Getting Ready for Wound Certification: Assessing and Managing Lower Extremity Venous Disease.

Abstract

Lower extremity ulcers are a common type of chronic wound, especially among older adults. Venous leg ulcers (VLUs) are the most prevalent type of lower extremity wound, impacting approximately 1% of the population in the United States.1 These ulcers may be painful, impair mobility, can be emotionally distressing to manage, are burdensome, and negatively impact quality of life. Economic impact of a VLU is significant for the patient through loss of work and costs associated with dressings and treatment. It is estimated that the United States spends $14 billion per year in VLU treatments.2 A comprehensive health assessment and a physical examination are necessary when assessing and treating lower extremity wounds due to the multitude of preexisting conditions that may impact these wounds and their healing potential. Specifically, lower extremity venous disease (LEVD) has key characteristics that often allow for diagnosis to be made based on patient history and physical examination. When gathering a patient history, the clinician should be sure to ask about any lifestyle habits, including employment, or conditions that could lead to valvular or calf muscle dysfunction as well as impediments to wound healing. Diabetes, edema, heart failure, tobacco use, reduced mobility, autoimmune disorders, obesity, cancer, and many other conditions are linked to LEVD and directly impact healing potential. Pain, fatigue, wound drainage, inflammation, and edema of the lower extremities, commonly experienced with VLUs, are symptoms that significantly affect quality of life and may increase the risk of delayed wound healing.3 Common physical exam findings associated with LEVD and VLU include lower leg edema, dilated veins, and skin changes. Hemosiderin staining, a darkened, discolored pigmentation of the skin over the lower legs, and venous dermatitis characterized by redness and flakiness are examples of skin changes that are often seen with LEVD and VLU. While the classic location for a VLU is superior to the medial malleolus, they may occur anywhere on the lower leg, including posterior calf and dorsum of the foot.1 Venous leg ulcers are typically shallow, with red and/or fibrinous slough-filled wound beds, tend to have moderate to heavy exudate, and have macerated periwound skin.1 Additional diagnostic testing should be considered if clinical presentation of a VLU is unclear or to determine the extent and severity of LEVD. Both LEVD and VLU require a holistic approach to healing and maintaining skin integrity. Standard treatment involves compression, leg elevation, and topical therapy to maintain a physiologic wound environment. Pharmacologic and surgical interventions may be of benefit for some patients. Management of preexisting comorbidities is necessary as part of the treatment plan for LEVD. Pain related to these wounds can be neuropathic, nociceptive, or mixed.3 A treatment plan should include identifying pain along with other symptoms such as itch, ache, and throbbing that affect quality of life to improve outcomes.3 Nutrition is also a significant factor in healing and should be managed appropriately with the involvement of a dietitian and/or a diabetic educator as part of the team. Blood glucose control, protein intake, and the overall percentage of meals consumed all play a role in the ability to heal a chronic and/or recurrent lower extremity wound. An interprofessional approach to management is key to optimal patient outcomes when it comes to short- and long-term care of patients with LEVD. Understanding the anatomy of a multiple-choice question is useful when preparing for a WOCNCB board exam. The main components to a multiple-choice question include the stem and the options. The stem is the text that asks the question. Be sure to pay close attention to what information is given in the stem and what is being asked. Do not read into the stem and add your own information. Try to think of the correct answer before looking at the possible options. The options will have a key, which is the correct answer, and distractors. Be sure to carefully read all options and start by eliminating known distractors. PRACTICE QUESTIONS Certified Wound Treatment Associate Question 1. The WTA-C provides the following education to patients about their compression stockings: Apply stockings in the morning after showering. Once the wound is healed, compression stockings will no longer be needed. To clean stockings, use delicate cycle for settings on washing machine and dryer. Stockings will need to be replaced every 3 to 6 months. Content outline: Domain II; task 2; Skill: k Cognitive level: Recall ANSWER: D Rationale: Compression stockings come in different pressure gradients, ranging from light support to very strong support. The minimal pressure gradient for compression stockings to be an effective therapy for chronic venous insufficiency (CVI) and VLU is 20 to 30 mm Hg. Over time, through wear, stockings will lose their compression and therefore will need to be replaced every 3 to 6 months, making this option the key. Each of the distractors in this question provided information that was either partially or completely incorrect. When donning stockings, it is important to apply when edema is minimal. Patients should be taught that the optimal time to apply their stockings would be in the morning before getting out of bed. Waiting until after a shower allows for edema to increase. The patients should then be instructed to elevate their legs for 20 to 30 minutes to reduce edema before applying if the stockings are not applied immediately upon getting out of bed. Compression therapy is a lifelong commitment to promote healing and prevent further occurrence of VLUs. Wearing compression stockings will reduce VLU recurrence, making it important to educate patients about continued use of compression even after their wounds are healed. Special care is required in cleaning compression stockings. Inappropriate laundering can compromise therapy by reducing the level of compression. Patients should be instructed to wash stockings daily by either hand or machine wash on delicate cycle. Stockings should be hung to dry. CWOCN Questions 2. The WOC nurse is consulted for a 66-year-old man with chronic leg ulcers. His past medical history includes heart failure, diabetes mellitus type 2, arthritis, and emphysema. Recommendations are discussed with the primary care provider to include the most reliable and commonly used noninvasive test to diagnose venous disease. This test is known as: Ankle-brachial index (ABI) measurement Venous duplex ultrasound Angiogram Air plethysmography Content outline: Wound task 4; Skill: 010404 Cognitive level: Recall ANSWER: B Rationale: When a diagnosis of CVI is questionable (based on risk factors, presentation, or medical history), noninvasive vascular studies are helpful to confirm the wound etiology and guide treatment options. Knowing what is being treated (wound etiology) is important, prior to initiating or recommending a treatment plan. Venous duplex ultrasound is used to identify the presence and direction of blood flow and to detect venous reflex or obstruction and the anatomic location of the obstruction.1 The information obtained from venous duplex ultrasound confirms the diagnosis of venous insufficiency and can be used to plan for interventions and an evidence-based plan of care for management. Air plethysmography and photoplethysmography are also noninvasive tests sometimes used to assess the presence and severity of venous reflex but are not used widely, given the availability of venous duplex ultrasound.1 An angiogram is an invasive test, so while it shows imaging of the blood vessels and can provide an image of a problem, it carries a higher risk than noninvasive testing. Ankle-brachial index measurement is another noninvasive test typically used to diagnose peripheral arterial disease.2 3. Long-term compression therapy has proven to be effective in the management and prevention of recurrent venous ulcers and remains the gold standard for therapy. The WOC nurse understands the indications and contraindications for compression therapy and recommends obtaining the following noninvasive test to rule out significant artery disease and determine the level of compression therapy that can safely be used to prevent new and recurrent VLUs in their patient: Ankle-brachial index Pulse palpation Photoplethysmography Venous duplex ultrasound Content outline: Wound task 4; Skill: 010406 Cognitive level: Application ANSWER: A Rationale: Patients with arterial disease require adjustments to their plan of care. The ABI is a noninvasive diagnostic test that measures the blood flow to the legs and feet, assessing for any component of artery disease. For patients with an ABI of more than 0.5 to less than 0.8 and ankle pressures of more than 70 mm Hg who have edema and open ulcers, a trial of reduced compression (23-30 mm Hg) with close supervision could be implemented. Compression is not recommended for individuals with an ABI of less than 0.5, ankle pressure of less than 70 mm Hg, or toe pressure of less than 50 mm Hg. These patients should be referred to a vascular specialist for a workup and possible revascularization as medically appropriate. For ABIs of 0.8 and greater, compression therapy may and should be considered as it is the gold standard for treatment.1 Pulse palpation is an important piece of the assessment but does not give us all of the information that we need to accurately recommend compression therapy. Photoplethysmography is another noninvasive test sometimes used to assess the presence and severity of venous reflex but is not used widely, given the availability of venous duplex ultrasound. Venous duplex ultrasound is used to identify the presence and direction of blood flow and to detect venous reflex or obstruction and the anatomic location of the obstruction. The information obtained from venous duplex ultrasound confirms the diagnosis of venous insufficiency and can be used to plan for interventions and an evidence-based plan of care for management.2 4. The WOC nurse is consulted for an 87-year-old man with a past medical history of heart failure. He has a superficial but large wound over the right lateral lower leg, which he states started about 2 months ago after he accidently walked into the nightstand in his bedroom. Wound borders are irregular and there is a copious amount of serous drainage. He changes the dressing with plain gauze 2 to 3 times per day. He describes the wound pain as aching and states that his quality of life is impacted greatly. After a thorough history and assessment, ruling out underlying conditions and disease, what is the diagnosis and preferred treatment? Lymphedema with chronic skin tear, compression Arterial ulcer, debridement Calciphylaxis, intravenous sodium thiosulfate Venous ulcer, compression Content outline: Wound task 4; Skill: 010402 Cognitive level: Analysis ANSWER: D Rationale: A thorough history and physical examination is necessary anytime a new, chronic, or recurrent wound is assessed. Understanding family history, preexisting comorbidities, and wound etiology is paramount prior to recommending a treatment plan. With lymphedema, skin appearance is typically thick and firm. Cellulitis is common but skin ulcers are not. The treatment focuses on skin care/hygiene, weight control, and lymphatic drainage. Compression may also be used. Arterial ulcers usually present as round or punched out painful areas over the lower legs, feet, and ankles. The wound bed usually appears dry, scabbed, or with eschar. The legs are typically cool to touch, there may be difficulty palpating a pulse in the feet, and there may be the absence of hair. The treatment would depend on the unique patient situation, and the absence/presence or ability to restore blood flow to the extremity typically guides the treatment plan.1 Calciphylaxis is a rare but serious condition in which calcium deposits or vascular calcifications form in small blood vessels, causing painful skin ulcers that usually lead to necrosis of the skin and fatty tissue, secondary to ischemic injuries. It is often seen in patients with end-stage renal disease or other kidney complications. Diagnosis can be made based on the clinical presentation, but punch biopsy is often used to differentiate from similar conditions. Treatment focuses on pain management and systemic control and involves a multidisciplinary approach. Systemic treatment is standard therapy for calciphylaxis, and intravenous sodium thiosulfate is administered during the last hour of hemodialysis.2 Venous leg ulcers are found on the lower extremities, usually have irregular borders, are superficial, and are highly draining. Wound beds usually appear moist, and maceration can be present. Extremities are often edematous, more so when the patient spends increased time with legs in a dependent position. Seventy-four percent of VLUs start with a specific trigger such as cellulitis, trauma, scratching, insect bites, edema, or burns and progress into a chronic wound.1 Compression therapy and elevation are key components in the management of LEVD and VLUs. Advanced Practice Question 5. An advanced practice registered nurse has been managing a patient with a VLU using compression and optimal topical therapy for 6 weeks with minimal progress. Which oral medication would be indicated to use in addition to standard compression therapy for wound healing? Prednisone Clindamycin Pentoxifylline Paroxetine Content outline: 4C1a Cognitive level: Application Answer: C Rationale: Pentoxifylline is an indicated medication to use in conjunction with compression and topical treatments for those who fail to progress with standard therapy.1 While it is considered an off-label use, studies have shown that pentoxifylline is an effective addition to compression therapy through its effects on microcirculation. Tissue oxygenation is increased through lowered blood viscosity, increased erythrocyte flexibility, and increased leukocyte deformability, along with decreased neutrophil adhesion and activation. Dosages of 400 mg 3 times per day is the recommended dosage for the treatment of VLUs.1 When prescribing, one must consider cost as well as potential side effects, which are most commonly gastrointestinal related, to determine if benefits of the medication outweigh its risks. The distractor options have either been known to be used in the wound care setting or at first glance may be a “look-alike” to the correct option. The following distractors will be discussed. Many individuals with VLUs also experience venous dermatitis, also known as venous eczema.2 Venous dermatitis is typically managed with topical corticosteroids and not systemic prednisone.3 Medications that suppress the body's immune response, such as prednisone, can impair wound healing, making prednisone an incorrect answer.4 Clindamycin is a versatile antibiotic that is effective with streptococcal and Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus, infections.5 The information provided in the stem does not indicate infection is an issue and routine use of antibiotics, such as clindamycin, is not appropriate. Paroxetine is a selective serotonin reuptake inhibitor indicated to treat depression and anxiety disorders.6 This distractor served as a “look-alike” medication as there is no known effect of paroxetine on wound healing.