The Differences Between Arterial And Venous Ulcers
Understanding Arterial Insufficiency (PAD)
Recognizing the differences between these two difficult and often complicated types of ulcers is important for the following reasons:
· Correct assessment will result in correct as well as optimal treatment options.
· All health care team members will be able to follow the plan of care set by the physician thoroughly and efficiently.
· The treatment time for the patient will be significantly shortened
Although as nurses we do not diagnose, nevertheless it is our assessment that the physician reads or hears first. The physician relies heavily on the nurse’s knowledge and correct assessments in order to facilitate the best care for the patient. So, as nurses, we give "just the facts ma'am" and then we wait. We need to be prepared to give the physician any additional information; however, if you have all your information neat and tidy the physician will be able to take it from there.
That being said, let's discuss the signs of arterial ulcers.
· May be found on tips of toes, between the toes or on the outside of ankles.
· May or may not have swelling (edema) of the lower extremities
· Skin on lower extremities often tight, hard, shiny
· Skin is often cool or cold to touch
· There may not be any hair on the toes or on the legs
· There may be pain with walking (claudication)
· Faint to absent pedal pulse
· Ulcers are most likely to be perfectly round with smooth edges, minimal drainage and odorless
What are the causes of arterial ulcers?
· Exactly as the name implies; poor circulation. But remember, circulation goes two ways, oxygen enriched blood FROM the lungs to the arteries and the venous blood arriving INTO the lungs to become oxygenated.
· Often the primary diagnosis is Peripheral Arterial Disease (PAD). This diagnosis has been in the media for quite some time. It is not a diagnosis to be taken lightly and needs skilled and consistent care to avoid severe complications.
In and of itself PAD does not result in the arterial ulcer. The occurrence of an ulcer on the lower extremity is a risk factor in the diagnosis of PAD. The older we become, the easier it is to have a small injury, a scrape, a bump and because the arterial circulation itself is already compromised, the area never heals properly. A hard substance called plaque forms at the site of the injury and the body thinks it has done its job. That’s the end of it. Oh, if only that were true!
The heart is very selfish. It will save its strength always. It is like the King on a chessboard. All may perish, but never lose your King! The heart protects itself and its surrounding area.
That means your feet?
Don't forget those poor old bony ankles.
They are just the pawns; expendable as far as your heart is concerned.
But wait! Didn't you just say these ulcers are lower on my legs? What if I bump myself on my thigh or my knee? That's where I usually wind up with bruises in the first place, I rarely stump my toe.
That's correct, that’s what I said. The injury is not the site where the ulcer forms; rather it forms below (distally) the area of injury. This makes sense, of course. The lower extremity is compromised, you get hurt somewhere above your feet and ankles, and plaque encases that injury to the vessels which decreases circulation even further. Now the area below that bump is in high risk territory! Without adequate circulation the artery begins to pump blood slower and slower and the slower the pump, the more tissue dies. That is harsh, but there is no better way to put it. It isn't that I want to frighten you, but to keep on instructing in what to do to prevent this from happening if at all possible!
Yes, Prevention at every level! The sooner you know there could be a problem the sooner you can start to prevent that problem. It's like preventing termites. You know that if you buy home, even if it’s a brick home that there is a risk of termite damage. So what do you do? You get a termite bond through your local pest control company!
Well. It’s the same with arterial insufficiency or ulcer formation from arterial insufficiency (PAD). If you have diabetes, high blood pressure, high cholesterol, stress, high triglycerides, obesity, family history of PAD or of ulcers on feet or ankles then one or a combination of several put you at risk of peripheral artery disease and therefore, arterial ulcers.
Now, with high blood pressure your physician may tell you to walk. This is the best way to make the pump (your heart) work! Even if you feel the weather is inclement or your poor arthritic joints cannot manage the outside for walking just walk in place. Stand tall, bend your arms at your elbows, and swing in time to your march! If you feel your balance is not good enough to do it this way then stand at your sink or your kitchen counter, hold on and march in place. In fact, exercise is actually the one thing that all of the above disease processes benefit from and the number one way to help prevent ulcers of the lower extremities!
The one thing you must NOT do with PAD is elevate your legs. I know, this just sounds weird doesn't it? But it’s true; for arterial insufficiency (PAD) the legs may be dependent or in a neutral position ONLY! Otherwise your pump (heart) is trying to pump uphill and remember what I said about that selfish thing called the heart? RIght... so it's not going to break a sweat to do something extra for your toes.
You can really scare yourself, though, by doing it just to see what will happen. Your patient's whole foot will go completely white as a sheet! It is the best assessment tool for nurses, as a matter of fact, to see if it's an arterial or a venous ulcer. Have the patent lying down a few minutes, and then lift the foot above the heart. When you perform this assessmet for the first time and that leg and foot go white I bet you do as well!
Understanding Venous Insufficiency
Remember what was discussed earlier about the importance of having neat and tidy information ready for your physician? Well, we are going to stay along the same path with venous ulcers.
What are the signs of a venous ulcer?
· Venous ulcers can be small or large but one thing is for sure The edges are NOT A PERFECT CIRCLE
· These ulcers are wet all the time, and depending on how long the patient legs are kept dangling will determine how much drainage there will be
· Almost always there will be edema (swelling of the leg) and in fact, edema is usually the FIRST thing you will find.
· There usually is no pain with walking, per se, but the patient will say it hurts to stand up. Once they are up and start walking, the pain subsides
What are the causes of venous ulcers?
· You know that high blood pressure is increased pressure on the heart right? The more pressure it takes for your heart work (pump your blood around your body) the higher your blood pressure will be? Well, venous insufficiency is high blood pressure of the deep and superficial veins of your lower extremities!
· So, high blood pressure of the veins in your legs.
The first thing that happens with an arterial ulcer will be like a deep bruise or a bump or a scrape, remember?
It doesn't occur with a venous ulcer. It is thought that, yes, the veins have high pressure but the most likely cause is that there was a thrombus or a clot in the veins of the leg at some time. That clot becomes encased in plaque in again, the heart figures "OK! I fixed it! La-De-Da"
The end result, tissue death, is the same in both arterial and venous ulcers but the way the tissue dies is different in both types. Different in the way the ulcers look physically as well as different in the way you can help prevent the ulcers from happening in the first place.
Venous insufficiency happens because the stress of the high pressure in the vein causes the veins to compress, then the smaller capillaries cannot get enough blood so they shut off and then cell death (tissue death) occurs.
The most important thing to remember about venous ulcers is the edema. When you see swelling of the lower extremities what do you need to do?
Absolutely! Elevate the legs! Discourage rubbing, picking, pulling or scratching of the skin. Because the heart is so mean and will not go out of it's way to get the blood back to the top of the body; if the patient keeps their feet down all the time, the edema will worsen to the point that the fluid will not have anywhere to go! If the fluid cannot be reabsorbed into the blood stream guess what happens to all that extra fluid?
Right! That fluid will come out of every available hole, or rather pore in the skin. All you have to go on is that the legs will look as if they will pop if you so much as breathe on them. If that happens you can bet that when you come back to that patient's home the next time the legs will be weeping copiously. The next thing that may happen is the skin starts to slough or come off in patches. When that happens you will be dealing with a skin ulcer and these types of ulcers take a long time to heal. And conversely, an ulcer may form with or without edema though usually edema is present.
With arterial insufficiency you must never elevate the leg. With arterial insufficiency you must NEVER use compression. Totally Opposite for Venous Ulcers
· Ted Hose
· Elevation of the lower extremities.
And finally, where the venous ulcers are most likely to form is the last clue as to whether it is venous or arterial. Arterial between the toes and on outer ankles, remember? But with venous it may be above the ankle, on the side of the leg or the shin.
With venous insufficiency you may sometime also see arterial insufficiency at the same time! So how do you know if there are both occurring at the same time? Well, the ulcers may never heal for one or they may be on the foot itself or it may look almost round. But the one way to know for sure? Ask the physician for an order to do a Doppler study for both arterial and venous on both legs. Of course, this was probably done at some point in the past, remember that things can change over time and it does not hurt to get repeat reports and additional information. Especially when the end result will be to improve the health and well being of your patient!
What is written here does not now nor does it ever take the place of your physician’s advice and services of your physician.
Consult your physician every time for all things medically related and of course, if you feel you have any of the signs or symptoms of what has been written in this hub, please contact your physician for a consultation as soon as possible.
- Lower Extremity (Leg and Foot) Ulcers
Cleveland Clinic Heart Center, leaders in the treatment and prevention of vascular disease, leg and foot ulcers.
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