Exam 4: Chapter 30: Assessment and Management of Patients with Vascular Disorders and Problems of Peripheral Circulation Flashcards
What is a leg ulcer?
An excavation of the skin surface that occurs when inflamed necrotic tissue sloughs off.
Patho behind leg ulcers?/
Inadequate exchange of oxygen and other nutrients in the tissue is the metabolic abnormality that underlies this development
Alternations in blood vessels at the arterial, capillary, and venous levels may affect
cellular processes and lead to the formation of ulcers
Chronic arterial disease is characterized by
intermittent claudication, which is pain caused by activity and relieved after a few minutes of rest
Patients with Arterial Ulclers may also complain of
digital or forefoot pain at rest
If arterial occlusion is acute, pain is
unrelenting and rarely relieved even with opoids
Typically, arterial ulcers are
small, circular, deep ulcerations on the tips of toes or in the web spaces between the toes
Ulcers often occur on the
medial side of the halllux, or lateral fifth toe and may be caused by a combination of ischemia and pressure
Arterial Ulcers and Edema and Pulses?
No Edema / No Pulse or Weak Pulse
Chronic Venous Insufficiency is characterized by
pain described as aching or heavy.
Venous Ulcers are in the area of
the medial or lateral malleolus and are typically large, superfiical, or lateral malleolus and are typically large, superfifical, and highly exudative
Venous Ulcers: Venous Hypertension causes
extravasation of blood, which discolors the area.
Arterial ulcer occurs where?
A clot at the very end of the foot
A ulcer from venous stasis happens around the
ankle
What Antiseptic Agents can inhibit the growth and development of most skin organisms?
Povidone-Iodine
Cadexomer Iodine
Acetic Acid
Chlorhexidine
Silver Wound Products
Once a wound is colonized with pathogens shows signs of infection, a
systemic antibiotic is necessary
What antibiotic is suaully prescribed for leg ulcers?
Oral Antibiotics usually are prescribed because topical antibiotics have not proven to be effective
Nutrition and Leg Ulcers
They need protein, and this can be tested by Albumin
Why does Compression Therapy work for Leg Ulcers?
Adequate compression therapy involves the application of external or counter pressure to the lower extremity to facilitate venous return to the heart
How long should the patient wear stockings for?
At all times except at night and to reapply the stockings in the mornin g
Debridement: To promote healing the wound is
kept clean of drainage and necrotic tissue
Debridement: Usual method is to
flush teh area with normal saline solution or clean it with a noncytotoxic wound-cleansing agent
Debridement: What is this?
Removal of nonviable tissue from wounds. Can be accomplished by several different methods.
What is Surgical Debridement:
Fastest method and can be performed by a physician or other qualified person
What is Nonselective Debridement:
Can be accomplished by applying isotonic saline dressing of fine mesh gauze to the ulcer. When dressing dries, it is removed along with debris adhereing to gauze
What is Enzymatic Debridement:
Application of enzyme ointments may be prescribed to reat the ulcer. Ointment applied to lesion.
What are Calcium Alginate Dressings useful for?
Used for debridemenet when absorption of exudate is neded. Dressings changed when exudate seeps through the cover dressing or at least every 7 days
Why are foam dressings useful?
They absorb exudate into the foam, keeping the wound moist
Wound Dressing: SEmiocclusive or Occlusive Wound Dressings prevent
evaporative water loss from the wound and retain warmth; these factors facor healing
Wound Dressing: Available options that promote the growth of granulation tissue and reepithelization include
the hydrocolloids
Hydrocolloids also provide a
barrier for protection because they adhere to the wound bed and surrounding tissue.
Wound Dressing: Foam Dressings are permeable to both
gases and water vapor due to their hydrophilic properties and are indicated for wounds with moderate exudate, granulating, or slough covered
Wound Dressing: Semipermeable film dressings may be selected because
they keep the wound moist and are impervious to bacteria while allowing some gas exchange. May not be effective treatment for deep wounds and infected wounds
Wound Dressing: GRowth Factor dressings may directly provide
a growth factor, or they may stimulate important growth substances within the wound
Wound Dressing: Calcium Alginate, Hydrofiber, and Hydroconductive dresings are used for wounds with
moderate to high amounts of exudate
Wound Dressing: Hydroconductive dressings provide
a capillary action that lifts and moves exudate away from a wound into the core of the dressing form where is disperses into second layer
Stimulated Healing: Tissue-engineered human skin equivalent is a
skin product cultured form human dermal fibroblasts and keratinocytes used in combination with therapeutic compression
Stimulated Healing: When applied, it
interacts with the patients cells within the wound to stimulate the production of growth factors
Stimulated Healing: What is PriMatrix
A bioactive and regenerative extracellular matrix that binds with the patietns own cells and growth factors
Stimulated Healing: PriMatrix has been used successfully for
tunneling wounds, as well as wounds with exposed tendon and bone, in which Apligraf cannot be used.
Hyperbaric Oxygenation: May be beneficial as
an adjunct treatment in patietns with diabetes with no signs of wound healing after 30 days of standard wound treatment
Hyperbaric Oxygenation: Accomplished by
placing the apteitn into a chamber that increases barometric pressure while the patient is breathing 100% oxygem
Hyperbaric Oxygenation: Treatment regimens vary from
90 to 120 minutes once dail for 30 - 90 dessions
Hyperbaric Oxygenation: Edema in wound area decreased because
high oxygen tension facilitates vasoconstriction and enhances the ability of leukocytes to phagocytize and kill bacteria.
Hyperbaric Oxygenation: Also thought to
increase diffusion of oxygen to the hypoxic wound, thereby enhancing epithelial migration and improving collagen production
Hyperbaric Oxygenation: Two most common adverse effects are
middle-ear barotrauma and confinement anxiety
Negative Pressure Wound Therapy: Research findings suggest that
negative pressure wound herapy using vacuum-assisted closure (VAC) devices decreases time to healing in complex wounds that have not healed in a 3-week period
Negative Pressure Wound Therapy: Wound VAC therapy has been found to be effective in treating pateints who develop
postoperative groind wound infections, decreasing hospital length of stay, rates of graft infection, and likelihood ofl imb loss
Nursing Diagnoses for Leg Ulcers
Impaired Skin Integrity RT Vascular Insufficiency
Impaired Physical Mobility RT Active Restrictions of the Therapeutic Regimen and Pain
Imbalance Nutrition
Potential complications of Leg Ulcers may include
Infection
Gengrene
Major goals for patient with Leg Ulcers include
restoration of skin integrity
Improved physical mobility
Adequate nutrition
Absence of complications
HEAL ULCER
Restoring Skin Integrity: Cleansing requires
very gentle handling, a mild soap, and lukewarm water
Restoring Skin Integrity: If there is arterial insufficiency, patient should be referred for
evaluation of vascular reconstruction
Restoring Skin Integrity: is there is venous insufficiency,
dependent edema cna be avoided by elevating the lower extremities
Restoring Skin Integrity: Decrease in edema promotes
the exchange of cellular nutrients and waste products in the area of the ulcer, promoting healing
Restoring Skin Integrity: Protective boots useful because
they are soft and provide warmth and protection from injury and displace tissue pressure to prevent ulcer formation
Restoring Skin Integrity: If pt on bed rest, important to
relieve pressure on the heels to prevent pressure ulcerations
Restoring Skin Integrity: When in bed, what can be used to relieve pressure from bed linens?
Bed cradle, and also prevents anything from touching the legs
Restoring Skin Integrity: HEating pads, hot water bottles, or hot baths are avoided because
they increase the oxygen demands and this the blood flow demands of the already compromised tissue.
Restoring Skin Integrity: Heating pads problematic with diabetics because
heating pads may produce injury before the patient is aware of being burned
Improving Physical Mobility: Physical activity is initally
restricted to promote healing
Improving Physical Mobility: When infection resolves and healing begins, ambulation should
resume gradually and progressively
Improving Physical Mobility: activity promotes
arterial flow and venous return and is encourage after the acute phase of the ulcer process
Improving Physical Mobility: Activity to promote blood flow;
encourage patient to move about in bed and exercise upper extremities
Improving Physical Mobility: If pain is present
Analgesic agents may be taken before scheduled activities to help the patient participate more comfortably
Promoting Adequate Nutrition: Eating a diet high in what promotes healing?
protein, Vitamins C and A, Iron, and Zinc is encouraged to promote healing.
Promoting Adequate Nutrition: Particular consideration should be given to
iron intake, because many older patients are at risk for iron deficiency anemia
Expected Outcomes
Demonstrates Restored Skin integrity
Increased Physical Mobility
Attains Adequate Nutrition
What is Cellulitis?
Most common infectious cause of limb swelling
Cellulitis can occur as
single isolated event or a series of recurrent events
Cellulitis occurs when
an entry point through normal skin barriers allows bacteria to enter and release their toxins in the subcutaneous tissues
Cellulitis: Pathogen is usually
Sreptoccus speices or S. Aureus
Cellulitis: Signs and Symptoms include
swelling, localized redness, warmth, and pain
Cellulitis: systemic signs include
fever, chills, and sweating
Regional lymph nodes may also be tender and enlarged
Cellulitis: Redness may not be uniform and often skips areas and eventually develops
a pitting “orange” peel appearance.
Mild cases of Cellulitis can be treated on
an outpatient basis with oral antibiotic therapy
If Cellulitis is severe, patient is treated with
IV antibiotics
Key to preventing recurrent episodes of Cellulitis lies in
adequate antibiotic therapy for the initial event and in identifying the site of bacterial entry
Cellulitis: Cracks and Fisures that occur in the skin between the toes must be
examined as potential sites of abcterial entry
Cellulitis: Other entry points include
Drug Use Injection Sites, Contusions, Abrasions, Ulceration, Ingrown Toenails, Hangnails
Cellulitis: Patient is instructed to elevate the affected area to
3-6 inches above heart level and apply cool, moist packs at teh site every 2-4 hours until inflammation has resolved and then transition to warm packs
Cellulitis: ducation should focus on
preventing a recurrent episode. Patient with peripheral vascular disease or diabetes should recieve education or reinforcement about skin and foot care
Cellulitis:Labs for this?
WBC. Also monitor temperature
Stage 1 Pressure Ulcer
Sign of Risk. Intact skin with nonblanchable redness of localized area
Stage II Pressure Ulcer
Partial thickness loss of dermis presenting as shallow open ulcer with red or pink wound bed
Stage III Pressure Ulcer
Full-thickness tissue loss. Subcutaneous may be visible but bone, tendon, or muscle are not exposed. Slough may be present
Stage IV Pressure Ulcer
Bone is exposed here
If pressure continues long enoug,
small vessel thrombosis and tissue necrosis occur and pressure ulcer results
Susceptible areas for pressure ulcers include
sacrum and coccygeal areas, ischial tuberosities, greater trochanter, heel,, knee, malleolus, medial condyle of the tibia, fibular head, scapula, and elbow
Prolonged pressure impedes
blood flow, reducing nourishment of the skin and underlying tissues
Anemia decreases the
bloods oxygen carry ability and predisposes the patient to pressure ulcers.
Serum albumin and prealbumin levels are sensitive indicators of
protein deficiency
Serum albumin levels of less than 3 are associated with
hypoalbuminemic tissue edema and increased risk for pressure ulcers
Prealbumin levels are more sensitive indicator of
protein status than albumin levels
Shear is the result of
gravity pushing down on the patients body and resistance between the patient and the chair or bed
When shear occurs,
tissue layers slide over one another, blood vessels stretch and twist, and the microcirculation of the skin and subcutaneous tissue is disrupted
Improving Tissue Perfusion: Massage of erythematous areas avoided because
damage to the capillaries and deep tissue may occur
Improving Tissue Perfusion: In patients who hav evidence of compromised peripheral circulation (edema),
positioning and elevation of the edematous body part ot promote venous return and dimish congestion improve tissue perfusion
