10/9/2015. Differential Assessment of Lower Extremity Wounds. Disclosure Statement. Program Objectives

Transcription

1 3M All Rights Reserved 3M All Rights Reserved 2 3M All Rights Reserved 3 Differential Assessment of Lower Extremity Wounds Presented by: Lynn Peterson RN, BSN, CWOCN 3M Health Care November 3, 2015 Disclosure Statement Lynn Peterson is employed by 3M Health Care, Critical & Chronic Care Solutions Division as a Product Service Specialist Program Objectives Differentiate between arterial, neuropathic and venous leg ulcerations Identify key risk factors for lower extremity ulcerations List five key wound assessment parameters Describe appropriate methods of treating lower extremity ulcerations 1

2 3M All Rights Reserved 4 3M All Rights Reserved 5 3M All Rights Reserved 6 treated Etiology leg ulcers 72% 8% 14% 6% venous arterial combined other Do you know the difference? Comprehensive bilateral lower-extremity assessment General appearance Trophic changes Thin & shiny epidermis, loss of hair growth, thickened nails (LEAD) Edema, hyperpigmentation, scaly, eczematous skin (LEVD) Dryness, fissures, cracks, foot deformities (LEND) Hair, nail, skin patterns Veins Skin color, shape, texture, integrity Edema Ermer-Seltun J. Lower Extremity Assessment. In: Bryant BA, Nix DP. In: Acute & Chronic Wounds; Current Management Concepts, 4 th ED. St. Louis, MO: Elsevier Mosby; 2012:

3 3M All Rights Reserved 7 3M All Rights Reserved 3M All Rights Reserved 9 Comprehensive bilateral lower-extremity assessment Functional-sensory status Gait and mobility Range of motion of ankle joint Pain Perfusion Elevational pallor or dependent rubor Skin temperature Blood flow (bruit/thrill) Capillary refill Pulses Ankle-brachial index Ermer-Seltun J. Lower Extremity Assessment. In: Bryant BA, Nix DP. In: Acute & Chronic Wounds; Current Management Concepts, 4 th ED. St. Louis, MO: Elsevier Mosby; 2012: Lower Extremity Arterial Insufficiency (LEAD) & Arterial Ulcers Lower Extremity Arterial Disease (LEAD) Insufficient arterial perfusion from arteriosclerotic changes Peripheral vascular disease (PVD) Peripheral arterial occlusive disease (PAOD) Lower-extremity peripheral arterial disease (PAD) When arterial flow is diminished: Minor injuries can become non-healing wounds Ulcers occur often at distal locations May progress to gangrene or tissue necrosis amputation 3

4 3M All Rights Reserved 10 3M All Rights Reserved 11 3M All Rights Reserved 12 LEAD prevalence & significance 8-12 million adults 40yrs. of age 40% in individuals 80 yrs. of age 50-80% individuals undiagnosed, untreated or undertreated secondary to atypical symptoms $21 billion US cost of treatment $4.37 billion - US hospitalization costs Medicare eligible patients Risk Factors Atherosclerosis Diabetes Smoking Age Hyperlipidemia Genetics Hypertension Characteristics of arterial insufficiency Dependent rubor/pallor with elevation Peripheral pulses absent or diminished ABI < 0.9 Ischemic pain Skin cool or cold, thin, dry, shiny epidermis 4

5 3M All Rights Reserved 13 3M All Rights Reserved 14 3M All Rights Reserved 15 Characteristics of arterial insufficiency (continued) Atrophy of skin Shiny, thin, taut, dry Hair loss on lower extremity Localized edema Dystrophic nails Ischemic pain Intermittent claudication cramping, aching, fatigue, weakness or calf pain Pain with moderate to heavy exercise Relieved by 10 minutes of rest Vessel ~ 50% occluded Nocturnal pain Pain at rest in bed, feet elevated Relieved by lowering legs Rest Pain Pain at rest Legs dependent Advanced occlusive disease Doughty D. Arterial Ulcers. In: Bryant BA, Nix DP. In: Acute & Chronic Wounds; Current Management Concepts, 4 th ED. St. Louis, MO: Elsevier Mosby; 2012:p.182. Arterial Ulcer: Clinical presentation Base: pale, minimal granulation tissue, necrosis, eschar Exudate: minimal exudate Size: Variable, often small Margins: Punched out appearance, rolled edges, smooth, undermined Ischemic toes Pain: common Infection: frequent, may be subtle 5

6 3M All Rights Reserved 16 3M All Rights Reserved 17 3M All Rights Reserved 18 Common locations for Arterial Ulcer Tips of toes and web spaces Phalangeal heads Over lateral malleolus Areas exposed to repetitive pressure or repetitive trauma Mid-tibia (shin) Interventions Vascular consult Re-establish perfusion Diagnostic evaluations Ankle-brachial pressure (ABI) Toe Pressure (TP) measurements patients with diabetes and suspected LEAD (indicated for ABI >1.3) Transcutaneous Oxygen (TcPO2) Angiography or Arteriography may be ordered Interventions (continued) Surgical intervention bypass/ angioplasty, skin grafts, amputation Reduce risk factors Smoking cessation Increased activity Prevent infection Pain management: Walking, specialist referral Aspirin, Cilostazol, Prostaglandins?, Pentoxifylline? 6

7 3M All Rights Reserved 19 3M All Rights Reserved 20 3M All Rights Reserved 21 ABPI (ankle-brachial pressure index) A method for comparing blood pressure in the arm to blood pressure in the leg Reflects the degree of perfusion loss in the leg Should be a resting pressure obtained with the patient in a supine position Interpretation Normal range < 0.9 LEAD < 0.6 to 0.8 Borderline perfusion < 0.5 Severe Ischemia, wound healing unlikely unless revascularized Nursing management Avoid debridement until perfusion is determined Do NOT debride dry, stable eschar Determine proper use of antiseptics to assist with maintenance of stable eschar Infected, necrotic wounds Refer for surgical debridement and antibiotic therapy Do not rely on topical antibiotics to treat infected, ischemic wounds Choose appropriate dressings. May need frequent visualization and inspection of wound Nursing management Edema - patients with mixed venous and arterial disease, use reduced compression under close supervision ABI >0.5 to <0.8: modified compression, mm / Hg at the ankle, may promote healing ABI <0.5: compression should not be used Pain management Nutritional consult Patient/family education 7

8 3M All Rights Reserved 3M All Rights Reserved 23 3M All Rights Reserved 24 Lower Extremity Neuropathic Disease (LEND) & Diabetic Foot Ulcers Lower Extremity Neuropathic Disease (LEND) LEND Autonomic dysfunction & loss of sensation Lowerextremity ulcer LEND significance Diabetes global epidemic 370 million people globally 23.6 million people in U.S. 25% lifetime risk of diabetic foot ulcer development Patients with diabetic neuropathy & wounds: 66% rate of relapse over 5 years, 12% progress to amputation US cost of care - $174 billion/yr. 8

9 3M All Rights Reserved 25 3M All Rights Reserved 26 3M All Rights Reserved 27 Risk factors Diabetes Advanced age Impaired glucose tolerance Family history Smoking Hypertension, obesity, Raynaud s disease Spinal cord injury Trauma to lower extremity Lower Extremity Neuropathic Disease (LEND) Wounds Mechanism of damage: Peripheral Neuropathy (loss of protective sensation) Peripheral Vascular Disease (decreased blood perfusion) Vascular changes (occlusion & calcification) Tissue injury Neuropathic damage Progressive due to uncontrolled hyperglycemia Sensory neuropathy Loss of protective sensation Numbness, burning, tingling pain/sensation Loss of vibration and positional sensation, sensory ataxia Motor neuropathy Gait, muscle weakness Orthopedic deformities Hammer toes, claw-toes Muscle atrophy Autonomic neuropathy Decrease sweat and oil production dry skin Loss of skin temperature regulation Abnormal blood flow in soles of feet Fissures, cracks, callus Rigid arteries ischemia, edema 9

10 3M All Rights Reserved 28 3M All Rights Reserved 29 3M All Rights Reserved 30 Assessment parameters Wound status Perfusion ABI (Ankle brachial index) TBI (Toe brachial index) Transcutaneous oxygen (TCP02) Screening for loss of protective sensation Pain May be superficial, deep, aching, stabbing, dull, sharp, burning, or cool May be worse at night Clinical presentation Location Plantar surface or areas of exposed to trauma Metatarsal heads Dorsal and distal aspects of toes Heels Base: pale, pink, necrosis/eschar Size: Varies Clinical presentation Depth: Varies; partial thickness to full thickness with exposed bone Shape: Round or oblong Exudate: small to moderate Foul odor and purulence indicate infection Periwound Callus common Erythema, induration May have dry, cracked skin or maceration Pain May be superficial, deep, aching, stabbing, dull, sharp, burning, or cool May be worse at night 10

11 3M All Rights Reserved 31 3M All Rights Reserved 32 3M All Rights Reserved 33 Diabetes Common presentation NOTE: Neuropathic ulcers Are NOT pressure ulcers! Think of their etiology NEUROPATHY! Diabetic Ulcers Nursing management Wound care Offloading, referral, education & support Provide moist environment for healing Dressing selection periodic reevaluation Maintain dry stable eschar on noninfected, ischemic wounds Observe clinical manifestations of infection may be subtle due to reduced blood flow Optimize healing process through management of blood glucose levels Pain management Monitor patients receiving compression therapy due to decreased sensation of pain Nutritional support, control of blood glucose Patient & family education Offloading Wound care Routine foot surveillance/daily foot inspection Appropriate footwear Pain management Nutrition/glycemic control Smoking cessation 11

12 3M All Rights Reserved 3M All Rights Reserved 35 3M All Rights Reserved 36 Lower Extremity Venous Disease (LEVD) & Venous Leg Ulcers Lower Extremity Venous Disease (LEVD) Prevalence 7 million individuals worldwide, 2-5% of Americans 3 million progressing to ulceration (VLU) Account for 80-90% of all leg ulcers 600,000 new VLU each year Common in women More common in aging $ 1.9 to 3.5 billion/year in US 26-28% VLU reoccur within 12 months When damage occurs to the venous system Incompetent valves Damaged or dysfunctional veins Impaired calf muscle pump Chronic ambulatory venous hypertension occurs which is the underlying cause of venous ulcers 12

13 3M All Rights Reserved 37 3M All Rights Reserved 38 3M All Rights Reserved 39 Impact on Quality of Life Decreased self esteem Decreased mobility Decreased functionality of affected limb Difficulty finding appropriate clothing/shoes Inability to manage ADL s Inability to work, job loss Adverse effect on finances Housebound Depression Cost to health care system and personal life disruption for repeat admissions for cellulitis Sen Chandan, Gordillo Gayle, Roy Sashwat, Kirsner R, et al; Human skin wounds: A major and snowballing threat to public health and the economy Wound Rep Reg (2009) Clinical conditions present with LEVD Edema Wound drainage Pain Periwound margins Skin changes Maceration Common characteristics of the venous ulcer Warm, palpable pulses Edema: usually hard, non-pitting Characteristic location Above medial malleolus Calf to malleolus Irregular shape, margins Dark red ( ruddy ) base Hemosiderin staining 13

14 3M All Rights Reserved 40 3M All Rights Reserved 41 3M All Rights Reserved 42 Effect of Chronic Edema in Lower Extremities Clinical Presentation Maceration Dermatitis Inflammation of the epidermis and dermis Inside-out problem. Only way to heal it is to remove the edema * Characteristic: Scaling Crusting Weeping Erythema Erosions Intense itching * Dr. David Keast, Enhancing Wound Healing with Compression Therapy Presentation at Wounds International 2011, Cape Town Africa Dermatitis vs. Cellulitits Dermatitis Inflammation of epidermis and dermis Cellulitis Diffuse acute inflammation and infection of the skin and subcutaneous tissues that signifies a spreading infectious process 14

15 3M All Rights Reserved 43 3M All Rights Reserved 44 3M All Rights Reserved 45 ABPI (ankle-brachial pressure index) A method for comparing blood pressure in the arm to blood pressure in the leg Reflects the degree of perfusion loss in the leg Should be a resting pressure obtained with the patient in a supine position Interpretation > 1.0 Normal > 0.8 LEVD < 0.6 to 0.8 Borderline < 0.5 Severe Ischemia Topical therapy goals Control edema Absorb exudate Prevent trauma/injury Identify/treat infection Promote wound healing/maintain moist wound bed Protect periwound skin Minimize pain Optimal wound bed preparation Complete debridement of devitalized and poorly functioning tissue Restoration of bacterial balance Maintenance of optimal moisture balance Control of edema/lymphedema Protect surrounding skin Alcohol free barrier film, ointment Topical corticosteroids to reduce inflammation Bland emollients for moisturization Avoid fragrances, dyes Promote comfort 15

16 3M All Rights Reserved 46 3M All Rights Reserved 47 3M All Rights Reserved 48 Topical therapy Choose dressings to manage ulcer characteristics Protect surrounding skin Non alcohol barrier film, ointment Topical corticosteroids to reduce inflammation Bland emollients for moisturization Avoid fragrances, dyes Promote comfort Provide Compression Most essential component of venous leg ulcer treatment. Reduce edema/lymphedema by providing resistance against the calf muscle Improves speed of blood flow to heart Decrease exudate/weeping of the leg Reduces MMP s and inflammatory cytokines Improve wound healing Decreases aching and heaviness of the leg Management of edema In patients with mixed venous and arterial disease, use reduced compression under close supervision ABI >0.5 to <0.8: modified compression, mm/hg ABI <0.5: compression should not be used 16

17 3M All Rights Reserved 49 3M All Rights Reserved 50 Thank You Did I meet the objectives for this session? Differentiate between arterial, neuropathic and venous leg ulcerations Identify key risk factors for lower extremity ulcerations List five key wound assessment parameters Describe appropriate methods of treating lower extremity ulcerations Questions? References Ermer-Seltun J. Lower Extremity Assessment. In: Bryant BA, Nix DP. In: Acute & Chronic Wounds; Current Management Concepts, 4th ED. St. Louis, MO: Elsevier Mosby; 2012:Chapter 10. Arterial: A quick reference guide for lower-extremity wounds: venous, arterial, and neuropathic. Doughty D. Arterial Ulcers. In: Bryant BA, Nix DP. In: Acute & Chronic Wounds; Current Management Concepts, 4 th ED. St. Louis, MO: Elsevier Mosby; 2012: Chapter 11. Wound, Ostomy and Continence Nurses Society. (2014). Guideline for the Management of Wounds in Patients with Lower-Extremity Arterial Disease. WOCN clinical practice guideline series 1. Mt. Laurel: NJ. Author. Neuropathic: Driver VR, LeBretton Jm, et al. Neuropathic Wounds: The Diabetic Wound. In: Bryant BA, Nix DP. In: Acute & Chronic Wounds; Current Management Concepts, 4th ED. St. Louis, MO: Elsevier Mosby; 2012: Chapter 14. Wound, Ostomy and Continence Nurses Society. (2012). Guideline for the Management of Wounds in Patients with Lower-Extremity Neuropathic Disease. WOCN clinical practice guideline series 3. Mt. Laurel: NJ. Author. Venous A quick reference guide for lower-extremity wounds: venous, arterial, and neuropathic. Carmel JE. Venous Ulcers. In: Bryant BA, Nix DP. In: Acute & Chronic Wounds; Current Management Concepts, 4th ED. St. Louis, MO: Elsevier Mosby; 2012: Chapter 12. Wound, Ostomy and Continence Nurses Society. (2011). Guideline for the Management of Wounds in Patients with Lower-Extremity Venous Disease. WOCN clinical practice guideline series 4. Mt. Laurel: NJ. Author. 17