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When arterial flow is diminished: 9 Minor injuries can become non-healing wounds 9 Ulcers occur often at distal locations 9 May progress to gangrene or tissue necrosis → amputation
• Avoid debridement until perfusion is determined • Do NOT debride dry, stable eschar • Determine proper use of antiseptics to assist with maintenance of
stable eschar • Infected, necrotic wounds 9 Refer for surgical debridement and antibiotic therapy 9 Do not rely on topical antibiotics to treat infected, ischemic wounds
• Choose appropriate dressings. May need frequent visualization and inspection of wound
• Edema - patients with mixed venous and arterial disease, use reduced compression under close supervision 9 ABI >0.5 to <0.8: modified compression, 23 – 30 mm / Hg at the ankle, may
promote healing 9 ABI <0.5: compression should not be used
Diabetes – global epidemic • 370 million people globally • 23.6 million people in U.S. • 25% lifetime risk of diabetic foot ulcer development Patients with diabetic neuropathy & wounds: 9 66% rate of relapse over 5 years, 9 12% progress to amputation
Diabetes Advanced age Impaired glucose tolerance Family history Smoking Hypertension, obesity, Raynaud’s disease Spinal cord injury Trauma to lower extremity
Depth: Varies; partial thickness to full thickness with exposed bone Shape: Round or oblong Exudate: small to moderate • Foul odor and purulence indicate infection
Periwound • Callus common • Erythema, induration • May have dry, cracked skin or maceration
Pain • May be superficial, deep, aching, stabbing, dull,
• Wound care 9 Offloading, referral, education & support 9 Provide moist environment for healing 9 Dressing selection – periodic reevaluation 9 Maintain dry stable eschar on noninfected, ischemic wounds
• Observe clinical manifestations of infection – may be subtle due to reduced blood flow
• Optimize healing process through management of blood glucose levels • Pain management • Monitor patients receiving compression therapy due to decreased
sensation of pain • Nutritional support, control of blood glucose
Prevalence • 7 million individuals worldwide, 2-5% of Americans • 3 million progressing to ulceration (VLU) • Account for 80-90% of all leg ulcers • 600,000 new VLU each year • Common in women • More common in aging • $ 1.9 to 3.5 billion/year in US • 26-28% VLU reoccur within 12 months
• Decreased self esteem • Decreased mobility • Decreased functionality of affected limb • Difficulty finding appropriate clothing/shoes • Inability to manage ADL’s • Inability to work, job loss • Adverse effect on finances • Housebound • Depression • Cost to health care system and personal life disruption for repeat
admissions for cellulitis
Sen Chandan, Gordillo Gayle , Roy Sashwat, Kirsner R, et al; Human skin wounds: A major and snowballing threat to public health and the economy Wound Rep Reg (2009) 17 763-771
• A method for comparing blood pressure in the arm to blood pressure in the leg • Reflects the degree of perfusion loss in the leg • Should be a resting pressure obtained with the patient in a supine position
Interpretation > 1.0 Normal > 0.8 LEVD < 0.6 to 0.8 Borderline < 0.5 Severe Ischemia
• Most essential component of venous leg ulcer treatment. • Reduce edema/lymphedema by providing resistance against the
calf muscle • Improves speed of blood flow to heart • Decrease exudate/weeping of the leg • Reduces MMP’s and inflammatory cytokines • Improve wound healing • Decreases aching and heaviness of the leg
In patients with mixed venous and arterial disease, use reduced compression under close supervision • ABI >0.5 to <0.8: modified compression, 23 – 30 mm/Hg • ABI <0.5: compression should not be used
• Ermer-Seltun J. Lower Extremity Assessment. In: Bryant BA, Nix DP. In: Acute & Chronic Wounds; Current Management Concepts, 4th ED. St. Louis, MO: Elsevier Mosby; 2012:Chapter 10.
Arterial: • A quick reference guide for lower-extremity wounds: venous, arterial, and neuropathic. www.wocn.org • Doughty D. Arterial Ulcers. In: Bryant BA, Nix DP. In: Acute & Chronic Wounds; Current Management Concepts, 4th ED. St. Louis, MO: Elsevier Mosby; 2012:
Chapter 11. • Wound, Ostomy and Continence Nurses Society. (2014). Guideline for the Management of Wounds in Patients with Lower-Extremity Arterial Disease. WOCN
clinical practice guideline series 1. Mt. Laurel: NJ. Author.
Neuropathic: • Driver VR, LeBretton Jm, et al. Neuropathic Wounds: The Diabetic Wound. In: Bryant BA, Nix DP. In: Acute & Chronic Wounds; Current Management Concepts,
4th ED. St. Louis, MO: Elsevier Mosby; 2012: Chapter 14. • Wound, Ostomy and Continence Nurses Society. (2012). Guideline for the Management of Wounds in Patients with Lower-Extremity Neuropathic Disease. WOCN
clinical practice guideline series 3. Mt. Laurel: NJ. Author.
Venous • A quick reference guide for lower-extremity wounds: venous, arterial, and neuropathic. www.wocn.org • Carmel JE. Venous Ulcers. In: Bryant BA, Nix DP. In: Acute & Chronic Wounds; Current Management Concepts, 4th ED. St. Louis, MO: Elsevier Mosby; 2012:
Chapter 12. • Wound, Ostomy and Continence Nurses Society. (2011). Guideline for the Management of Wounds in Patients with Lower-Extremity Venous Disease. WOCN
clinical practice guideline series 4. Mt. Laurel: NJ. Author.