THE GOAL OF THIS VASCULAR WOUND CARE CONTINUING EDUCATION PROGRAM is to provide healthcare professionals with the knowledge and skills to dif- ferentiate accurately the causes of vascular lower extremity ulcers and understand evidence-based diagnostic and treat- ment goals for managing arterial- and venous-related ulcers. After studying the information presented here, you will be able to:

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Describe the etiology and pathophysiology of arterial and venous ulcers

Identify distinguishing clinical features for identifica- tion of arterial and venous ulcers

Discuss the major diagnostic and treatment objec- tives for arterial and venous ulcers

Understand the synergy and improved patient outcomes resulting from interprofessional teamwork and team-based care in the management of vascular wounds

By Tanya Munger, DPN, FNP, RN, CCHP

Glenda, age 68, lived in a single-story home with her husband. Glenda was 5 feet 4 inches tall and 170 pounds, a former smoker (had not smoked in about 13 years), and did not have diabe- tes. She was retired from a distribution center for a large retailer, where she spent most of her workdays standing and lifting pack- ages. Her four adult children lived nearby. During her annual Medicare wellness visit at her primary care

provider’s office, she presented with a moderate amount of edema in her lower legs and feet, and a lower extremity ulcer was identi- fied. She said it had been present for several years, and she typical- ly wore long pants to hide it. She did not have any pain and tried several over-the-counter creams, lotions, and ointments. The ulcer would get smaller but never fully healed. Her primary care provid- er instructed her to clean the wound daily with hydrogen peroxide and apply antibiotic ointment. She was advised to elevate her legs when possible, which decreased the swelling. Glenda cared for the wound as instructed for about six to eight weeks with no results. She had not had additional diagnostic testing or been evaluated by other providers. The healthcare sys- tem where she received her medical care had a well-established wound-care clinic.

be up to 5%, and peak prevalence is between 60 and 80 years.2 The most prevalent type are ulcers due to vascular disease. Although venous ulcers account for nearly 80% of all ulcer types, many other causes exist for lower extremity ulcers.3


lenda’s situation is common. The prevalence of lower extremity ulcers is about 1% to 2% and increases slightly with age.1

For patients older than 65, prevalence can

healing of a lower extremity ulcer requires thorough assessment to identify the correct etiology and determine the proper treat- ment regimen. Complete wound healing is best achieved with an interprofessional approach, which can include primary care, nursing, nutrition, radiology, surgery, and psychosocial and physical therapy services, among others.

Etiology and pathophysiology of venous ulcers Venous disease or venous insufficiency is the cause of venous ulcers (also known as venous insufficiency ulcers), which are the most common type of lower extremity ulcers. The ulcer results from venous stasis that leads to venous hypertension.5 Multiple pregnancies, obesity, and varicose veins can cause venous stasis and hypertension. Valves in the deep and perforating

veins become damaged from surgery, trauma, or deep vein thrombosis. There is a back flow of blood typically from the point of injury, which then causes venous hypertension.1,2


to the high pressure in the veins, red blood cells leak into the tissues, and iron deposits cause a red-brown pigment known as hemosiderin in the gaiter area of the leg (between the knee and the ankle).6

Waste products

from the blood proteins and fibrinogen leak into the tissues causing irritation to the skin, known as venous stasis dermatitis or venous eczema. The skin will be erythematous with a very dry and flaky appearance. As the tissues become fibrotic, the lower leg can develop a woody appearance and an appearance of an upside-down champagne bottle.1,3 Lipodermatosclerosis, which is the change in appearance of

the lower leg, can present with peripheral edema that increases with prolonged standing or sitting.7

Ankle flare may be present

which consists of distended veins in the medial aspect of the ankle, also called the malleolar flare. Calf pump failure can contribute to the development of venous

ulcers. Contraction and relaxation of the calf muscle aides in circulation of venous blood return to the heart. Absence of this mechanism leads to stasis of venous blood and increased pressure in the veins. Calf pump failure is associated with paralysis, ankle arthrodesis (fused ankle), immobility, or sleeping in chairs with the legs dependent for long periods.8, 9


module will focus on those caused by vascular disease: venous and arterial ulcers. Chronic wounds affect nearly 7 million individuals in the

United States and cost nearly $25 billion each year to diagnose and treat.4

This places a significant financial burden In the United States, nearly 4.6 million workdays are

missed, and more than $1 billion is spent per year as a result of venous ulcerations.1

on the healthcare system, payers, and the community. These ulcerations have a significant effect on the patient’s physical and mental health, finances, and overall quality of life. The successful

Etiology and pathophysiology of arterial ulcers Arteries that normally carry oxy- gen-rich blood throughout the body become narrowed or blocked in ar- terial disease. The arteries can no longer carry enough blood to the lower legs and feet. If the blockage occurs slowly, collateral circulation can develop.9

Atherosclerosis is the

most common cause of plaque depos- its on the arteries walls. These depos- its cause the narrowing or blockage that leads to decreased blood flow,

Copyright © 2006 by Wound Care Education Institute. All Rights Reserved.

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Copyright © 2006 by Wound Care Education Institute. All Rights Reserved.

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