Flashcards in Venous Insufficiency Ulcers Deck (80)
What percent of the population is diagnose with chronic venous insufficiency, aka post-phlebetic syndrome?
Of the 7 million Americans with venous insufficiency, __% will develop a venous insufficiency ulcer
__-__% of leg ulcers are due to VI
Are men or women more at risk for developing VI ulcers?
women have 3x greater risk
The risk of ulceration is __ times greater in individuals over the age of 65
What is the recurrence rate of venous ulcers?
What is correlated with recurrence?
Pressure within the venous system generaly drops to around __ mm Hg and decreases to almost _ mm Hg by the time it reaches the R atrium
Although the names of the 3 layers of the veins is the same as the arteries there are 3 differences, what are they?
- Smaller amounts of smooth muscle
- Less connective tissue support
At any one time, the venous system stores approximately __-__% of the total blood volume
What are the 3 types of veins?
What are 3 examples of deep veins?
The deep veins carry __-__% of blood back to heart
What are 2 examples of superficial veins?
greater and lesser saphenous
What are the 2 roles of superficial veins?
- Drain skin and subcutaneous tissues
- Assist with temperature regulation
What is the function of the perforating veins?
Connect deep and superficial veins
The proximal flow of venous blood relies on what 3 things?
- Respiratory pump
- Calf muscle pump
It is generally agreed that sustained _____ _______ is required for the development of venous insufficiency ulcerations
What are the 2 most common causes of venous HTN?
- Vein dysfunction
- Calf muscle pump failure
What are the 2 main theories as to the etiology of venous insufficiency ulcers?
- fibrin cuff theory
- WBC trapping theory
According to the fibrin cuff theory vessel HTN and distention cause what?
an increase in vascular permeability
Describe the fibrin cuff theory
Fluid and proteins are allowed to move from within these vessels into the interstitium, the protein fibrinogen is converted to fibrin. Fibrin adheres to capillary walls, forming a "cuff", This cuff is thought to pose a barrier to the exchange of oxygen and nutrients, causing local hypoxia and malnutrition and ultimately cell death and ulceration.
What is hemosiderin staining caused by?
Leakage of red blood cells into the tissue
According to the WBC trapping theory vessel HTN and distention cause what?
Describe the WBC trapping theory
WBCs trap and plug capillaries leading to tissue ischemia. The WBCs move into the interstitium and release proteolytic enzymes and inflammatory mediators causing tissue damage.
What are the 6 risk factors contributing to VI ulcers?
- Vein Dysfunction
- Calf Muscle Pump Failure
- Previous VI Ulcer
- Advanced Age
- Diabetes Mellitus
What is the main cause for venous HTN?
What are 5 means of valvular damage?
- Clot sequelae
Describe why retrograde flow exacerbates venous HTN
The valves may close completely but fail to prevent retrograde flow due to venous distention. Distended veins have an increased vessel diameter allowing some blood to flow backward through the closed, but not overlapping, valve leaflets
What are varicosities?
Dilated veins characterized by an increase in length and tortuosity
What are 4 risks for developing calf muscle pump failure?
- calf weakness/paralysis
- decreased DF
- prolonged standing
- incompetent valves
Venous ulcer recurrence rates are as high as __%
What are the 3 reasons why repeat ulcerations commonly occur in the same location as previous ulcers?
- repeat ulcer may be due to the same cause as the first ulcer
- the scar tissue resulting rom previous ulceration has less tensile strength and elasticity
- VI ulcers will recur if the precipitating factors are not addressed
Valve degeneration may explain the ____fold increase in venous insufficiency in individuals over the age of 65
How does diabetes lead to an increased risk for VI ulcers?
- increased microvascular disease
- impaired immune response
- impairs all 3 phases of wound healing
What are the 5 most common clinical tests and measures used to assess individuals with venous insufficiency?
- Clinical Assessment for DVT
- Ankle-Brachial Index
- Trendelenburg Test
- Doppler Ultrasound
- Venous Filling Time
What is the gold standard for assessing DVT?
When using the clinical assessment guideline for DVT patients scoring less than or equal to _ should be considered to have a high probability of DVT and further assessment should be requested.
Coexisting AI and VI coexist in __-__% of all LE ulcers
Patients with venous insufficiency ulcers and an ABI less than __ should not be managed with compression due to coexisting arterial insufficiency
What is the suggested pathology if it takes less than 20 seconds for venous distention to occur with the tourniquet on in the Trendelenburg test?
deep or perforating vein incompetence
What is the suggested pathology if it takes less than 10 seconds for venous distention to occur with the tourniquet removed in the Trendelenburg test?
superficial vein incompetence
What is the gold standard for evaluating the venous system?
What is the difference between venous and arterial Doppler ultrasound?
When performing an arterial Doppler the clinician must identify the presence or absence of sound.
When performing a venous Doppler the clinician must also interpret changes in the sound's intensity.
A Doppler examination consists of 3 parts, what are they? What is the suggested pathology if each test is found positive?
- Resting test: venous obstruction
- Augmentation test: partial venous obstruction
- Reflux test: valve incompetence
How is venous filling time assessed?
Patient supine, note superficial veins on dorsal foot.
Elevate the limb 60° for 1 minute or until veins are drained by gravity.
Lower limb to dependent position, note time for veins to refill.
What is normal venous filling time?
What is immediate venous filling predictive of?
What are the 4 indications for venous filling time?
- Unable to tolerate ABI
- ABI > 1.1
- History of diabetes or vessel calcification
- Suspected concomitant arterial insufficiency
What are the 7 CEAP Classification System for Chronic Venous Disease?
Describe C0 classification for chronic venous insufficiency
Describe C1 classification for chronic venous insufficiency
Describe C2 classification for chronic venous insufficiency
varicose veins greater than or equal to 3 mm
Describe C3 classification for chronic venous insufficiency
Describe C4 classification for chronic venous insufficiency
skin and subcutaneous tissue changes
Describe C4A classification for chronic venous insufficiency
Describe C4B classification for chronic venous insufficiency
Describe C5 classification for chronic venous insufficiency
healed venous ulcer
Describe C6 classification for chronic venous insufficiency
current venous ulcer
Describe pain complaints associated with venous insufficiency ulcers
mild to moderate pain complaints
Typically complain of dull, aching leg pain or "heaviness"
What increases and what decreases pain associated with VI ulcers?
Increased with dependency and relieved by elevation
Are VI ulcers most usually located medially or laterally?
What is the typical presentation of a VI ulcer?
Generally superficial, irregularly shaped and have moderate to high amounts of drainage. The wound bed contains beefy red granulation tissue but may take on a ruddy appearance. A thin, yellow fibrous coating may cover the wound bed giving it a glossy look.
What are typical periwound characteristics associated with VI ulcers?
dermatitis, cellulitis, edema, hemosiderin deposition, lipodermatosclerosis
Are pulses generally decreased or normal in VI ulcers?
Is temperature generally decreased, increased, or normal in VI ulcers?
normal to mild warmth
What is the average healing time for full-thickness venous ulcers with appropriate interventions?
What is the healing time for full-thickness smaller venous ulcers with appropriate interventions?
What is the healing time for full-thickness larger venous ulcers with appropriate interventions?
What are 5 guidelines for patients with VI ulcers?
- Control swelling
- Protect your feet and legs
- Live healthy
- Know when to call clinician
- Inform patients of proper positioning and exercises to enhance venous return
What are the 3 precautions for patient to be aware of with VI ulcers?
- concomitant arterial disease
- allergic reactions and sensitization
- inappropriate whirlpool use
Under what 5 circumstances should further medical testing be requested?
- Patients scoring 3 or more on DVT clinical prediction guidelines
- Wounds that fail to progress
- Suspected infection
- If bone or capsule is exposed request bone scan/X-ray
- Wounds that do not present with typical VI ulcer characteristics
What are the 4 keys to local VI ulcer wound care?
- Protect Surrounding Skin
- Address Wound Bed
- Enhance Venous Return
- Educate Patient/Caregivers
What are the keys to protecting the surrounding skin?
- moisturize dry, scaling skin
- use topical steroids to decrease inflammation or weeping
- use topical agents prudently to avoid sensitization
What are 2 suggestions when addressing the wound bed?
choose absorptive dressings and use skin sealants
What are 2 ways to enhance venous return?
- Apply compression (if appropriate)
- Instruct patients in methods to decrease edema
List the 8 effects of compression
- Enhances calf muscle pump
- Improves venous return
- Decreases peripheral edema
- Reduces venous distension
- Increases tissue oxygenation
- Softens lipodermatosclerosis
- Protects limb from trauma
- Limits need for prolonged elevation/bed rest
What are the general compression parameter recommendations for mild to moderate venous insufficiency at the ankle? At the infrapatellar notch?
30-40 mm Hg
10 mm Hg
For severe venous insufficiency, distal pressures of __-__ mm Hg may be required