W.P. was consulted by “SWAT” as an inpatient at Bassett Healthcare

1. W.P. was consulted by “SWAT” as an inpatient at Bassett Healthcare Fawn Mumbulo

2. CC: 55 Year old male with left leg open wound  HPI • Direct admit from clinic • WP reports he has had wounds for the past 2 yrs that heal & reappear • WP reports that the wound on his left leg has grown in size (patient is unreliable about when this started, duration, or any event) • WP reports that had been going to the wound center twice wkly for unna boot dressings, he reports that he has been noncompliant with his appointments • WP reports no pain at site, drainage is clear

3. PMH • Medical Hx: HTN, hypothyroidism, DM II, morbid obesity, GERD, anxiety, depression, venous insufficiency, cellulites, ulcers of lower extremities, ulnar neuropathy & sleep apnea • Surgical Hx: Carpal tunnel release 2008 & 2009, I & D complicated 2010 • Immunizations: Flu 2013, Td 2009 • Medications: Tylenol, Aspirin, Docusate Sodium, Insulin Lispro, levothyroxine, Lisinopril, Lorazepam, Metoprolol, MVI, Pantoprazole EC, Paroxetine, senna tabs • Allergy: Clindamycin • Nutrition: Consists of processed foods that are easy & quick to prepare (TV dinners), water, milk, diet soda • Social: Sleep patterns consist of 10 hours at night with frequent naps throughout day, stays in bed for 10-12 hrs during day time. Uses C-pap at HS. Not currently employed. Does not exercise. Uses safety measures, seat belt, smoke detectors. Reports not sexually involved, is not married or have any children. Reports that he does not want to leave his home. • Family: Patient reported that mother died of stomach cancer age 55 & father died of stomach cancer at age 65. All family members are morbidly obese. Patient reports a sister & a brother that he has no contact with. Patient cannot remember any other family medical history.

4. ROS • General  WP reports a loss of 30 pounds in the last 3 months • Skin  WP reports that the nurse at the clinic reported to him that he had a open wound on his left leg that was getting larger with clear liquid drainage • Respiratory  Denies pain, dyspnea at rest, cyanosis, orthopnea, wheezing, asthma, bronchitis, cough, sputum, hemoptysis, night sweats, TB. Reports positive of DOE • Cardiac/PV  Denies heart murmur, pain/distress, palpitations, dyspnea at rest, edema, claudication, MI, ECG, or any other dx tests; denies leg cramps, varicose veins, or hx of clots • GI  Reports poor appetite due to the fact that he wants to lie in bed all day & not deal with ADL’s, reports heartburn especially when he eats while in bed • GU  Patient reports that it is difficult to find his penis which makes it difficult to urinate & frequently urinates on himself • MS/Neuro  Reports that he chooses not to walk due to there is no reason to get out of bed • Psych  Reports anxiety, depression, no motivation to live. WP reports he has been referred to the crisis center twice in the last 5-6 months & was sent home due to not determined a threat to self or others • Vital signs  BP 130/60; R 24; P 66; T 35.8 celcius; WT 497 lbs; HT 6’ 3”, No pain • Health Maintenance  last ophthalmology exam 4/2012 (is due); colorectal screening 4/2008 (due in 2018); HIV screening addressed 4/2011; immunizations are up to date.

5. Differential Dx • Severe depression • Social phobia • Diabetic ulcer& neuropathy • Systemic illnesses (RA, Vasculitis, Osteomyelitis, & skin malignancy) • PVD • Arterial insufficiency • DVT • Reflux disease and/or obstruction • Cellulitis • Pressure ulcer • Burn

6. What do you think? (Consultant360.com, 2011)

7. PE • Skin  Lower ext dark purple to tan in color on both claves with scaly skin on anterior, lateral & medial surfaces, feet have no skin break down with only scaly skin. No skin break down on sacrum or coccyx area. 2+ edema in bilateral lower ext. Scores high for skin breakdown. Braden scale is a 14. (AD med, 2012)

8. PE • MS/Nuero Wobbly gait d/t morbid obesity, fall risk high, assessment was difficult d/t limited space in the hospital room. Left leg is externally rotated from the knee down with ROM slightly limited, all other ROM intact. Sensation intact. • Thorax  DOE w/o retractions or accessory muscle use, lungs clear, no cough; heart RRR, no gallops, murmurs, or rubs; no carotid bruits; thyroid boarders nonpalpable, no enlargement or nodules. WP has a slumped posture. • Abdomen  Symmetrical, rounded, multiple folds – skin intact, BS present & tympanic in all 4 quads. No tenderness over CVA. • Lower ext  Toenails yellow, thick & in need of a podiatrist. Lesion on left lateral aspect of calf is 9 cm L X 9 cm H X 0.3 D, edges are attached, wound is beefy red with healthy appearance and granulating tissue. Drainage is serous & moderate. No tunneling, undermining, evidence of induration, fluctuance, or crepitance. Old scarring present around wound. Dorsalis pedis, popliteal, & posterior tibial pulses are 2+ • LABS  All within normal range (LFT’s were not done) • Diagnostics  None performed (venous duplex scan to evaluate for DVT’s d/t sedentary lifestyle & obesity)

9. ICD – 9 Problem List

10. Venous Stasis (www.bestveintreatment.com, 2010) Incidence Etiology – Change of Reaction • One – two percent of the population, representing 70-90% of lower extremity wounds (highest % over age 60) • 500,000 – 600,000 people in the U.S. suffer from venous stasis ulcers • Cost estimated at $775 million - $1 billion annually • Risk factors: • Women & elderly • Obesity • Previous leg injury • DVT • Phlebitis • Prevalence is 6-7 million in the U.S. • Refractory nature of venous stasis ulcers increase the risk of morbidity & mortality, which has a significant impact on • Characteristics  formation of edema which rises the tissue pressure causing a dull ache in the legs, hyperpigmentation, varicose eczema, & lipodermatosclerosis • Venous ulcers are irregular & shallow with granulating tissue & fibrin present at ulcer base • Ambulatory venous hypertension – valvular incompetence, obstruction of vein lumen, or both in the Gaiter area of the leg (from knee to ankle), ulcers repeating in the same area are distinctive of venous stasis • Secondary – inflammatory & fibrotic events d/t DVT that causes valvular dysfunction in distal veins that impair calf muscle pump dysfunction (pooling & chronic edema) • Co-morbidity  Diabetes Mellitus & PVD are related to macrovascular complication • Genetic predisposition – venous insufficiency (pregnancy or prolonged standing) (Collins & Seraj, 2010; Comerota, 2011; Domino, 2013; Kahle, Hermanns, & Gallenkemper, 2011; Hegarty, Grant, & Reid, 2009; Simms & Ennen, 2010)

11. Venous Stasis Pathophysiology • Lower extremities aid in the hemodynamic pump, by contracting calf muscles, refractory ulcers not healing after 3 months of therapy or have not healed after 12 months of adequate treatment • According to Domino (2013) the primary mechanisms are unclear, suggesting the same sequence as below • Ineffective calf muscles & incompetent venous valves increase tissue pressure  causing edema • Venous hypertension leads to distended capillary beds, enlarging endothelial pores that allow fibrinogen to escape into the interstitial fluid ; thus causing a barrier that does not allow oxygenation to the tissue • Activating the inflammatory process  leukocyte activation, endothelial damage, platelet aggregation, & intracellular edema • Pooling of venous blood distends veins, distorting venous valves, causing leaky valves (creating sheer stress to the skin) (Collins & Seraj, 2010; Comerota, 2011; Domino, 2013)

12. Review of the Literature • Articles that contributed to this presentation all suggest the same etiology & pathophysiology • The literature suggests that determining the etiology is a critical step in the management • Collins & Seraj (2010) suggest that clinical presentation is diagnostic enough to diagnose; the use of ankle-brachial index, color duplex ultrasonography, plethysmography, & venography can be helpful in determining venous stasis diagnoses if clinical presentation is unclear • Treatments differ in articles, from compression to chemical agents used on the skin • Conservative measures include compression therapy, leg elevation & dressings • Mechanical treatment include vacuum-assisted closure. According to Collins & Seraj (2010) this therapy has no evidence to support healing of venous ulcers. • Drug therapy includes Trental, ASA, Iloprost (not available in U.S.), oral zinc is not proven to be beneficial according to Collins & Seraj (2010), antibiotics & antiseptics (if infection only), & hyperbaric oxygen therapy has not proven benefit (Collins & Seraj, 2010). • Surgical management includes debridement, human skin grafting, artificial skin grafting, & surgery for venous insufficiency (such as bypass graft) • Venous ulcers rarely need debridement, if necrotic areas are profound then suggest arterial ulcers; debridement can be done with wet-to-dry dressings or maggot therapy according to Simms & Ennen (2010) (Collins & Seraj, 2010)

13. Interventional Plan • Dressings: • Alginate enhances wound closure & promotes granulation; they are biodegradable & made from brown seaweed – absorbs large amounts of exudate, needs to be changed often or can cause maceration of surrounding tissue. • Promogran acts as a protease modulator – degrades components of extracellular matrix at wound beds that inhibit healing. • Vacuum compression therapy – allows fluid drainage via vacuum allowing edges to become proximate, removes edema increasing blood flow to help heal wound. • Bio-engineered tissue: • Synthetic grafting helps heal wounds faster (dermagraft, apligraf). Synthetic grafting is cheaper then human tissue grafting surgeries. • Silver sulfadiazine: • Used to be the number one treatment of chemical debridement of eschar on ulcers • Radom trials identified in Miller, Rashid, Falzon, Elamin, & Zehtabchi (2010) article showed no significant improvement in the increased rates of healing time with the use of silver sulfadiazine compared to placebo’s (Collins & Seraj, 2010; Simms & Ennen, 2010)

14. Compression Therapy Unna boot: stockinet, Unna boot, kerlix, elastic wrap Multiple Layer: Cotton role, elastic wrap, then Co-ban (angiologist.com, 2014; HealthyKin.com, 2014; venacure-evlt.com, n.d.)

15. Interventional Plan • Compression therapy: GOLD STANDARD – healing rates 40-70% after 3 months & 50-80% after 6 months (inelastic, elastic or multilayer) • Increases fibrinolytic activity, inhibiting platelet aggregation • Inelastic: no resting pressure (Unna boot containing zinc oxide) • Elastic: such as Jobst which are gradient (ace wraps are not recommended) • Multilayer elastic: most effective, needs skilled application, consists of a cotton layer applied to skin, long-stretch bandage, medium-stretch bandage (Coban) change every 5-7 days • Intermittent Pneumatic Compression (IPC) • Consists of an air pump periodically inflating & deflating that delivers pulsating compression (no significance differences in studies than the above compression treatments) • Patient compliance is a problem • Compression stockings, intermittent pneumatic compression (IPC) (tolerable & enhances compliance) • These pumps wrap around the lower ext and pulsate filling up with air in different chambers • In Comertoa’s (2011) study IPC demonstrated increased venous return, reduced edema, increased endogenous fibrinolysis, reduced intravascular coagulation, & improved duration of treatment (Collins & Seraj, 2010; Comerota, 2011; Hegarty, Grant, & Reid, 2009; Simms & Ennen, 2010)

16. Intermittent Pneumatic Compression (IPC) (sensorprod.com, 2008)

17. Interventional Plan • Stimulation Technology – New Treatment on the Rise • Battery operated device that produces bursts of square-wave stimuli that produces stimulation to make the calf muscle contract • Increasing the total volume of flow in the popliteal veins • Decreasing incidence of DVT • Decreasing edema in lower ext by reducing venous pressure which increases venous hemodynamics • More random studies need to be performed on venous stasis patients • Drug Therapy: • Pentoxifylline (Trental): Inhibits platelet aggregation (400 mg po Tid) • Aspirin: once daily (Collins & Seraj, 2010; Griffin, Nicolaides, Bond, Geroulakos, & Kalodiki, 2010)

18. Patient Education • Frequent follow up is required (1-2 times weekly) for dressing changes, monitoring, & maintenance of wound • If chronic then patient is seen less frequently if stable • Elevation & compression are difficult but essential for patients to adhere to • Other education needed to assist in healing would depend on co-morbidities such as DM glucose control • Promoting patient self care is important • Dressing application • Compression devise application • Infection prevention & signs/symptoms • Change in lifestyle habits • Smoking cessation to promote healing • Loss of weight • Addressing nutritional status (Kahle, Hermanns, & Gallenkemper, 2011; Simms & Ennen, 2010)

19. References • Comerota, A. J. (2011). Intermittent pneumatic compression: Physiologic and clinical basis to improve management of venous leg ulcers. Journal of Vascular Surgery, 53(4), 1121-1129. doi: 10.1016/j.jvs.2010.08.059 • Collins, L., & Seraj, S. (2010). Diagnosis and treatment of venous ulcers. American Family Physician, 81(8), 989-996. • Domino, F. (2013). The 5-minute clinical consult, 21 ed., Philadelphia, PA: Lippincott Williams & Wilkins, Wolters Kluwer. • Griffin, M., Nicolaides, A. N., Bond, D., Geroulakos, G., & Kalodiki, E. (2010). The efficacy of a new stimulation technology to increase venous flow and prevent venous stasis. European Journal of Vascular Endovascular Surgery, 40, 766-771. doi: 10.1016/j.ejvs.2010.06.019 • Hegarty, M. S., Grant, E., & Reid, L. (2009). An overview of technologies related to care for venous leg ulcers. IEEE Transactions on Information Technology in Biomedicine, 14(2), 387-393. doi: 10.1109/TITB.2009.2036009 • Kahle, B., Hermanns, H., & Gallenkemper, G. (2011). Evidence-based treatment of chronic leg ulcers. Deutsches Arzteblatt International, 108(14), 231-237. doi: 10.3238/arztebl.2011.0231 • Miller, A. C., Rashid, R. M., Falzon, L., Elamin, E. M., & Zehtabchi, S. (2010). Silver sulfadiazine for the treatment of partial-thickness burns and venous stasis ulcers. American Academy of Dermatology, 66(5), e159-e165. doi: 10.1016/j.jaad.2010.06.014 • Simms, K. W. & Ennen, K. (2010). Lower extremity ulcer management: Best practice algorithm. Journal of Clinical Nursing, 20, 86-93. doi: 10.1111/j.1365-2702.2010.03431.x