Week 5 | Arterial Wounds (16180-SP)

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Topics

Normal arterial perfusion and terms

Etiology

  • Atherosclerosis
  • Arterial trauma
  • Acute embolic syndrome
  • Entrapment syndromes
  • Buerger’s Disease (thromboangitis obliterans)
  • Sickle cell
  • Associated with autoimmune diseases, collagen abnormalities, vasculitic disorders, clotting abnormalities such as protein C deficiencies and vasospastic diseases such as Raynaud’s disease.

Pathology of atherosclerosis

Risk Factors

  • Modifiable:
    • Tobacco use
    • Hypertension
    • Dyslipemia
    • Diabetes
  • Predisposing:
    • Advanced Age
    • Male gender
    • Family history
    • African American ethnicity
  • Emerging:
    • Hyperhomocysteinemia
    • Increased C-Reactive Protein
    • Chronic renal disease
    • Chlamydia pneumoniae
    • Peridontal disease

Arterial disease and diabetes

Structured assessment approach

  • Patient assessment
  • Pain history and assessment
    • Common locations, characteristics, alleviating and aggravating factors
    • Intermittent Claudication
    • Nocturnal
    • Rest
  • Lower extremity exam
    • General appearance of limb
    • Ischemic Skin Changes
      • Epidermal thinning
      • Atrophy of subcutaneous tissue
      • Shiny, taut, dry skin
      • Purpura
      • Loss of hair
      • Thick toenails
    • Color changes
      • Elevational pallor
      • Dependent rubor
    • Assess pulses
    • Doppler signal quality
    • Ankle-Brachial Index
    • Skin temperature
    • Capillary refill
    • Non-invasive assessment
      • TBI
      • Transcutaneous oxygen
  • Focused wound assessment

Ulcer characteristics and pathology

  • Location: Distal aspect of extremity, phalangeal heads, lateral malleolus, areas of repetitive trauma
  • Punched out appearance, well defined borders
  • Pale or necrotic wound bed
  • Minimal exudate
  • Faint halo of erythema, infection common
  • Extremely painful

Treatment

  • WOCN guidelines: Relate treatment to adequacy of perfusion (ABI).
  • Referral to vascular surgeon: surgical/endovascular options
    • Limb salvage/preservation
    • Bypass grafts
    • Angioplasty
    • Thrombolysis
    • Amputation
  • Pharmacologic options
    • Analgesics
    • Risk factor modification
      • Statins
      • Antiplatelet agents
      • Cilostazol
  • Referral indications
  • Adjunctive therapies
    • Hyperbaric oxygen therapy
    • Arterial flow augmentation
  • Measures to improve perfusion
    • Smoking cessation
    • Maintenance of hydration
    • Avoidance of cold
    • Avoid caffeine
    • Avoid constrictive garments
    • Graduated walking program
    • Nutritional supplements

Topical Management Issues

  • Identify and treat infection
  • Maintain dry non-infected necrotic wound
  • Cleansing.
  • Cautious use of occlusive dressings
  • Manage edema in mixed disease
  • Principles
  • Appropriate use antiseptics and topical antibiotics
  • Pain management
  • Indicators of wound infection in the ischemia limb.

Patient education

Summary​

Objectives for Learning Outcomes

After completing this session, you will be able to:

  1. Describe the etiology and risk factors for lower extremity arterial disease (LEAD). 
  2. Discuss the assessment, clinical presentation, and management of lower extremity arterial ulcers.
Course summary

Renee Anderson, MSN, RN, CWON
Certified Wound Ostomy Nurse; Co-Director, Wound Management Education Program (WMEP) and Wound Management Fundamentals Course (WMFC), Continuing Nursing Education, University of Washington School of Nursing, Seattle; President, Rainier Clinical Consultants, Inc, Seattle, WA

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