Week 5 | Arterial Wounds (17180-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
Available: 
04/07/2017
Expires: 
07/02/2018

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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