skin when the leg is raised above the heart What do arterial ulcers look like? They are usually on the foot, but can be on the lower leg too. The wound: is pale & dry with little drainage can have yellow or black tissue is often found on the tips of toes, on the heels, or sides of foot, but can be on the lower leg has a deep, punched out appearance the edges are even and often round in shape Wound Care: There is no dressing that can improve the circulation. Dry Arterial Ulcers A dry ulcer that is not causing severe pain or getting larger can be cared for over a long period of time. The nurse and physician may choose to try to dry it even further. This works well if it involves a toe or a small area on the foot. The goal is to dry it completely to prevent infection. In a toe, this is called mummification or dessication The nurse may paint it with an antiseptic solution, and cover with a dry dressing. This does not have to be changed every day, but should be kept clean. Over several weeks or months, if infection does not occur, new skin will grow under the dry black dry area and heal from the edges. If an ulcer that has been dry starts to drain, lift from the edges, feel boggy or get reddened around, you must call the nurse or your doctor. This is a change that will need a new treatment plan. Draining Arterial Ulcers If the ulcer is clean and draining, it should be kept moist. It is important that the drainage does not soak through to the outside of the dressing. Bacteria can enter the wound through the wet dressing. 13

5 12 5 Sources of zinc are: meat, fish, seafood (especially oysters), poultry, liver, eggs, milk, legumes, whole wheat products, and wheat germ. Sources of iron are: meat, poultry, fish, liver, organ meats, eggs, legumes, nuts, dried fruit, fortified breads, cereals, and pastas. Iron from animal sources is more bioavailable than that provided by plant foods. Iron absorption is improved if taken with foods containing vitamin C. Healing requires extra calories, and a diet high in protein is needed to build new tissue. Increase your protein intake: meat, eggs, fish and dairy products, nuts, whole grains combined with beans, soya tofu. *With thanks to CarePartners/ET NOW for use of this information References: Harris CL, Fraser C. (2004) Malnutrition in the institutionalized elderly: the effects on wound healing. Ostomy Wound Management 50(10): Fraser C. (2007) Foods first: nutrition, pressure ulcer management and skin health. Wound Care Canada 5(1):28-29 What are the risks with an arterial ulcer? Arterial ulcers can be very, very painful. This pain can prevent you: from sleeping in bed, from having a healthy appetite from enjoying life. Gangrene can occur if the circulation gets worse, or from infection. Amputation may be needed if this happens. Pain Control and Medications: The pain can be described as stinging, burning, stabbing, searing or like an electric shock It is often more painful at the end of the day Pain that is not controlled: Wakes you when asleep Reduces your appetite Limits your mobility Prevents you from working or doing things you enjoy Can make you feel blue Your nurse will assess your pain and work with your doctor to find the best treatments for you. Take your pain medication regularly to be comfortable Take your prescribed antibiotics until they are finished

6 6 11 Other Pain Control Measures If your pain is worse when you are in bed, and you sleep with your leg over the side, or in an easy chair, the feet and legs can become swollen, making things even worse. Here are some things that you can do: o Raise the head of your bed by placing the legs on 4-6 blocks. Your legs and feet will be a little lower than your heart, letting the blood to get to them by gravity. You might still have a little swelling of the legs and feet, but less than if they are down on the floor all the time. o If the weight of the sheets, blankets and covers cause more pain when you are in bed, you can buy a bed-cradle or have someone make a board to put at the foot of the bed that will lift the covers up so that they do not press on your feet and legs. o Wear warm loose socks to bed. How long will my ulcer take to heal? Sometimes these wounds cannot heal. Your doctor may order some other tests to be done in the lab to see where your problem is. It may heal if the blood supply can be improved. You may need to have an operation or procedure to help to improve the blood flow. Nutritional Information for Wound Healing Note - If you have diabetes you may not be able to follow all of these suggestions. You may also be on a restricted diet due to other health conditions, or have food allergies. You should cut down on fatty foods and snacks. Don t skip meals. If you are not hungry, eat small amounts more often. Ask your doctor about having a small glass of sherry before meals, or for a prescription of Maltlevol liquid vitamin to help improve your appetite. Many vitamins and minerals are important in the healing process, including vitamins A & C, zinc and iron. If your appetite is poor, ask your pharmacist about taking a multivitamin and mineral supplement. If you are taking vitamin E please stop taking it while the wound is healing (it delays healing). The following foods are important for healing: Sources of vitamin C are: citrus fruits and juices, strawberries, tomatoes, sweet peppers (especially red), potatoes, broccoli, cauliflower, brussels sprouts and cantaloupe. Sources of vitamin A are: liver, milk/dairy products, egg yolk, and fish oils.

7 10 Learning Self Care: Your nurse may teach you or a family member how to change your dressing Skin Care Tips Skin can become dry, itchy and/or flaky Use clean water and a mild soap such as Dove, in a gentle circular motion. Pat dry using a clean towel. Never rub to dry this causes friction damage Never rub or scratch itchy areas Moisturize your legs with products like: Glaxal Base, plain Vaseline petroleum ointment, Cliniderm or Moisturel lotions (not creams). Activity and Exercise Exercising is important when you have arterial disease. Walking can improve cramping in the calf muscles seen in early arterial disease. Slowly increase the distance you walk. Walking longer distances can help to form new blood vessels which carry blood around the blockage (collateral circulation). You should notice that you have less pain within 6-8 weeks of starting as new circulation opens up. Tests that might be ordered: Ankle Brachial Pressure Index (ABPI) The ABPI can be done in your home, the clinic or in a lab that tells the nurse/doctor/nurse practitioner about your blood flow. The results, plus any signs and symptoms of arterial disease are used to decide what amount of compression therapy will be safe to use. You should not drink caffeine or smoke for 30 minutes before the test. You must lay flat for 15 minutes, without sitting up at all. A blood pressure cuff and an ultrasound doppler are used to measure the pressures in your ankles and arms and possibly your feet. Segmental Compression Studies This is similar to the ABPI, but the blood pressure cuffs are placed mid-calf, above the knee and mid-thigh. This study also gives pulse volume readings. Toe Brachial Pressure Index The pressure in your great toe can be measured using a tiny cuff and special Doppler probe, used when the ankle pressures cannot be measured. 7 If your readings are very low, your doctor may talk with you about seeing a vascular surgeon to see if any treatment can be offered to improve the circulation.

8 8 9 Other things that can help to improve the circulation include: Do not sit or stand in one position for a long time Do not cross your legs Do not sit in a chair so that the edge of the seat is pressed against the back of your legs If traveling for a long distance, stop every hour or two to get out and walk around This will improve the blood flow to and from your legs. Things to do to prevent more ulcers: DO NOT take LONG or really HOT baths DO NOT put disinfectants or salt in the bathwater Keep your heels smooth to prevent open areas DON T expose your legs to strong heat sources such as electric heaters or sunburn. Avoid bumps and bangs Take care of your skin don t scratch! Exercise regularly. Infection This happens when harmful germs enter your body through the wound. Infection can make the ulcer larger or cause gangrene. Local infection on the wound surface can have an antimicrobial dressing. Deeper wound infection will need antibiotics. Spreading infection may need intravenous antibiotics and can be life threatening. Symptoms of an infection: The ulcer gets larger Toes turn blue or dusky New, increased or altered pain Increased bleeding from the ulcer Tissue in ulcer becomes darker or green/ gray in colour Unpleasant smell coming from your ulcer Increased drainage from ulcer Drainage that is green or contains pus Warmth or redness of skin around ulcer New swelling or firmness of skin around ulcer Fever higher than 38 C (100 F) --- older individuals may have fever at a lower temperature 37 C (99 F) *If you have any of these symptoms contact your doctor or nurse right away