What are is the pathophysiology of a venous ulcer?
- venous stasis
- valvular insufficiency
- increased venous pressure of capillaries
- leakage of fluids and macromolecules
What is the pathophysiology of an arterial ulcer?
- arterial insufficiency
- arteriosclerosis
- emboli
Define a neuropathic ulcer
Loss of protective sensation commonly on the foot in which trauma causes a wound
Define a neuro-ischaemic ulcer
Loss of protective sensation and arterial disease
What are the aetiological factors of an ulcer?
1) Vascular - arteriosclerosis, venous stasis, vasculitis
2) Lymphatic - lymphangitis, lymphoma, lymphoedema
3) Haematological - anaemia, sickle cell anaemia, polycythemia
4) Metabolic - diabetes
5) Immunological - rheumatoid arthritis, Raynaud’s disease, scleroderma
6) Infection
7) Trauma - mechanical, chemical, thermal
8) Allergy - contact dermatitis
9) Malignancy - BBC, SCC, Melanoma
What are the goals of ulcer care?
1) remove or treat precipitating cause
2) improve circulation
3) promote and sustain healing
4) preventative care
What aspects of assessment are required for ulcer care?
- Clinical assessment
- Medical & surgical history
- Identify predisposing factors
- Identify factors that inhibit healing
- Ankle/brachial index
What are the predisposing factors for an arterial ulcer?
Arteriosclerosis Advanced age Diabetes Hypertension Smoking
What are predisposing factors for a venous ulcer?
History of DVT
Valvular incompetence in the perforating veins
Obesity
Chronic constipation
What changes occur in the lower leg in arterial ulcers?
Thin, shiny dry skin Absence of hair growth Thickened nails Pallor on elevation Limb may be cool
What changes occur in the lower leg in venous ulcers?
Firm brawny oedema Reddish/brown pigmentation (haemosiderin) Evidence of healed ulcers Varicosities Warm leg Hair on lower limb
What are common locations for arterial ulcers?
Phalangeal hands Toes (between or tips) Above lateral malleolus Over metatarsal heads On side or sole of foot
What are common locations for venous ulcers?
Anteriomedial malleolus
Pretibial area
Gaiter area
Describe the clinical appearance of an arterial ulcer
Demarcated, punched out edges
Deep, pale wound base
Necrotic or sloughy
Describe the clinical appearance of a venous ulcer
Ragged edges
Ruddy-red colour unless infected
Shallow ulcer
What type of ulcer is associated with pain?
Arterial, relieved by lowering legs or walking. Venous can be with severe oedema or if infected but is relieved by elevation
Describe the surround skin of an arterial ulcer
Neuropathic, thin, shiny, hairless
Describe the surround skin of an venous ulcer
Haemosiderin staining, leaking oedema may result in maceration, pruritus, scaly skin, oedema, hair
Which type of ulcer has normal pedal pulses?
Venous, arterial ulcers are associated with diminished, or absent pulses.
What are the 7 points for general management?
1) daily inspection
2) skin hygiene
3) moisturise skin
4) stop smoking
5) avoid trauma
6) nutritious diet
7) loose weight
What is some advice specific to a venous ulcer?
- regular ambulation
- calf and foot muscle exercises
- elevate feet when sitting (above the heart)
- elevate foot of bed
- avoid constipation
What is some advice specific to a arterial ulcer?
- avoiding constrictive leg wear
- sit with legs down in a neutral position
- elevate head of bed for night pain
- increase exercise as tolerated
- avoid trauma
- regular podiatry
- avoid sudden temperature changes
What are treatment options for an Arterial ulcer?
Consult a vascular specialist
Chemical or surgical sympathectomy for small vessel disease
Angioplasty or by-pass surgery for large vessels
Amputation in severe cases
What are three goals of care for an arterial ulcer?
1) pain management
2) prevent infection
3) healing if tissue perfusion adequate
