July 18, 2012

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ABIs: Do you or don’t you?

BY: NANCY MORGAN, RN, BSN, MBA, WOCN, WCC, CWCMS, DWC

You’ve identified your patient’s lower extremity ulcer as a venous ulcer. It has irregular edges, a ruddy wound base, and a moderate amount of drainage. The patient’s bilateral lower extremities are edematous. As a wound care clinician, you know sustained graduated compression is key to healing stasis ulcers and preventing their recurrence.

So are you ready to wrap? Not yet. As wound care clinicians, we always put our patients’ safety first. We need to be sure that compression won’t harm our patients and that there’s no underlying arterial component. Obtaining the ankle brachial index (ABI) gives us the information we need.

Obtain an ABI when pulses aren’t clearly palpable, on patients with lower extremity ulcers, and before starting compression therapy. The ABI rules out significant arterial disease and determines the amount of compression (if any) that can be applied safely. The normal ABI is ≥ 1.0 to 1.3.  An ABI of ≤ 0.9 indicates lower extremity arterial disease. An ABI of 0.6 to 0.8 signals borderline ischemia; ≤ 0.5 signifies severe ischemia.

For high-pressure compression (40 to 50 mm Hg) or moderate-pressure compression (30 to 40 mm Hg), the patient’s ABI should be above 0.8. For low- to moderate-pressure compression (25 to 35 mm Hg), it should be 0.5 to 0.8. With low-pressure compression (18 to 24 mm Hg), ABI should be at least 0.5. NEVER apply compression if ABI is less than 0.5! With your ABI completed, you now can apply compression safely.

When do you obtain an ABI in practice? In long-term care situations, how often do you obtain ABIs before applying compression? If you’re not obtaining ABIs, what’s the reason?

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DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

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14 thoughts on “ABIs: Do you or don’t you?”

  1. Yvonne Rice says:

    I am the director of nursing services in my facility and a WCC. They entrust me with the assessments outlined above and even bought me a doppler to make obtaining an ABI easier. In LTC/ SNF we do follow these same guidelines. My facility saves money, because rather than calling in a third party to complete such a simple test, they utilize my expertise. Certified Wound Care Clinicians are not very common in San Antonio, but we are growing. The problem is that many facilities do not utilize their wound care experts for these types of exams. Thanks for the great information as always Nancy!

    Latasha (Yvonne) Rice

    MSN- Leadership in Healthcare Systems, BSN, RN, WCC

  2. betty says:

    I have heard that ABI’s are a 5th vital sign in wound care and does not require a physician order and does not need to result the test. IS this true?

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