SWM Module 15: Assessing the Wound — Lower Extremity Ulcers Flashcards

Lower extremity ulcers are open sores or ulcers occurring on the lower legs, typically below the knee (DynaMed, 2022).

• Venous leg ulcer (VLU)
• Arterial leg ulcer
• Diabetic foot ulcer (DFU)
• Mixed venous and arterial leg ulcers

• Chronic Venous Insufficiency (CVI) or (lower extremity venous disease - LEVD)
• Arterial Disease (lower extremity arterial disease - LEAD) or (peripheral arterial occlusive disease - PAOD)
• Diabetes (Neuropathic)

underlying conditions impairing blood flow

tissue oxygenation

and skin integrity

• Pressure injuries
• Infections
• Malignancies
• Trauma
• Insect bites
• Sickle cell anemia
• Pyoderma Gangrenosum
• Vasculitis

Accurate diagnosis allows for tailored treatment, addressing issues like poor circulation, arterial disease, or diabetes to promote healing and avoid missteps like inappropriate treatment.

Arterial ulcer

Diabetic foot ulcer

Venous leg ulcer

venous insufficiency

is often linked with poor wound healing and increased risk of ulcers.

like rheumatoid arthritis or lupus can impact skin integrity and healing. These patients are often on anti-inflammatory/steroid medications which can impair the inflammatory phase of wound healing.

• Smoking or Vaping: Nicotine impairs blood flow and increases the risk of blood clots and infection (Troiano et al., 2019).
• Nutrition: Poor nutrition hinders wound healing and immune response.
• Physical Activity: A decreased activity level can lead to poor circulation and increase the risk of ulcers.

• Glycemic Control: Hyperglycemia negatively impacts healing by prolonging the inflammatory phase and decreasing the immune system's efficiency.
• Diabetic Neuropathy: Loss of sensation, tingling, or numbness in the extremities increases the risk of unseen injuries and subsequent ulcers.

Hyperglycemia negatively impacts healing by prolonging the inflammatory phase and decreasing the immune system's efficiency.

Loss of sensation, tingling, or numbness in the extremities increases the risk of unseen injuries and subsequent ulcers.

Poorly controlled blood pressure (BP) can contribute to poor circulation and delayed healing (WOCN, 2024).

• History of Claudication: Pain, cramping, or complaints of fatigue in the legs during physical activity that is relieved within 10 minutes of rest can indicate PVD. Intermittent claudication is considered the most typical symptom of LEAD, but most patients are asymptomatic.
• Nocturnal or Positional Pain: Occurs in the absence of activity. Sleep is affected by throbbing pain with leg elevation that is relieved by dangling affected leg(s) in a dependent position.
• Previous Vascular Interventions: Record past vascular procedures such as angioplasty, stenting, or bypass surgery.

• History of Claudication:

• Nocturnal or Positional Pain:

The Cardiff Wound Impact Schedule (CWIS)

• Demographic and clinical characteristics
• Global HRQoL
• Satisfaction with HRQoL
• Impact of the wound on lifestyle

The Wound-QoL

• Physical symptoms
• Psychological well-being
• Everyday life

Assessing whether the edema is in one or both LEs can help determine if the cause is a systemic disease affecting the entire body (e.g., heart failure) or related to a condition that affects part of the body (e.g., venous insufficiency) (DynaMed, 2023).

• Non-Pitting Edema: Often caused by conditions like lymphedema or thyroid disorders
• Pitting Edema: Often associated with venous insufficiency, congestive heart failure, or kidney disease

Non-Pitting Edema

Pitting Edema

Indicates mild pitting edema with a slight indentation that is barely noticeable and about 2 mm deep, disappearing almost immediately.

Is moderate pitting edema with a deeper indentation, about 3 to 4 mm, disappearing within 15 seconds.

Is moderately severe pitting edema with a noticeably deep indentation, about 5 to 6 mm, remaining for more than 15 seconds but less than 1 minute.

Grade 4

Grade 4 indicates severe pitting edema with a very deep indentation, about 8 mm or more, remaining for 2 minutes or longer.

Hyperpigmentation, shiny taught skin, no hair growth, thickend, evidence of scaling, and ulceration present

Sensory testing is important to determine if patients can detect pain, pressure, and temperature changes, especially for those with diabetes (McNichol et al., 2021). Tests include:

This checks for protective sensation in the feet using a 10G monofilament (McNichol et al., 2021). The monofilament is pressed against the bottom of the foot until it bends. Ask the patient to close their eyes while you perform the test and have them say “yes” each time they feel the pressure from the monofilament.

The following is the procedure for performing the assessment:

• Instruct the patient to close their eyes to eliminate visual input.
• Strike the tuning fork firmly against the palm of your hand to initiate vibration (it should vibrate for approximately 30–40 seconds).
• Apply the vibrating fork to a familiar bony area—such as the forehead, sternum, or arm—to ensure the patient understands what the vibration sensation feels like (as distinct from touch).
• Place the vibrating tuning fork on the bony prominence of the great toe, just below the nail bed.
• Ask the patient if they feel the vibration.
• Stop the vibration (e.g., by touching the tines) and immediately ask the patient if they feel the loss of vibration.
• If the patient does not feel vibration at the toe, repeat the test on more proximal sites, such as the mid dorsum of the foot and the lateral malleolus.

A 128 Hz tuning fork is used to test for vibratory sensation loss, which indicates large fiber nerve damage (McNichol et al., 2021).

Test the Achilles tendon reflex by gently tapping the Achilles tendon with a reflex hammer while the patient’s foot is dorsiflexed (WOCN, 2024).

• With the patient seated, place one hand on the plantar foot and passively dorsiflex the ankle to a right angle.
• Tap the Achilles tendon gently with a reflex hammer.
• A normal response is plantar flexion of the foot (like pressing a gas pedal).

A diminished or absent Achilles reflex may suggest peripheral neuropathy. While this reflex is typically present in healthy individuals, it often decreases with age. Bilateral absence in older adults may not be clinically significant.

Located on the top of the foot, between the first and second metatarsal bones.

Located behind the medial malleolus.

0 = ABSENT

1 = DECREASED

2 = NORMAL

3 = BOUNDING

* A strong pulse indicates good blood flow

2 seconds.

3 seconds

True

Dependent Rubor

PAD ; limb ischemia

20°

45-60°

After assessing pallor, have the patient sit up with their legs in a dependent position. If their legs slowly revert to their normal color, followed immediately by an intensely red coloration when dependent, this is known as reactive hyperemia, and the leg will eventually return to its normal color after a few minutes

ischemia

* Vascular referral may be necessary

• Transcutaneous Oxygen Measurement (TCPO2)
• Skin Perfusion Pressure (SPP)
• Near Infrared Light (NIR)
• Ankle-Brachial Index (ABI)
• Toe-Brachial Pressure Index (TBPI)

• Doppler Waveform Analysis
• Segmental Limb Pressure
• Pulse Volume Recording (PVR)
• Color Duplex Imaging

Assesses blood flow by measuring the partial pressure of oxygen at the periwound skin surface using special sensors

Memory :

___ Normal

___ Borderline ischemia

___ Critical limb ischemia

> 40 mmHg

30 to < 40 mmHg

< 30 mmHg

...

Transcutaneous Oxygen Measurement

Skin Perfusion Pressure

Near Infrared Light

Ankle-Brachial Index

Pulse Volume Recording

Toe-Brachial Pressure Index

noncompressible arteries

The skin perfusion pressure (SPP)

1. > 50 mmHg

2. 30 to < 50 mmHg

3. < 30 mmHg

Normal , PAD , Severe PAD

30 mmHg

It is a noninvasive method that quantifies microcirculation and healing potential, photographs the wound, and measures the wound surface area.

NIR

It is standard of care to check the perfusion of a leg before applying any compression.

It is calculated by dividing the ankle's systolic blood pressure (SBP) measurement by the arm's SBP measurement (Stanford Medicine 25, n.d.).

Testing requires a blood pressure cuff and handheld Doppler. It takes about 10 minutes to complete.

Patient is comfortable in a supine position and allow them to rest for 10 minutes. Socks and shoes must be removed for the test.

• Place the blood pressure cuff on the arm, keeping the limb at heart level.
• Apply ultrasound gel over the brachial pulse in the antecubital fossa.
• Place the Doppler transducer on the gel, adjusting to maximize signal intensity.
• Inflate the cuff to about 20 mmHg above the expected systolic blood pressure.
• Confirm that the Doppler signal disappears.
• Slowly deflate the cuff at about 1 mmHg per second.
• The brachial systolic pressure is noted when the Doppler signal reappears.
• Record the brachial systolic pressure.

• Place the blood pressure cuff just above the malleoli.
• Apply ultrasound gel over the dorsalis pedis (DP) and posterior tibial (PT) artery areas on the foot.
• Locate the DP artery Doppler signal.
• Inflate the cuff at least 20 mmHg above the point the Doppler signal disappears.
• Slowly deflate the cuff until the signal reappears, then record the pressure.
• Next, find the PT Doppler signal posterior to the medial malleolus.
• Follow the same inflation and deflation technique as for the DP artery.
• Repeat the DP and PT measurements on the opposite leg.

TRUE

1. Calcification of vessels suspected
2. Normal
3. Acceptable, may indicate mild PAD
4. Indicates PAD
5. Severe PAD, critical limb ischemia

Calcification of vessels suspected

Acceptable, may indicate mild PAD

Severe PAD, critical limb ischemia

there may not be sufficient blood flow to heal a chronic wound. This can be limb-threatening, and these patients will need prompt referral to a vascular specialist for further workup and potential interventions to improve blood flow necessary for healing.

severe arterial disease ; there may not be sufficient blood flow to heal a chronic wound. This can be limb-threatening,

It is calculated the same way as an ABI, with the SBP of the great toe (hallux) divided by the highest brachial SBP

A toe-brachial pressure index (TBPI) is useful to determine the presence or lack of perfusion in the toes.

Toe-Brachial Pressure Index (TBI)

Uses a Doppler probe to assess the shape and quality of arterial waveforms. It helps evaluate blood flow and detect defects in arterial supply

Doppler Waveform Analysis

• Forward flow
• Flow reversal
• Second forward component

Biphasic ; monophasic

• Forward flow
• Reverse flow

continuous forward flow

localize ; disease

Monophasic

Biphasic

Triphasic

The pulse volume recording (PVR) graphs limb volume changes with blood flow.

Special cuffs that incorporate pneumoplethysmography (detects volume changes in the arteries) capability are placed around the limb at multiple points along the limb and inflated to standard pressure

PVR is useful for locating areas of blockage in limb segments, especially in patients with non-compressible vessels.

normal PVR

flattened peaks

size or shape

It helps identify a general location of arterial blockages or stenoses but is not exact.

This test is performed on both legs to compare the arterial flow from the left and right limbs. A difference of 30 mm Hg at the same level between the left and right legs could suggest an occlusion or blockage in blood flow

significant pressure drop (e.g., greater than 20 mmHg)

Ultrasound checks blood flow in the veins, looking for signs of reflux lasting more than 0.5 seconds after muscle contraction or applying pressure (Baranoski & Ayello, 2020).

This advanced ultrasound technique combines traditional ultrasound imaging with Doppler flow studies. It provides detailed images of blood vessels and flow properties in color. It is ideal for a comprehensive evaluation of both arterial and venous systems. It helps detect precise locations of stenosis, occlusions, aneurysms in arteries.

Color Duplex Ultrasound

Angiography and Arteriography.

What Invasive LE Diagnositc tests are usually completed with a vascular specialist in an interventional radiology suite.

Contrast Angiogram (Arteriogram)

ABI / ABI

calcification of vessels

* No compression, it's not recommend until we know there is adequate blood flow present in the limb.

venous system

1. Superficial

2. Deep

3. Perforator

• Found in subcutaneous tissue

• Found in the muscular fascia
• Accompany major arteries

• Connect superficial to deep veins
• Equipped with one-way bicuspid valves to prevent blood reflux

• Blood drains from skin and subcutaneous tissue to superficial veins under low pressure
• This blood flows through perforator vein to the deep veins.
• Deep veins push blood upward using muscle contraction under high pressure
  • The deep vein system is responsible for pushing blood upwards using surrounding muscle contraction to the inferior vena cava of the heart and central veins for reoxygenation.

Chronic venous insufficiency (CVI)

hyperpigmentation ; thickening ; breakdown of tissue integrity

Risk factors for CVI and VLUs include

Venous Dermatitis: Also known as “stasis dermatitis,” this dermatitis is a chronic, non-contagious skin inflammation in patients with CVI. It is often confused with cellulitis but is uniquely different, as it is not infectious.

Prompt detection and early intervention

• Routine cleansing with mild non soap cleanser with no artificial colors or fragrances to remove scales, crusts, bacteria
• Apply emollients to damp peri wound skin to prevent excessive drying of the skin
• Avoid products with known sensitizing agents such as Lanolin as VLU patients have higher risk for allergic contact dermatitis
• If heavy wound exudate, provide high-level peri wound protectio

• 2-week use of a mild potency topical corticosteroid ointment may be used (i.e., Triamcinolone ointment 0.1%)
• After 2 weeks, switch to an emollient
• If there is no improvement, may refer to dermatology

• Cause: Bacterial infection, most commonly Staphylococcus or Streptococcus, entering through a break in the skin.
• Symptoms May Include: Local heat and tenderness, increasing erythema, red streaks up the limb (lymphangitis), rapid increase in wound size, and fever
• Diagnostic Testing: ESR, CBC, WBC are usually high
• Appearance: Skin may feel tight, glossy, and stretched.
• Location: Can occur anywhere, but common in the lower legs. Presents unilaterally
• Treatment: Typically involves oral or IV antibiotics.
  • Wound cultures should be performed when there are clinical signs and symptoms of significant infection to guide antibiotic therapy