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822: Integumentary > Arterial Insufficiency Ulcers > Flashcards

Arterial Insufficiency Ulcers Flashcards

1
Q

-% of all lower extremity ulcerations are due to arterial insufficiency, or lack of adequate blood supply

A

5-10

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2
Q

What are the 3 layers of an artery from outermost to innermost?

A
  • adventitia
  • tunica media
  • intimal layer
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3
Q

Describe the structure and function of the adventitia (tunica externa)

A

Composed of connective tissue along with collagen and elastin fibers.
It provides support to the vessel walls

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4
Q

Describe the structure and function of the tunica media

A

Made of thick, smooth muscle, collagen, and elastin.

It modulates vessel diameter

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5
Q

Describe the structure of the intimal layer

A

It is a single layer of endothelial cells in direct contact with circulating blood.

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6
Q

What are the smallest type of arteries?

A

arterioles

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7
Q

Pressure within the arterial system is normally between __-__ mmHg in larger arteries and as low as __-__ mmHg in arterioles

A

90-100

25-35

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8
Q

Describe the structure of capillaries

A

They are composed of a single layer of endothelial cells and are only 1 mm in length and are wide enough for a single RBC to squeeze through at a time

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9
Q

What are 6 causes of arterial insufficiency?

A
  • Arteriosclerosis
  • Trauma
  • Acute embolism
  • Diabetes mellitus
  • Rheumatoid arthritis
  • Thromboangiitis (Buerger’s disease)
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10
Q

What is arteriosclerosis?

A

thickening and hardening of the arterial walls

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11
Q

What is the most common form of arteriosclerosis and the leading cause of arterial insufficiency ulcers in the US?

A

Atherosclerosis

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12
Q

Describe the etiology of atherosclerosis

A

Circulating cholesterol is deposited on vessel walls, causing fatty streaks or plaques. The body attempts to repair the damaged endothelial cells, resulting in a buildup of blood products. Lipids, calcium, and scar tissue accumulating on the damaged intimal layer bulge into the lumen, causing progressive narrowing.

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13
Q

Atherosclerosis also leads to thickening of the basement membrane which results in what?

A

decreased exchange of oxygen and nutrients to affected tissues

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14
Q

What is one of the first signs of arterial insufficiency?

A

Intermittent Claudication

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15
Q

What is Intermittent Claudication?

A

Activity-specific discomfort due to local ischemia, which stops within 5 minutes of ceasing the provocative activity

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16
Q

Patients generally have at least __% vessel stenosis if they are experiencing intermittent claudication

A

50

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17
Q

The pain patients experience with intermittent claudication is typically _____ to the site of occlusion

A

distal

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18
Q

How does the body accommodate for increased tissue demands associated with intermittent claudication?

A

By decreasing the sympathetic output, thereby causing vasodilation

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19
Q

Once there is about __% vessel occlusion even maximal vasodilation does not provide sufficient circulation

A

70

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20
Q

What represents more significant arterial disease than intermittent claudication and is frequently characterized as a burning pain that is exacerbated at night or with elevation and is relieved by dependency?

A

Ischemic Rest Pain

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21
Q

Describe the progression of atherosclerotic pain

A

Intermittent Claudication –> Ischemic Rest Pain –> Ulcer

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22
Q

The prevalence of asymptomatic arterial insufficiency is _____ than that of symptomatic disease

A

greater

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23
Q

What can be used to describe dead tissue that is dry, dark, cold, and contracted when compared to similar areas or the contralateral side

A

gangrene

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24
Q

What ultimately results when local tissue oxygen requirements exceed perfusion?

A

ulceration and gangrene

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25
Q

Do arterial insufficiency ulcers tend to occur on the medial or lateral aspect of the limb?

A

lateral

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26
Q

What are 6 Risk Factors Contributing to AI Ulcers?

A
  • Hyperlipidemia and Elevated LDL
  • Smoking
  • Diabetes
  • Hypertension
  • Trauma
  • Advanced Age (70+)
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27
Q

What is the #1 modifiable risk factor for peripheral vascular disease?

A

smoking

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28
Q

What are the 4 ways in which smoking can contribute to arterial ulceration?

A

1) nicotine causes vasoconstriction, thus decreasing tissue perfusion
2) decreases the availability of oxygen by increasing the amount of nonfunctioning hemoglobin
3) increases the rate of clot formation and blood viscosity, thus decreasing tissue perfusion
4) nicotine enhances cholesterol deposition within vessel walls, thus hastening the atherosclerotic process and further impairing circulation

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29
Q

Smoking just one cigarette decreases wound and tissue oxygen saturation by __% for one hour in healthy individuals

A

30

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30
Q

People with diabetes have an increased prevalence of what type of arterial insufficiency?

A

Calcific, in which their vessel walls tend to accumulate calcium

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31
Q

True or False

Calcium deposits in the tunica media and basement membrane can be seen on x-ray

A

True

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32
Q

What effect does hyperglycemia have on wound healing?

A

decreases all 3 phases of wound healing and decreases the body’s ability to fight infection

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33
Q

Describe how HTN increases the risk of AI ulcers

A

It initiates and perpetuates endothelial cell injury

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34
Q

How do arteries respond to sustained hypertension?

A

By thickening the layer of smooth muscle within the tunica media and increasing the production of vasoconstrictive agents

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35
Q

What are the 3 forms of initiating trauma?

A
  • mechanical
  • chemical
  • thermal
36
Q

What are 4 reasons why AI ulcers are more common in the elderly?

A
  • they are less able to adapt to vessel diameter based on demand
  • they have increased rate of comorbidities
  • they have a slowed immune response
  • they have a decreased inflammatory response
37
Q

What are 6 of the most common clinical tests and measures used to assess individuals with arterial insufficiency?

A
  • Pulses
  • Doppler Ultrasound
  • Ankle-Brachial Index
  • Segmental Pressures
  • Rubor of Dependency
  • Venous Filling Time
38
Q

What 4 pulses should clinicians assess?

A
  • femoral
  • popliteal
  • dorsalis pedis
  • posterior tibial
39
Q

What is the most common site of occlusion?

A

The bifurcation of the common femoral artery

40
Q

Pulse are generally palpable if the pulse present is greater than __ mm Hg

A

80

41
Q

What method of assessment should be performed when pulses are not easily palpable?

A

Doppler Ultrasound

42
Q

_____ ABI values are correlated with increased severity of atherosclerosis and CAD

A

Lower

43
Q

When is an ABI indicated?

A
  • Decreased or absent pulse
  • Signs/symptoms of AI
  • History of PVD
44
Q

Describe the procedure for an ABI

A
  • calculate brachial pressure on both UEs, using the highest value to calculate the ABI
  • determine the posterior tibial pressure
45
Q

How do you calculate the ABI?

A

Take the systolic pressure of the LE divided by the systolic pressure of the UE

46
Q

An ABI from __-__ signifies vessel calcification

A

1.1-1.3

47
Q

What is normal ABI?

A

0.9-1.1

48
Q

An ABI from __-__ signifies mild to moderate arterial insufficiency

A

0.7-0.9

49
Q

What are the possible vascular interventions for an ABI ranging from 0.7 to 0.9?

A

Conservative interventions normally provide satisfactory wound healing

50
Q

What does an ABI from 0.5-0.7 signify?

A

Moderate arterial insufficiency, intermittent claudication

51
Q

What is the suggested intervention for an ABI that ranges from 0.5 to 0.7?

A

Trial of conservative care; the physician may consider revascularization

52
Q

An ABI less than __ signifies severe arterial insufficiency and pain at rest

A

0.5

53
Q

What is the prognosis for an AI with an ABI less than 0.5?

A

The wound is unlikely to heal without revascularization and it is considered limb-threatening arterial insufficiency

54
Q

Patients typically experience rest pain and gangrene when the ABI is less than __.

A

0.3

55
Q

What is the suggested intervention for an ABI less then 0.3?

A

Revascularization or amputation

56
Q

What clinical measure can help localize areas of decreased arterial blood flow?

A

Segmental Pressure Measurements

57
Q

A pressure drop of greater than __ mm Hg in adjacent segments is indicative of significant arterial occlusion in the interim segment

A

20

58
Q

What is segmental pressure measurements are best at identifying what?

A

distal arterial occlusion or stenosis rather than proximal

59
Q

What is a reliable indicator of surface arterial blood flow?

A

capillary refill

60
Q

What is normal capillary refill time?

A

less than 3 seconds

61
Q

To asses rubor of dependency elevate the LE __ degrees for 1 minute then return the leg to the surface and note the time it takes to return to its original color

A

60

62
Q

Normal arterial flow, color returns within __-__ seconds

A

15-20

63
Q

In individuals with mild arterial insufficiency, pallor usually occurs within __-__ seconds of elevation

A

45-60

64
Q

In individuals with moderate arterial insufficiency, pallor usually occurs within __-__ seconds of elevation

A

30-45

65
Q

In individuals with severe arterial insufficiency, pallor usually occurs within __ seconds of elevation

A

25

66
Q

When is assessment of rubor of dependency indicated?

A
  • Unable to tolerate ABI
  • ABI > 1.1
  • History of diabetes or vessel calcification
67
Q

To asses venous filling time elevate the LE __ degrees for 1 minute then return the leg to the surface and note the time it takes the veins to refill

A

60

68
Q

A venous filling time anywhere from _-__ seconds is normal

A

5-15

69
Q

A venous filling time less than _ seconds indicates venous insufficiency

A

5

70
Q

A venous filling time greater than __ seconds indicates arterial insufficiency

A

20

71
Q

When is assessment of venous filling time indicated?

A
  • Unable to tolerate ABI
  • ABI >1.1
  • History of diabetes or vessel calcification
  • Suspected concomitant venous insufficiency
72
Q

What does the 5PT method stand for?

A
  • Pain
  • Position
  • Presentation
  • Periwound
  • Pulses
  • Temperature
73
Q

Describe pain associated with arterial ulcers

A

severe and often increased with elevation

74
Q

Describe the typical positioning of arterial ulcers

A

Primarily occur in the LE, typically the toes, lateral malleolus, and anterior leg

75
Q

Describe the typical presentation of arterial ulcers

A

They are typically round and regular and can conform to precipitating trauma

76
Q

Do arterial ulcers bleed or drain much?

A

No

77
Q

Describe the periwound and structural changes associated with arterial ulcers

A

The periwound area is typically thin, shiny, and anhydrous. Hair loss is common and nails appear thick and yellow. Skin is pale, dusky and cyanotic.

78
Q

What temperature changes occur with arterial ulcers?

A

cool or cold to the touch because of decreased blood supply

79
Q

What factors should be considered when determining the prognosis for AI ulcer healing?

A
  • size
  • depth
  • local tissue perfusion
80
Q

An ABI greater than __, a toe pressure greater than or equal to 50 mm Hg, and a tpO2 greater than __ mm Hg signifies a good prognosis for AI ulcer healing

A

0.5

50

30

81
Q

List 6 foot care guidelines to instruct your patient with AI ulcers

A
  • Protect from trauma
  • Protect from chemicals
  • Protect from excessive heat/cold
  • Protect open wounds
  • Live healthy
  • When to call clinician
82
Q

What are the 3 wound care precautions for patients with arterial insufficiency?

A
  • avoid compression and compression dressings
  • avoid sharp debridement of dry, eschar-covered, uninfected ulcers in patients with low ABIs
  • gangrenous tissue must be removed surgically
83
Q

What are the 4 keys to local wound care for patients with arterial insufficiency?

A
  • Protect Surrounding Skin
  • Address Wound Bed
  • Maximize Circulation
  • Educate Patient/Caregivers
84
Q

What are the keys to protecting the surrounding skin?

A
  • moisturize dry skin
  • avoid adhesions
  • reduce friction between the toes
  • provide padding to protect ischemic tissues
85
Q

Describe Buerger’s exercises

A

Consists of cyclic leg elevation until blanching, followed by leg lowering until reactive hyperemia occurs

822: Integumentary (16 decks)

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