15. CCA Study Notes: Venous and Arterial Leg and Foot Ulcers

The Big Picture

Poor blood flow to or from the legs and feet can lead to pain, swelling, and open wounds. These wounds can be difficult to heal and can become infected.

Circulatory ulcers are classified as venous ulcers or arterial ulcers. The difference depends on whether the problem involves blood returning through the veins or blood flowing through the arteries.

For CCA care, prevention includes protecting the skin, following the care plan, watching the legs and feet for changes, and reporting concerns when directed.

Look for Nova Scotia CCA Notes throughout this page for current provincial guidance.

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Course Notes: Key Ideas You Need to Know

What Are Circulatory Ulcers?

A circulatory ulcer, also called a vascular ulcer, is an open wound on the lower leg or foot caused by reduced blood flow through arteries or veins.

People with diseases that affect blood vessels have a greater risk of these ulcers. Circulatory ulcers can cause pain and can be difficult to heal.

Circulatory ulcers are classified as:

• Venous ulcers, which involve poor blood return through veins
• Arterial ulcers, which involve poor arterial blood flow

Poor circulation and an open wound can lead to infection or gangrene. Gangrene occurs when tissue dies and then decays. Gangrenous tissue may look black and have a foul smell.

Clients with leg or foot ulcers need special skin care as directed by a physician. The nurse uses the care-planning process to help prevent skin breakdown on the legs and feet.

Venous Ulcers

A venous ulcer, also called a stasis ulcer, is an open wound on the lower leg or foot caused by poor blood return through the veins.

How Venous Blood Flow Works

Blood travelling from the feet back toward the heart moves against gravity. When a person is active, the leg muscles help the valves in the leg veins move blood upward.

Problems can occur when a client:

• Is not active
• Is extremely obese
• Has circulatory problems

Blood may collect in the leg veins, or the valves may not close properly. Blood and fluid can then build up in the legs and feet.

This fluid buildup causes edema, which means swelling in tissues caused by accumulated fluid.

Pitting Edema

Pitting edema is swelling that leaves an impression in the skin after fingers press into the swollen tissue and are then removed.

With more recent edema, the skin may look:

• Swollen
• Shiny
• Stretched

Signs and Appearance of Venous Ulcers

Venous ulcers and edema can be painful and can make walking difficult.

Other findings include:

• Fluid may seep from the ulcer.
• Healing can be slow.
• Infection is a major risk.
• Itching is common.

When edema continues for a long time, the skin can change. Small veins in the skin may rupture. Hemoglobin ⓘ from the blood can enter the tissues, causing the skin to darken and become dry, hard, and leathery.

Common Sites and Causes of Venous Ulcers

The heels and inner sides of the ankles are common locations because they can be injured easily.

Venous ulcers can also result from:

• Scratching
• Injury
• An injury that occurs without a specific known cause

Medical Care for Venous Ulcers

A physician may order elastic stockings or elastic bandages. These provide support and pressure to the veins and help promote comfort and circulation.

The physician or nurse practitioner may also order:

• Foot care from a professional with specialized foot-care training
• Medications
• Wound-care products

Preventing Venous Ulcers

Prevention focuses on reducing skin breakdown and supporting circulation according to the care plan.

Stockings, Socks, and Skin Care

• Apply elastic stockings or wraps according to the care plan when doing so is within your scope of practice.
• Do not use elastic garters to hold socks or hose in place.
• Make sure stocking tops are not tight enough to restrict the client.
• Provide good skin care each day.
• Clean and dry between the toes.
• Have the client wear comfortable socks and shoes.

Protect the Legs and Feet

• Avoid injuries to the legs and feet.
• Keep linens clean, dry, and free of wrinkles.
• Do not scrub or rub the skin during bathing or drying.
• Avoid massaging pressure points.
• Never rub or massage reddened areas.

Positioning and Movement

• Remind the client not to sit with the legs crossed.
• Follow the care plan for walking and exercise. Movement increases venous blood flow.
• Reposition the client at least every 2 hours and follow the care plan.
• Place enough padding between body parts when positioning the client in bed. Pillows, soft blankets, or towels may be used.
• Elevate the client’s legs according to the care plan.

Protect the Heels

Keep the client’s heels off the bed. Use pillows or other devices as instructed by the supervisor.

Place the pillows or devices beneath the lower legs from the middle of the calf to the ankle.

Use protective devices as directed by the supervisor and the care plan.

Report: Report signs of skin breakdown, venous ulcers, or pressure injuries at once.

Arterial Ulcers

An arterial ulcer is an open wound on the lower leg or foot caused by poor arterial blood flow.

Signs and Appearance of Arterial Ulcers

The affected leg or foot may:

• Feel cold
• Look grey
• Look blue
• Look shiny

An arterial ulcer is often painful when the client is resting. The pain is usually worse at night.

Common locations include:

• Between the toes
• On top of the toes
• On the outer sides of the ankles
• On the heels of people on bed rest
• Pressure areas caused by shoes that fit poorly

Causes and Risk Factors for Arterial Ulcers

Arterial ulcers can result from diseases or injuries that reduce arterial blood flow to the legs and feet.

Examples include:

• High blood pressure
• Diabetes
• Narrowing of the arteries related to aging

Smoking is an important risk factor for vascular disease ⓘ, including atherosclerosis, arteriosclerosis, venous ulcers, and arterial ulcers.

Treatment and the CCA Role

The physician directs care for a client with an arterial ulcer. The physician treats the disease causing the ulcer and may order:

• Medications
• Wound care
• A walking program

Role limit: Never provide foot care to a client with an arterial ulcer unless the client’s care plan specifies that you should do so. This restriction helps prevent further injury.

Preventing Arterial Ulcers

Reduce Pressure and Protect the Feet

• Make sure the client’s shoes fit properly.
• Keep the feet clean and dry.
• Keep pressure off the heels and other bony areas.
• Avoid pressure beneath the knees.
• Use protective devices as directed by the supervisor and care plan.

Avoid Restrictions and Skin Injury

• Remind the client not to cross their legs.
• Do not expose the client to cold.
• Do not use elastic garters to hold socks or hose in place.
• Make sure the tops of stockings are not tight enough to restrict the client.
• Avoid massaging pressure points.
• Never rub or massage reddened or newly discoloured areas.

Smoking

Encourage a client who smokes to quit smoking.

Observe and Report

Check the client’s legs and feet every day.

Report these changes to the supervisor:

• Changes in skin colour
• Breaks in the skin

Venous Ulcers and Arterial Ulcers Compared

Venous Ulcers	Arterial Ulcers
Caused by poor blood return through veins	Caused by poor arterial blood flow
Edema is common	The affected leg or foot may feel cold
Skin may look swollen, shiny, and stretched with recent edema	Skin may look grey, blue, or shiny
Long-term edema can lead to dark, dry, hard, leathery skin	Pain often occurs at rest and is usually worse at night
Common around the heels and inner ankles	Common between or on top of toes and on outer ankles
May seep fluid	Can occur on heels during bed rest or at pressure sites from poorly fitting shoes