Long-Term Care Survey Alert

Published on Fri May 05, 2006 PDF

Check out these surprisingly simple solutions to greatly improve wound care.

Using the right wound-care strategies can turn around serious venous and arterial ulcers--and keep your facility off the path to F309 tags.

Take the first step: To determine whether a lower-extremity wound is an arterial wound, use a Doppler to calculate an ankle-brachial index (ABI), suggested Arthur Stone, DPM, speaking at the March 2006 American Medical Directors Association annual meeting in Dallas. Many clinicians now carry hand-held Dopplers to see if a resident has circulatory issues, he said. "The person doing the Doppler study can tell you how to calculate the ABI and what to do with the findings."

Tip: For patients with diabetes, perform transcutaneous oximetry to detect problems with microcirculation, suggests Michael Miller, DO, a wound care specialist in Linton, IN.

Do the rule out: Say a non-diabetic patient has a wound on the side of the leg that wasn't caused by pressure, postulates Miller. The patient doesn't have arterial problems and the wound doesn't look autoimmune-related. In that case, Miller knows the wound is probably caused by venous disease. In that case, he orders compression therapy. Providing compression therapy can help heal even longstanding venous ulcers, say wound care experts.

"The resident needs a wrap around the leg that provides significant, even pressure to force the blood back into the bigger vessels which then flows back to the heart," says Peggy Dotson, RN, principal of Healthcare Reimbursement & Strategy in Yardley, PA.
In that regard, an Ace bandage won't suffice, say wound experts.

Free resource: For details on providing compression therapy and other medical treatments that can help venous ulcers, go to www.owm.com/article/4083. Also see the chart on various options for providing compression therapy.

Simple Interventions Trump Surgery

The care plan for a venous ulcer should also include these simple nursing remedies:

• Ambulation. Walking is the best way to improve venous return, says Laura Bolton, PhD, a wound expert and researcher in Metuchen, NJ. "If the person can't walk, then he or she can do 30 ankles flexes every half hour," she says.

• The right positioning techniques. The person should elevate his or her affected extremity above the heart for at least 30 minutes every two hours, suggests Bolton. The worst position for someone with a venous ulcer is sitting in a chair with the legs hanging down, she adds. In fact, the revised F314/309 survey guidance states that keeping the leg in a dependent position can increase pain in a person with a venous ulcer.

• A weight loss program for obese residents, if they agree.  Weight loss for someone who is overweight can have a significant impact on venous return, says Miller.

Know When to Go for the Cure

"Individuals with chronic superficial venous insufficiency with a venous ulcer will benefit from endovenous laser ablation or a radio frequency closure of the non-functioning vein," counsels Michael Krusch, MD, with Carolina Vein Specialist in Greensboro, NC. "If the problem originates within the deep veins, unfortunately, there is no way currently to correct the underlying problem, although compression therapy can help heal the wound," Krusch adds.

Once the person stops wearing the stockings, however, the wound is likely to return, Krusch cautions.

Improve Circulation Before Trying to Heal Arterial Wounds

The prospects for healing an arterial wound in patient with poor blood flow to the wound is "abysmal," says Miller. But the clinician can order treatments to improve blood flow before attempting wound therapy, he adds.

"Diagnostic and treatment options include a dye study angiogram with balloon angioplasty or stenting," Miller says. "Surgical intervention is also a possibility if the patient is a candidate for surgery.

"Last, but not least, there are some good potential pharmacotherapies," adds Miller. These include:

• Pletal for all patients with arterial ischemia.

• The statins. These drugs, which are usually ordered to treat high cholesterol, have shown some beneficial effect on the arterial vascular system for diabetics, Miller tells Eli.

• ACE inhibitors. These drugs also help diabetics. "Some early studies suggest this class of medication may benefit all patients," adds Miller.

"The statins and ACE inhibitors increase nitric oxide levels in the artery wall," Miller adds.

"Nitric oxide relaxes smooth muscle so the diameter of the blood vessels gets larger, improving blood flow," advises Miller.

Address Mixed Etiology Wounds

If a wound has a mixed etiology of vascular and arterial insufficiency, you have to walk a fine line to fix the venous problem without aggravating the arterial one, advises Bolton.

In treating a venous ulcer with arterial involvement, Miller does what he can to improve the patient's arterial circulation and then may order low-compression therapy.

"If the resident has an arterial brachial index of less than 1, you need to use clinical judgment as to what level of compression the patient with a venous stasis ulcer can tolerate," adds Krusch.