which is called peripheral artery disease (PAD). It can lead to thrombosis, embolization, and ischemia. Other causes of arterial disease are diabetes, trauma, and vasospastic diseases, such as Raynaud disease.1 Several risk factors contribute to the development of arterial


disease. Smoking, obesity, and high-fat diet are some modifiable risk factors. Those with hypertension, diabetes, heart disease, and elevated cholesterol are also at greater risk.1,4 Those with arterial disease may experience intermittent clau-


dication, which is calf pain when walking that resolves with rest. Pain may be present when the legs are elevated, and they may also experience numbness or tingling.1,4,9


The lower leg has reduced


levels or no hair and may be cool to touch. The lower leg and foot may have pallor when raised and dependent rubor. Pulses may be weak or absent, and capillary refill reduced. Due to poor oxygenation, the patients are at risk for fungal infections, and toenails may be thick, yellow, and brittle.


Assessment of lower extremity ulcers Regardless of the type of lower extremity ulcer, much of the assessment will be the same. The whole person must be assessed to identify any risks factors that may impede wound healing. Knowing patient risk factors will be helpful when addressing pre- vention. It is important to identify if the patient has a past history of nonhealing wounds; if so, what were the past treatments and outcomes?10


History should be obtained regarding any previous


diagnostic tests that have been performed. When assessing the current wound. it is important to know


what may have caused the wound and how long has it been present. Accurate assessment and documentation are crucial for determining the appropriate treatment plan. All wounds must be measured, and length, width, and depth should be recorded (cm).11


Assessing and measuring depth and location for any


undermining or tunneling should be done by using the face of a clock for orientation. It is important to describe the characteristics of the wound bed, noting color, exudates, and odor, and inspect the periwound skin.11


Examination should be performed on the


lower extremity, noting condition of skin, temperature, presence of edema, hair distribution, pulses, and capillary refill. Do not forget the fifth vital sign — assess the patient’s pain (see CE80-60 Wounds, Part 1: Nursing Assessment, Care, and Product Selection or “Wound measurement: assessment” at https://www.youtube. com/watch?v=ZWMaR-jheGY for more information).


Characteristics of venous ulcers Venous ulcers/venous insufficiency ulcers are generally on the gaiter area of the lower leg and ankle on the medial mal- leolar aspect. Patients may mention a feeling of heaviness in their legs or a dull ache, but the ulcers are painless. The ulcers frequently extend into the dermal


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skin layer. Venous ulcers vary in size and are irregularly shaped. The wound bed has a ruddy red color with granulation tissue. The wound may have a yellow slough with exudate (see clinical presentation of venous insufficiency ulcers at https://www.youtube. com/watch?v=nYt12EK_cFY for more information).1-6


Characteristics of arterial ulcers Arterial ulcers, also known as isch- emic ulcers, are commonly found on tips of toes, phalangeal head, lateral border of the foot, or the lateral mal- leolus.1,4,12


They tend to be in places


of repetitive trauma from shoes or a brace. Arterial ulcers have a punched-out appearance with uniform edges and are smaller than venous ulcers; however, arterial ulcers can be deep.1


The wound bed


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is pale or gray due to decreased oxygenated blood to the area. Frequently, necrosis is present, and there is minimal to no exu- dates.9,12


The surrounding skin may be tight and shiny. Compli- cations of arterial ulcers include infection, gangrene, and death.4


Diagnostics Duplex ultrasound is an inexpensive, noninvasive test that can be done quickly, allowing a provider to assess the distribution and extent of vascular disease. It is the test of choice for diagnosis thrombosis, venous reflux, arterial obstruction, and aneurysms. This test can differentiate between stenosis and occlusion, and provide information about plaque content and surface charac- teristics of the vessels.1 Ankle brachial index test (ABI) is a noninvasive Doppler test


performed to identify PAD of the legs where the ratio of the systolic pressures of the ankle and the brachial artery are calculated. This test can help predict the severity of PAD and evaluate response to treatment.13


The ABI can be elevated falsely in patients with


diabetes due to calcifications in the arteries (calcifications prevent the artery from fully being compressed).14


ABIs can be performed


at the bedside or in the home by an RN with a Doppler and blood pressure cuff; however, bedside testing will not include the waveforms provided with ultrasound.


ANKLE BRACHIAL INDEX TEST Test Result Finding


1.4 to 1 0.8 to 1


Normal Borderline or mild PAD


0.5 to 0.8 PAD, claudication may be present > 0.5


PAD = peripheral arterial disease. For a demonstration of the ABI test, see https://www.youtube.


com/watch?v=8q4Cz-a6zkQ. Transcutaneous oxygen pressure measurement (TcPO2


) is


a noninvasive test that measures the amount of oxygen in the tissues underneath the skin (results are not accurate in the


Severe PAD, tissue loss, pain at rest, threatened limb


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