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Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 1
Waterloo Wellington Integrated Wound Care Program Evidence-Based Wound Care
Arterial Leg Ulcer Clinical Pathway
0-7 Days Expected Outcomes Notes
Patient admitted to service/facility
Most Responsible Physician(MRP)/Nurse Practitioner (NP) identified/informed
Refer patient to ‘Care Connects’ if no responsible practioner currently involved with patient
Determine if MRP/NP is part of family health team (FHT) or community health centre (CHC) and consider additional supports available
Medical/surgical history and co-morbidity management considered within care plan
Risk factors include:
Smoking
Diabetes mellitus
Hyperlipidemia
Hypertension
Poor nutrition
Low hemoglobin
Obesity
Decreased thyroid function
Coronary artery disease
Psoriasis
History of cerebral vascular accident (CVA)
Autoimmune diseases
Chronic renal disease
Congestive heart failure
Impaired liver function
Use of systemic steroids, immunosuppressives and chemotherapy
>70 years of age
Age 50-69 years with history of diabetes or smoking
< 50 years with diabetes and one other atherosclerotic factor
History of vascular surgery or deep vein thrombosis
Bleeding disorders
Family history of arterial disease
Current ongoing adjunctive therapies integrated into care plan
Medication reconciliation and their impact on wound healing reviewed
Prescription, non-prescription, naturopathic and illicit drug use (including e-cigarettes, inhaled substances and nicotine replacement therapy)
Medications that can affect healing include: chemotherapy, anticoagulants, antiplatelets, corticosteroids, vasoconstrictors, antihypertensives, diuretics and immunosepressive drugs
Other medications used to treat acute episodic illnesses may affect healing (eg. antibiotics, colchicine, anti-rheumatoid arthritics)
Vitamin and mineral supplementation
Recent blood work and other diagnostic test results reviewed and implictions for wound healing considered
Determine bloodwork and other diagnostic tests required
Physical examination performed
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 2
Bilateral lower leg assessment completed Signs and symptoms of Peripheral Arterial Disease could include:
Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication)
Dependent rubor in lower legs and feet
Pallor in feet on elevation
Dry, shiny skin on lower legs
Edema subsequent to leg being dependent
Thick or flaking toe nails
Hairless lower legs and feet
Weak or absent pulses
Intense hyperesthesia (sensitive to light touch)
Limb muscle may appear wasted from ischemic atrophy
Delayed capillary refill
Distal gangrene
Erectile dysfunction in men
Non-healing wound
ABPI/TPBI completed within last 3 mths and results documented
If unable to obtain ABPI/TPBI, referral to vascular surgeon is recommended
Assess pulses (popliteal – behind knee , dorsalis pedis – top of foot , posterior tibial – medial ankle)
Measurement of edema
Assess capillary refill (normal less than 3 seconds)
Leg measurements (foot, ankle, calf, thigh)
Ankle range of motion (ROM)
Foot deformities
Ankle flare
Skin temperature (compare both legs)
Skin colour (dependent and on elevation)
Presence of pain
Nail changes
Presence of hair on lower leg, feet and toes
Presence of varicosities (varicose veins)
Dermatological changes due to impaired blood flow
Repeat ABPI/TPBI assessment every 3 months if healing is not progressing
Wound Assessment completed
Complete:
Bates-Jensen Wound Assessment Tool (BWAT) OR
Leg Ulcer Measurement Tool (LUMT)
Determine wound etiology Arterial ulcers are typically pale at base of wound, have ‘punched out’ appearance,
are more painful than expected and have low to no exudate Results of LLA and ABPI/TPBI
Document percentage of healing since last visit
Assessment for infection (NERDS and STONEES)
Obtain photos following best practice as per framework for individual organization policies and procedures. Suggest following publication as guideline:
ABPI 0.5 to 0.8 TBPI 0.64 to 0.7
Suggest Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies
ABPI <0.5 TBPI <0.64
Urgent vascular surgical consult needed
4 P’s of Arterial Ulcers Pale wound base
Punched-out appearance
Painful
Parched (low to no exudate)
Acute arterial occlusion is a life and limb-threatening situation which requires immediate emergency intervention
Signs and symptoms that may become severe may be associated with the following:
Pale or blue skin
Skin cold to the touch
Sudden decrease in mobility
No pulse where one was present prior to this
Sudden and severe pain
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 3
http://mydigitalpublication.com/publication/?i=206722
Compression therapy history documented and considered in plan
History of:
Previous compression garments
Age of compression garments
Adherence
Application and removal of compression in past
Finances
Reason compression treatment plan has changed if applicable
Pain management initiated Arterial pain is typically described as:
Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication)
Complete:
Brief Pain Inventory Short Form (BPI-SF)
Obtain physician/nurse practitioner orders for analgesics (opioids and non-opioids)
Patient’s nutritional status optimized
Review blood work results
Calculate Body Mass Index (BMI)
Determine recent weight loss/gain
Complete Mini Nutritional Assessment (MNA) If screening section results < 11 = complete assessment section If Assessment section results< 24 = Registered Dietician referral required
Wound etiology and appropriate pathway established
Patient and caregiver concerns and goals integrated into the care plan and shared with care team
Complete:
Cardiff Wound Impact Questionnaire OR
World Health Organization Quality of Life (WHOQOL) form
Wound treatment plan determined in accordance to treatment goal (healable, maintenance or non-healable)
Arrange for physician/nurse practitioner orders as required to begin plan of care including agreeance to professional referral recommendations
Identify any potential barriers to wound treatment plan
Utilize toolkit to determine wound cleansing, debridement and dressing selection (South West Region Wound Care Program: Wound Cleansing Table and Dressing Selection and Cleansing enablers and CAWC Product Picker chart)
Compression is typically contraindicated in the presence of
peripheral arterial disease. In some circumstances light
compression may be beneficial, but only if arterial supply is
sufficient. Sufficient arterial supply should be objectively
evidenced by diagnostic tests. In such cases, compression
should be ordered by an advanced wound care physician or
nurse practitioner only!
Caution: USE DRY WOUND HEALING 1. Keep eschar dry 2. No occlusive dressings 3. Do NOT debride 4. Avoid tourniquet effect when securing dressings 5. If eschar becomes wet/boggy – URGENT referral to
advanced wound care specialist is recommended
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 4
Patient counselled on the benefit of activity rest and head elevation in moderation (balancing need for pressure relief) for comfort measures and wound healing
Recent changes in overall activity level
Daily routine
Personal assistance available to perform activities of daily living
Ankle range of motion allowing for calf muscle pump to function
Determine where patient sleeps at night
Encourage patient to sleep in bed with no lower limb elevation (most arterial pain increases when feet elevated above heart level)
Mobility and dexterity aids currently being used
Safety of transfers
Recommendations for exercise
Consider Occupational Therapist referral for comfort measures
Patient/caregiver educational plan initiated
Emergency signs and symptoms of Peripheral Arterial Disease that require immediate medical attention (refer to lower leg assessment section)
Risks of compression
Smoking cessation including e-cigarettes and nicotene replacement
Appropriate footwear as discussed with foot care specialist (encourage use of white socks)
Skin care
Nail care (suggest use of foot care specialist)
Wound self care
Pain management
Diagnostic testing
Dietary
Rest/Activity
Prevention of injury – avoid extremes (hot/cold, loose/tight)
When to call primary care giver (eg. signs and symptoms of infection, deep vein thrombosis, cellulitis, impaired blood flow, difficulties with compression)
Self lower-leg assessment
Community support groups (i.e. walking groups)
Other ____________________________
Ability to self-manage optimized Barriers to participate (transportation, socioeconomic, social environment, other co-morbidities)
Cognitive ability
Review importance and potential barriers to smoking cessation at every visit
Hygeine
Foot inspection (including bottom of foot and between toes)
Enviroment
Wound care
Compression application and removal if prescribed
Coping strategies implemented into plan of care
Patient’s concerns and fears
Signs of anxiety or other mental health issues (eg. delusions, hallucinations, paranoid behaviour)
Depression screen using Geriatric Depression Scale assessment form –GDS15
Suicide assessment if applicable
ETOH and illicit /recreational drug use
Compression is typically contraindicated in the presence of peripheral arterial disease. In some circumstances light compression may be beneficial. In such cases, compression should be ordered by an advanced wound care physician or nurse practitioner only! See algorithm in guidelines.
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 5
Family and caregiver support identified and incorporated into plan of care
Family/caregiver actively able to participate in treatment plan
Social supports/community resources currently utilized is integrated into plan of care
Family support
Funding
Community resources
Caregiver conflicts
Long or short term placement
Assistance provided for financial concerns patient is experiencing
Determine:
Private insurance availability
Eligibility for Assistive Devices Program (ADP [lymphedema only], ODSP, High-needs fund, Veterans Affairs Canada or Aborignal Services)
Professional referrals are initiated
Primary Care Physician
Advanced Wound Specialist
Nurse Practitioner
Infectious Disease Specialist
Vascular Surgeon
Dermatologist
Plastic surgeon
Internist/Endocrinologist
Mental Health Specialist
Psychologists
Social work
Registered Dietitian
Pharmacist
Occupational Therapist
Physiotherapy
Chiropodist
Certified Pedorothist
Certified Orthotist
Certified Prosthetist
Podiatrist
Lymphatic Massage
Compression Stocking Fitter Other:___________________________
Physician/nurse practitioner orders received as required to change plan of care including agreeance to professional referral recommendations
Appropriate documents shared
Identify need to reassess ABPI/TPBI in 6 months
Lower leg assessment
Recent vascular study results (eg. ABPI, TPBI, Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies)
Relevant consultation notes
Diagnostic results
Current treatment plan If wound closed or eschar is stable send discharge summary outlining outstanding issues and teaching completed to:
Referral source and most responsible physician (MRP)/nurse
Acute care
Complex Continuing Care/Rehab
Long-term care
Community care
Primary care physician/Nurse Practioner
Professionals referred to Other _____________________________
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 6
practitioner (NP)
8-21 Days Expected Outcomes Notes
Most Responsible Physician(MRP)/Nurse Practitioner (NP) identified/informed
Communication with primary care physician and/or Nurse Practioner to update on any significant changes in patient’s condition.
Refer patient to ‘Care Connects’ if no responsible practioner currently involved with patient
Determine if MRP/NP is part of family health team (FHT) or community health centre (CHC) and consider additional supports available
Assessment of wound performed and percentage of healing documented
Complete:
Bates-Jensen Wound Assessment Tool (BWAT) OR
Leg Ulcer Measurement Tool (LUMT)
Determine wound etiology Arterial ulcers are typically pale at base of wound, have ‘punched out’ appearance,
are more painful than expected and have low to no exudate Results of LLA and ABPI/TPBI
Document percentage of healing since admission
Assessment for infection (NERDS and STONEES)
Potential need for wound care specialist considered if wound healing is not progressing and infection is absent
Obtain photos following best practice as per framework for individual organization policies and procedures. Suggest following publication as guideline: http://mydigitalpublication.com/publication/?i=206722
Wound treatment/compression plan is being followed
Review:
Adherence to plan
Real or potential barriers to wound treatment plan
4 P’s of Arterial Ulcers Pale wound base
Punched-out appearance
Painful
Parched (low to no exudate)
Caution: USE DRY WOUND HEALING 1. Keep eschar dry 2. No occlusive dressings 3. Do NOT debride 4. Avoid tourniquet effect when securing dressings 5. If eschar becomes wet/boggy – URGENT referral to
advanced wound care specialist is recommended
Compression is typically contraindicated in the presence of peripheral arterial disease. In some circumstances light compression may be beneficial. In such cases, compression should be ordered by an advanced wound care physician or nurse practitioner only! See algorithm in guidelines.
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 7
Pain management reviewed Arterial pain is typically described as:
Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication)
Review for changes
Brief Pain Inventory Short Form (BPI-SF)
Obtain physician/nurse practitioner orders for analgesics required (opioids and non-opioids)
Medical/surgical history and co-morbidity management considered within care plan
Review for changes
Medication reconciliation and their impact on wound healing reviewed
Review for changes:
Prescription, non-prescription, naturopathic and illicit drug use
Recent blood work and other diagnostic test results reviewed and implictions for wound healing considered
Determine bloodwork and other diagnostic tests required
Bilateral lower leg assessment completed Signs and symptoms of Peripheral Arterial Disease could include:
Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication)
Dependent rubor in lower legs and feet
Pallor in feet on elevation
Dry, shiny skin on lower legs
Edema subsequent to leg being dependent
Thick or flaking toe nails
Hairless lower legs and feet
Weak or absent pulses
Intense hyperesthesia (sensitive to light touch)
Limb muscle may appear wasted from ischemic atrophy
Delayed capillary refill
Distal gangrene
Erectile dysfunction in men
Non-healing wound
ABPI/TPBI completed within last 3 mths and results documented
If unable to obtain ABPI/TPBI, referral to vascular surgeon is recommended
Assess pulses (popliteal – behind knee , dorsalis pedis – top of foot , posterior tibial – medial ankle)
Measurement of edema
Assess capillary refill (normal less than 3 seconds)
Leg measurements (foot, ankle, calf, thigh)
Ankle range of motion (ROM)
Foot deformities
Ankle flare
Skin temperature (compare both legs)
Skin colour (dependent and on elevation)
Presence of pain
Nail changes
Presence of hair on lower leg, feet and toes
Presence of varicosities (varicose veins)
Dermatological changes due to impaired blood flow
Repeat ABPI/TPBI assessment every 3 months if healing is not progressing
ABPI 0.5 to 0.8 TBPI 0.64 to 0.7
Suggest Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies be performed ABPI <0.5 TBPI <0.64
Urgent vascular surgical consult needed
Acute arterial occlusion is a life and limb-threatening situation which requires immediate emergency intervention
Signs and symptoms that may become severe may be associated with the following:
Pale or blue skin
Skin cold to the touch
Sudden decrease in mobility
No pulse where one was present prior to this
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 8
Patient’s nutritional status optimized
Review:
Recent blood work results
Significant weight changes
Adherence to diet plan
Identify barriers to good nutrition
Patient and caregiver concerns and goals integrated into the care plan and shared with care team
Review for changes:
Cardiff Wound Impact Questionnaire OR
World Health Organization Quality of Life (WHOQOL) form
Patient counselled on the benefit of activity rest and head elevation in moderation (balancing need for pressure relief) for comfort measures and wound healing
Review for changes:
Recent changes in overall activity level
Daily routine
Personal assistance available to perform activities of daily living
Ankle range of motion allowing for calf muscle pump to function
Determine where patient sleeps at night
Encourage patient to sleep in bed with no lower limb elevation (most arterial pain increases when feet elevated above heart level)
Mobility and dexterity aids currently being used
Safety of transfers
Recommendations for exercise
Consider Occupational Therapist referral for comfort measures
Patient/caregiver educational needs reviewed using ‘teach-back’ method
Emergency signs and symptoms of Peripheral Arterial Disease that require immediate medical attention (refer to lower leg assessment section)
Risks of compression
Smoking cessation including e-cigarettes and nicotene replacement
Appropriate footwear as discussed with foot care specialist (encourage use of white socks)
Skin care
Nail care (suggest use of foot care specialist)
Wound self care
Pain management
Diagnostic testing
Dietary
Rest/Activity
Prevention of injury – avoid extremes (hot/cold, loose/tight)
When to call primary care giver (eg. signs and symptoms of infection, deep vein thrombosis, cellulitis, impaired blood flow, difficulties with compression)
Self lower-leg assessment
Community support groups (i.e. walking groups)
Other ____________________________
Ability to self-manage optimized Review for changes: Hygeine
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 9
Adherence to plan
Barriers to participate (transportation, socioeconomic, social environment, other co-morbidities)
Cognitive ability
Review importance and potential barriers to smoking cessation at every visit
Foot inspection (including bottom of foot and between toes)
Enviroment
Wound care
Compression application and removal if prescribed
Coping strategies implemented into plan of care
Review for changes
Patient’s concerns and fears
Signs of anxiety or other mental health issues (eg. delusions, hallucinations, paranoid behaviour)
Depression screen using Geriatric Depression Scale assessment form –GDS15
Suicide assessment if applicable
ETOH and illicit /recreational drug use
Family and caregiver support identified and incorporated into plan of care
Review:
Availability of assistance required
Social supports/community resources currently utilized is integrated into plan of care
Family support
Funding
Community resources
Caregiver conflicts
Long or short term placement
Assistance provided for financial concerns patient is experiencing
Review:
Private insurance availability
Eligibility for Assistive Devices Program (ADP [lymphedema only], ODSP, High-needs fund, Veterans Affairs Canada or Aborignal Services)
Professional referral status reviewed
Primary Care Physician
Advanced Wound Specialist
Nurse Practitioner
Infectious Disease Specialist
Vascular Surgeon
Dermatologist
Plastic surgeon
Internist/Endocrinologist
Mental Health Specialist
Psychologists
Social work
Registered Dietitian
Pharmacist
Occupational Therapist
Physiotherapy
Chiropodist
Certified Pedorothist
Certified Orthotist
Certified Prosthetist
Podiatrist
Lymphatic Massage
Compression Stocking Fitter
Other: ____________________________
Physician/nurse practitioner orders received as required to change plan of care including agreeance to professional referral
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 10
recommendations
Appropriate documents shared
Identify need to reassess ABPI/TPBI in 6 months
Lower leg assessment
Recent vascular study results (eg. ABPI, TPBI, Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies)
Relevant consultation notes
Diagnostic results
Current treatment plan
If wound closed or eschar is stable send discharge summary outlining outstanding issues and teaching completed to:
Referral source and most responsible physician (MRP)/nurse practitioner (NP)
Acute care
Complex Continuing Care/Rehab
Long-term care
Community care
Primary care physician/Nurse Practioner
Professionals referred to Other _____________________________
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 11
21-28 Days Expected Outcomes
Notes
Most Responsible Physician(MRP)/Nurse Practitioner (NP) identified/informed
Communication with primary care physician and/or Nurse Practioner to update on any significant changes in patient’s condition.
Refer patient to ‘Care Connects’ if no responsible practioner currently involved with patient
Determine if MRP/NP is part of family health team (FHT) or community health centre (CHC) and consider additional supports available
Assessment of wound performed and percentage of healing documented
Complete:
Bates-Jensen Wound Assessment Tool (BWAT) OR
Leg Ulcer Measurement Tool (LUMT)
Determine wound etiology Arterial ulcers are typically pale at base of wound, have ‘punched out’ appearance,
are more painful than expected and have low to no exudate Results of LLA and ABPI/TPBI
Document percentage of healing since admission
Assessment for infection (NERDS and STONEES)
Potential need for wound care specialist considered if wound healing is not progressing and infection is absent
Obtain photos following best practice as per framework for individual organization policies and procedures. Suggest following publication as guideline: http://mydigitalpublication.com/publication/?i=206722
Wound treatment/compression plan is being followed
Review:
Adherence to plan
Real or potential barriers to wound treatment plan
Pain management reviewed Arterial pain is typically described as:
Review for changes
Brief Pain Inventory Short Form (BPI-SF)
Obtain physician/nurse practitioner orders for analgesics required (opioids and non-opioids)
Arterial ulcers do not follow trajectory healing rate of venous ulcers (30% week 4 & healed at 12 weeks). Further intervention should be considered if conservative treatment does not improve healing in 4-6 weeks
4 P’s of Arterial Ulcers Pale wound base
Punched-out appearance
Painful
Parched (low to no exudate)
Caution: USE DRY WOUND HEALING 1. Keep eschar dry 2. No occlusive dressings 3. Do NOT debride 4. Avoid tourniquet effect when securing dressings 5. If eschar becomes wet/boggy – URGENT referral to
advanced wound care specialist is recommended
Compression is typically contraindicated in the presence of peripheral arterial disease. In some circumstances light compression may be beneficial. In such cases, compression should be ordered by an advanced wound care physician or nurse practitioner only! See algorithm in guidelines.
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 12
Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication)
Medical/surgical history and co-morbidity management considered within care plan
Review for changes
Medication reconciliation and their impact on wound healing reviewed
Review for changes:
Prescription, non-prescription, naturopathic and illicit drug use
Recent blood work and other diagnostic test results reviewed and implictions for wound healing considered
Determine bloodwork and other diagnostic tests required
Bilateral lower leg assessment completed Signs and symptoms of Peripheral Arterial Disease could include:
Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication)
Dependent rubor in lower legs and feet
Pallor in feet on elevation
Dry, shiny skin on lower legs
Edema subsequent to leg being dependent
Thick or flaking toe nails
Hairless lower legs and feet
Weak or absent pulses
Intense hyperesthesia (sensitive to light touch)
Limb muscle may appear wasted from ischemic atrophy
Delayed capillary refill
Distal gangrene
Erectile dysfunction in men
Non-healing wound
ABPI/TPBI completed within last 3 mths and results documented
If unable to obtain ABPI/TPBI, referral to vascular surgeon is recommended
Assess pulses (popliteal – behind knee , dorsalis pedis – top of foot , posterior tibial – medial ankle)
Measurement of edema
Assess capillary refill (normal less than 3 seconds)
Leg measurements (foot, ankle, calf, thigh)
Ankle range of motion (ROM)
Foot deformities
Ankle flare
Skin temperature (compare both legs)
Skin colour (dependent and on elevation)
Presence of pain
Nail changes
Presence of hair on lower leg, feet and toes
Presence of varicosities (varicose veins)
Dermatological changes due to impaired blood flow
Repeat ABPI/TPBI assessment every 3 months if healing is not progressing
ABPI 0.5 to 0.8 TBPI 0.64 to 0.7 Suggest Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies
ABPI <0.5 TBPI <0.64
Urgent vascular surgical consult needed
Acute arterial occlusion is a life and limb-threatening situation which requires immediate emergency intervention
Signs and symptoms that may become severe may be associated with the following:
Pale or blue skin
Skin cold to the touch
Sudden decrease in mobility
No pulse where one was present prior to this
Sudden and severe pain
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 13
Patient’s nutritional status optimized
Review:
Recent blood work results
Significant weight changes
Adherence to diet plan
Identify barriers to good nutrition
Patient and caregiver concerns and goals integrated into the care plan and shared with care team
Review for changes:
Cardiff Wound Impact Questionnaire OR
World Health Organization Quality of Life (WHOQOL) form
Patient counselled on the benefit of activity rest and head elevation in moderation (balancing need for pressure relief) for comfort measures and wound healing
Review for changes:
Recent changes in overall activity level
Daily routine
Personal assistance available to perform activities of daily living
Ankle range of motion allowing for calf muscle pump to function
Determine where patient sleeps at night
Encourage patient to sleep in bed with no lower limb elevation (most arterial pain increases when feet elevated above heart level)
Mobility and dexterity aids currently being used
Safety of transfers
Recommendations for exercise
Consider Occupational Therapist referral for comfort measures
Patient/caregiver educational needs reviewed using ‘teach-back’ method
Emergency signs and symptoms of Peripheral Arterial Disease that require immediate medical attention (refer to lower leg assessment section)
Risks of compression
Smoking cessation including e-cigarettes and nicotene replacement
Appropriate footwear as discussed with foot care specialist (encourage use of white socks)
Skin care
Nail care (suggest use of foot care specialist)
Wound self care
Pain management
Diagnostic testing
Dietary
Rest/Activity
Prevention of injury – avoid extremes (hot/cold, loose/tight)
When to call primary care giver (eg. signs and symptoms of infection, deep vein thrombosis, cellulitis, impaired blood flow, difficulties with compression)
Self lower-leg assessment
Community support groups (i.e. walking groups)
Other ____________________________
Ability to self-manage optimized Review for changes:
Adherence to plan
Barriers to participate (transportation, socioeconomic, social environment, other co-morbidities)
Cognitive ability
Review importance and potential barriers to smoking cessation at every visit
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 14
Hygeine
Foot inspection (including bottom of foot and between toes)
Enviroment
Wound care
Compression application and removal if prescribed
Coping strategies implemented into plan of care
Review for changes
Patient’s concerns and fears
Signs of anxiety or other mental health issues (eg. delusions, hallucinations, paranoid behaviour)
Depression screen using Geriatric Depression Scale assessment form –GDS15
Suicide assessment if applicable
ETOH and illicit /recreational drug use
Family and caregiver support identified and incorporated into plan of care
Review:
Availability of assistance required
Social supports/community resources currently utilized is integrated into plan of care
Family support
Funding
Community resources
Caregiver conflicts
Long or short term placement
Assistance provided for financial concerns patient is experiencing
Review:
Private insurance availability
Eligibility for Assistive Devices Program (ADP [lymphedema only], ODSP, High-needs fund, Veterans Affairs Canada or Aborignal Services)
Professional referral status reviewed
Primary Care Physician
Advanced Wound Specialist
Nurse Practitioner
Infectious Disease Specialist
Vascular Surgeon
Dermatologist
Plastic surgeon
Internist/Endocrinologist
Mental Health Specialist
Psychologists
Social work
Registered Dietitian
Pharmacist
Occupational Therapist
Physiotherapy
Chiropodist
Certified Pedorothist
Certified Orthotist
Certified Prosthetist
Podiatrist
Lymphatic Massage
Compression Stocking Fitter
Other: ____________________________
Physician/nurse practitioner orders received as required to change plan of care including agreeance to professional referral recommendations
Appropriate documents shared
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 15
Identify need to reassess ABPI/TPBI in 6 months
Lower leg assessment
Recent vascular study results (eg. ABPI, TPBI, Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies)
Relevant consultation notes
Diagnostic results
Current treatment plan If wound closed or eschar is stable send discharge summary outlining outstanding issues and teaching completed to:
Referral source and most responsible physician (MRP)/nurse practitioner (NP)
Acute care
Complex Continuing Care/Rehab
Long-term care
Community care
Primary care physician/Nurse Practioner
Professionals referred to Other _____________________________
Collaborative team/patient conference arranged to discuss barriers to healing and care plan if progression to healing is stalled
Arrange a Collaborative team/patient meeting to discuss barriers to healing and care plan
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 16
77-84 Days Expected Outcomes Notes
Most Responsible Physician(MRP)/Nurse Practitioner (NP) identified/informed
Communication with primary care physician and/or Nurse Practioner to update on any significant changes in patient’s condition.
Refer patient to ‘Care Connects’ if no responsible practioner currently involved with patient
Determine if MRP/NP is part of family health team (FHT) or community health centre (CHC) and consider additional supports available
Assessment of wound performed and percentage of healing documented
Complete:
Bates-Jensen Wound Assessment Tool (BWAT) OR
Leg Ulcer Measurement Tool (LUMT)
Determine wound etiology Arterial ulcers are typically pale at base of wound, have ‘punched out’ appearance,
are more painful than expected and have low to no exudate Results of LLA and ABPI/TPBI
Document percentage of healing since admission
Assessment for infection (NERDS and STONEES)
Potential need for wound care specialist considered if wound healing is not progressing and infection is absent
Obtain photos following best practice as per framework for individual organization policies and procedures. Suggest following publication as guideline: http://mydigitalpublication.com/publication/?i=206722
Wound treatment/compression plan is being followed
Confirm there are no changes:
Adherence to plan
Real or potential barriers to wound treatment plan
Pain management reviewed Arterial pain is typically described as:
Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication)
Confirm there are no changes:
Brief Pain Inventory Short Form (BPI-SF)
Obtain physician/nurse practitioner orders for analgesics required (opioids and non-opioids)
Medical/surgical history and co-morbidity management considered within care plan
Confirm there are no changes:
4 P’s of Arterial Ulcers Pale wound base
Punched-out appearance
Painful
Parched (low to no exudate)
Arterial ulcers do not follow trajectory healing rate of venous ulcers (30% week 4 & healed at 12 weeks). Further intervention should be considered if conservative treatment does not improve healing in 4-6 weeks
Caution: USE DRY WOUND HEALING 1. Keep eschar dry 2. No occlusive dressings 3. Do NOT debride 4. Avoid tourniquet effect when securing dressings 5. If eschar becomes wet/boggy – URGENT referral to
advanced wound care specialist is recommended
Compression is typically contraindicated in the presence of peripheral arterial disease. In some circumstances light compression may be beneficial. In such cases, compression should be ordered by an advanced wound care physician or nurse practitioner only! See algorithm in guidelines.
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 17
Medication reconciliation and their impact on wound healing reviewed
Confirm there are no changes:
Prescription, non-prescription, naturopathic and illicit drug use
Recent blood work and other diagnostic test results reviewed and implictions for wound healing considered
Determine bloodwork and other diagnostic tests required
Bilateral lower leg assessment completed Signs and symptoms of Peripheral Arterial Disease could include:
Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication)
Dependent rubor in lower legs and feet
Pallor in feet on elevation
Dry, shiny skin on lower legs
Edema subsequent to leg being dependent
Thick or flaking toe nails
Hairless lower legs and feet
Weak or absent pulses
Intense hyperesthesia (sensitive to light touch)
Limb muscle may appear wasted from ischemic atrophy
Delayed capillary refill
Distal gangrene
Erectile dysfunction in men
Non-healing wound
ABPI/TPBI completed within last 3 mths and results documented
If unable to obtain ABPI/TPBI, referral to vascular surgeon is recommended
Assess pulses (popliteal – behind knee , dorsalis pedis – top of foot , posterior tibial – medial ankle)
Measurement of edema
Assess capillary refill (normal less than 3 seconds)
Leg measurements (foot, ankle, calf, thigh)
Ankle range of motion (ROM)
Foot deformities
Ankle flare
Skin temperature (compare both legs)
Skin colour (dependent and on elevation)
Presence of pain
Nail changes
Presence of hair on lower leg, feet and toes
Presence of varicosities (varicose veins)
Dermatological changes due to impaired blood flow
Repeat ABPI/TPBI assessment every 3 months if healing is not progressing
Patient’s nutritional status optimized
Confirm there are no changes:
Recent blood work results
Significant weight changes
Adherence to diet plan
Identify barriers to good nutrition
ABPI 0.5 to 0.8 TBPI 0.64 to 0.7
Suggest Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies
ABPI <0.5 TBPI <0.64
Urgent vascular surgical consult needed
Acute arterial occlusion is a life and limb-threatening situation which requires immediate emergency intervention
Signs and symptoms that may become severe may be associated with the following:
Pale or blue skin
Skin cold to the touch
Sudden decrease in mobility
No pulse where one was present prior to this
Sudden and severe pain
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 18
Patient and caregiver concerns and goals integrated into the care plan and shared with care team
Confirm there are no changes:
Cardiff Wound Impact Questionnaire OR
World Health Organization Quality of Life (WHOQOL) form
Patient counselled on the benefit of activity rest and head elevation in moderation (balancing need for pressure relief) for comfort measures and wound healing
Confirm there are no changes:
Recent changes in overall activity level
Daily routine
Personal assistance available to perform activities of daily living
Ankle range of motion allowing for calf muscle pump to function
Determine where patient sleeps at night
Encourage patient to sleep in bed with no lower limb elevation (most arterial pain increases when feet elevated above heart level)
Mobility and dexterity aids currently being used
Safety of transfers
Recommendations for exercise
Consider Occupational Therapist referral for comfort measures
Patient/caregiver educational needs reviewed using ‘teach-back’ method
Emergency signs and symptoms of Peripheral Arterial Disease that require immediate medical attention (refer to lower leg assessment section)
Risks of compression
Smoking cessation including e-cigarettes and nicotene replacement
Appropriate footwear as discussed with foot care specialist (encourage use of white socks)
Skin care
Nail care (suggest use of foot care specialist)
Wound self care
Pain management
Diagnostic testing
Dietary
Rest/Activity
Prevention of injury – avoid extremes (hot/cold, loose/tight)
When to call primary care giver (eg. signs and symptoms of infection, deep vein thrombosis, cellulitis, impaired blood flow, difficulties with compression)
Self lower-leg assessment
Community support groups (i.e. walking groups)
Other ____________________________
Ability to self-manage optimized Confirm there are no changes:
Adherence to plan
Barriers to participate (transportation, socioeconomic, social environment, other co-morbidities)
Cognitive ability
Review importance and potential barriers to smoking cessation at every visit
Hygeine
Foot inspection (including bottom of foot and between toes)
Enviroment
Wound care
Compression application and removal if prescribed
Coping strategies implemented into plan of care
Confirm there are no changes:
Patient’s concerns and fears
Signs of anxiety or other mental health issues (eg. delusions, hallucinations, paranoid
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 19
behaviour)
Depression screen using Geriatric Depression Scale assessment form –GDS15
Suicide assessment if applicable
ETOH and illicit /recreational drug use
Family and caregiver support identified and incorporated into plan of care
Confirm there are no changes:
Availability of assistance required
Social supports/community resources currently utilized is integrated into plan of care
Confirm there are no changes:
Family support
Funding
Community resources
Caregiver conflicts
Long or short term placement
Assistance provided for financial concerns patient is experiencing
Confirm there are no changes:
Private insurance availability
Eligibility for Assistive Devices Program (ADP [lymphedema only], ODSP, High-needs fund, Veterans Affairs Canada or Aborignal Services)
Professional referral status reviewed
Primary Care Physician
Advanced Wound Specialist
Nurse Practitioner
Infectious Disease Specialist
Vascular Surgeon
Dermatologist
Plastic surgeon
Internist/Endocrinologist
Mental Health Specialist
Psychologists
Social work
Registered Dietitian
Pharmacist
Occupational Therapist
Physiotherapy
Chiropodist
Certified Pedorothist
Certified Orthotist
Certified Prosthetist
Podiatrist
Lymphatic Massage
Compression Stocking Fitter
Other: ____________________________
Physician/nurse practitioner orders received as required to change plan of care including agreeance to professional referral recommendations
Appropriate documents shared
Identify need to reassess ABPI/TPBI in 6 months
Lower leg assessment
Recent vascular study results (eg. ABPI, TPBI, Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies)
Relevant consultation notes
Acute care
Complex Continuing Care/Rehab
Long-term care
Community care
Primary care physician/Nurse Practioner
Professionals referred to Other _____________________________
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 20
Diagnostic results
Current treatment plan If wound closed or eschar is stable send discharge summary outlining outstanding issues and teaching completed to:
Referral source and most responsible physician (MRP)/nurse practitioner (NP)
Collaborative team/patient conference arranged to discuss barriers to healing and care plan if progression to healing is stalled
Arrange a Collaborative team/patient meeting to discuss barriers to healing and care plan
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 21
91-98 Days Expected Outcomes
Notes
Most Responsible Physician(MRP)/Nurse Practitioner (NP) identified/informed
Communication with primary care physician and/or Nurse Practioner to update on any significant changes in patient’s condition.
Refer patient to ‘Care Connects’ if no responsible practioner currently involved with patient
Determine if MRP/NP is part of family health team (FHT) or community health centre (CHC) and consider additional supports available
Assessment of wound performed and percentage of healing documented
Complete:
Bates-Jensen Wound Assessment Tool (BWAT) OR
Leg Ulcer Measurement Tool (LUMT)
Determine wound etiology Arterial ulcers are typically pale at base of wound, have ‘punched out’ appearance,
are more painful than expected and have low to no exudate Results of LLA and ABPI/TPBI
Document percentage of healing since admission
Assessment for infection (NERDS and STONEES)
Potential need for wound care specialist considered if wound healing is not progressing and infection is absent
Obtain photos following best practice as per framework for individual organization policies and procedures. Suggest following publication as guideline: http://mydigitalpublication.com/publication/?i=206722
Wound treatment/compression plan is being followed
Confirm there are no changes:
Adherence to plan
Real or potential barriers to wound treatment plan
Pain management reviewed Arterial pain is typically described as:
Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication)
Confirm there are no changes:
Brief Pain Inventory Short Form (BPI-SF)
Obtain physician/nurse practitioner orders for analgesics required (opioids and non-opioids)
Medical/surgical history and co-morbidity management considered within care plan
Confirm there are no changes:
Medication reconciliation and their impact on wound healing Confirm there are no changes:
4 P’s of Arterial Ulcers Pale wound base
Punched-out appearance
Painful
Parched (low to no exudate)
Arterial ulcers do not follow trajectory healing rate of venous ulcers (30% week 4 & healed at 12 weeks). Further intervention should be considered if conservative treatment does not improve healing in 4-6 weeks
Caution: USE DRY WOUND HEALING 1. Keep eschar dry 2. No occlusive dressings 3. Do NOT debride 4. Avoid tourniquet effect when securing dressings 5. If eschar becomes wet/boggy – URGENT referral to
advanced wound care specialist is recommended
Compression is typically contraindicated in the presence of peripheral arterial disease. In some circumstances light compression may be beneficial. In such cases, compression should be ordered by an advanced wound care physician or nurse practitioner only! See algorithm in guidelines.
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 22
reviewed
Prescription, non-prescription, naturopathic and illicit drug use
Recent blood work and other diagnostic test results reviewed and implictions for wound healing considered
Determine bloodwork and other diagnostic tests required
Bilateral lower leg assessment completed Signs and symptoms of Peripheral Arterial Disease could include:
Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication)
Dependent rubor in lower legs and feet
Pallor in feet on elevation
Dry, shiny skin on lower legs
Edema subsequent to leg being dependent
Thick or flaking toe nails
Hairless lower legs and feet
Weak or absent pulses
Intense hyperesthesia (sensitive to light touch)
Limb muscle may appear wasted from ischemic atrophy
Delayed capillary refill
Distal gangrene
Erectile dysfunction in men
Non-healing wound
ABPI/TPBI completed within last 3 mths and results documented
If unable to obtain ABPI/TPBI, referral to vascular surgeon is recommended
Assess pulses (popliteal – behind knee , dorsalis pedis – top of foot , posterior tibial – medial ankle)
Measurement of edema
Assess capillary refill (normal less than 3 seconds)
Leg measurements (foot, ankle, calf, thigh)
Ankle range of motion (ROM)
Foot deformities
Ankle flare
Skin temperature (compare both legs)
Skin colour (dependent and on elevation)
Presence of pain
Nail changes
Presence of hair on lower leg, feet and toes
Presence of varicosities (varicose veins)
Dermatological changes due to impaired blood flow
Repeat ABPI/TPBI assessment every 3 months if healing is not progressing
Patient’s nutritional status optimized
Confirm there are no changes:
Recent blood work results
Significant weight changes
Adherence to diet plan
Identify barriers to good nutrition
Patient and caregiver concerns and goals integrated into the care plan and shared with care team
Confirm there are no changes:
Cardiff Wound Impact Questionnaire
ABPI 0.5 to 0.8 TBPI 0.64 to 0.7
Suggest Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies
ABPI <0.5 TBPI <0.64
Urgent vascular surgical consult needed
Acute arterial occlusion is a life and limb-threatening situation which requires immediate emergency intervention
Signs and symptoms that may become severe may be associated with the following:
Pale or blue skin
Skin cold to the touch
Sudden decrease in mobility
No pulse where one was present prior to this
Sudden and severe pain
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 23
OR
World Health Organization Quality of Life (WHOQOL) form
Patient counselled on the benefit of activity rest and head elevation in moderation (balancing need for pressure relief) for comfort measures and wound healing
Confirm there are no changes:
Recent changes in overall activity level
Daily routine
Personal assistance available to perform activities of daily living
Ankle range of motion allowing for calf muscle pump to function
Determine where patient sleeps at night
Encourage patient to sleep in bed with no lower limb elevation (most arterial pain increases when feet elevated above heart level)
Mobility and dexterity aids currently being used
Safety of transfers
Recommendations for exercise
Consider Occupational Therapist referral for comfort measures
Patient/caregiver educational needs reviewed using ‘teach-back’ method
Emergency signs and symptoms of Peripheral Arterial Disease that require immediate medical attention (refer to lower leg assessment section)
Risks of compression
Smoking cessation including e-cigarettes and nicotene replacement
Appropriate footwear as discussed with foot care specialist (encourage use of white socks)
Skin care
Nail care (suggest use of foot care specialist)
Wound self care
Pain management
Diagnostic testing
Dietary
Rest/Activity
Prevention of injury – avoid extremes (hot/cold, loose/tight)
When to call primary care giver (eg. signs and symptoms of infection, deep vein thrombosis, cellulitis, impaired blood flow, difficulties with compression)
Self lower-leg assessment
Community support groups (i.e. walking groups)
Other ____________________________
Ability to self-manage optimized Confirm there are no changes:
Adherence to plan
Barriers to participate (transportation, socioeconomic, social environment, other co-morbidities)
Cognitive ability
Review importance and potential barriers to smoking cessation at every visit
Hygeine
Foot inspection (including bottom of foot and between toes)
Enviroment
Wound care
Compression application and removal if prescribed
Coping strategies implemented into plan of care
Confirm there are no changes:
Patient’s concerns and fears
Signs of anxiety or other mental health issues (eg. delusions, hallucinations, paranoid behaviour)
Depression screen using Geriatric Depression Scale assessment form –GDS15
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 24
Suicide assessment if applicable
ETOH and illicit /recreational drug use
Family and caregiver support identified and incorporated into plan of care
Confirm there are no changes:
Availability of assistance required
Social supports/community resources currently utilized is integrated into plan of care
Confirm there are no changes:
Family support
Funding
Community resources
Caregiver conflicts
Long or short term placement
Assistance provided for financial concerns patient is experiencing
Confirm there are no changes:
Private insurance availability
Eligibility for Assistive Devices Program (ADP [lymphedema only], ODSP, High-needs fund, Veterans Affairs Canada or Aborignal Services)
Professional referral status reviewed
Primary Care Physician
Advanced Wound Specialist
Nurse Practitioner
Infectious Disease Specialist
Vascular Surgeon
Dermatologist
Plastic surgeon
Internist/Endocrinologist
Mental Health Specialist
Psychologists
Social work
Registered Dietitian
Pharmacist
Occupational Therapist
Physiotherapy
Chiropodist
Certified Pedorothist
Certified Orthotist
Certified Prosthetist
Podiatrist
Lymphatic Massage
Compression Stocking Fitter
Other: ____________________________
Physician/nurse practitioner orders received as required to change plan of care including agreeance to professional referral recommendations
Appropriate documents shared
Identify need to reassess ABPI/TPBI in 6 months
Lower leg assessment
Recent vascular study results (eg. ABPI, TPBI, Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies)
Relevant consultation notes
Diagnostic results
Current treatment plan
Acute care
Complex Continuing Care/Rehab
Long-term care
Community care
Primary care physician/Nurse Practioner
Professionals referred to Other _____________________________
Waterloo Wellington Integrated Wound Care Program Arterial Pathway May 5 2016 25
If wound closed or eschar is stable send discharge summary outlining outstanding issues and teaching completed to:
Referral source and most responsible physician (MRP)/nurse practitioner (NP)
Collaborative team/patient conference arranged to discuss barriers to healing and care plan if progression to healing is stalled
Arrange a Collaborative team/patient meeting to discuss barriers to healing and care plan
Physician/nurse practitioner orders received as required to change plan of care including agreeance to professional referral recommendations
