Lower Leg & ankle wound wound care and TX Flashcards
Amkle brachial index ABI
- important measurement to screen for:
- -arterial insufficiency
- -safe level of compression
- -wound healability
0.8-1.2 = 30-40 mmHg
0.6-0.8= 20-30 mmHG
<0.6 = no compression
Predisposing factors Venous Leg Ulcers
- Venoous valve incompetence
- varicose veins
- history of ulcers
- DVT
- leg trauma
- history of LE surgeries
- LE weakness
- impaired ankle motion
- limited mobility
- advanced age
- medication
- smoking
- obesity
- multiplpe pregnancies
Pathophysiology of venous disease
3common components
- valve incompetence causng reflux
- venous obstruction
- calf muscle weakness causing insufficient venous return
–causes venous hypertension. leakage into tissue edema.
inflammation as a result of venous disease causes….
-increased capillary permeability, leading to fibrotic changes and hyperpigmentation
venous muscle pump
- involves venous valves and calf muscles
- compresses veins to force blood flow to heart
- most effective with unobstructed veins ad normal valves
typical VLU presentation
- located in gaiter area
- wound with red granulation tissue and/or cellular debris or crust
- irregular wound margins
- periwound skin color changes
venous disease Wound appearance key findings
- granulation tissue
- Fibrin
- Slough
- Crusted areas
- non granular tissue
- irregular wound margins
- superficial wound
- minimal to moderate pain
- moderate to heavy exudate
Treating venous disease by..
- compression wrapping or garments
- exercise
- elevation
- education
- Patient buy-in an dparticipation
- request venous ultrasound and referral to vascular surgeon if slow healing, history of recurrent venous leg ulcer
arterial leg ulcers Predisposing factors
- PVD
-smoking
Diabetes
-advanced age
-male gender
-hypertension
Arterial ulcers leg appearance
- think,shiny,dry skin
- hair loss on ankle and foot
- dystophic toenails
- elevation pallor
- dependent rubor
- decreased temp
- absent or diminished pulses
- cyanosis
- ischemic pain
arterial ulcers anatomic location
- between toes
- tips of toes
- pressure points
- sites of trauma or footwear rubbing
- typically distal to ankle
Arterial ulcers - common wound characteristics
- well-defined wound margins: punched out?
- pale or necrotic wound bed
- gangrene may be present
- minimal exudate
- painful
- infection common
- blanched or pupuric pwriwound
types of traumatic wounds
- contusion
- abrasion
- laceration
- bite
- puncture
- impalement
- avulsion/degloving
- crash injury
- burn
- post-surgical
how to treat a surgical site infection
- communicate with physician if infection is not controlled
- check for remaining sutures causing irritation or stitch abscess. get clearance from surgeon to remove
- check for factors causing trauma
- control edema
how to treat a pressure injury
- help nursing to educate and position at-risk patients; turning/ repositioning every 2 hour or less
- keep patients off of existing pressure injuries
- increase mobility and independence of your patients as quickly as possible
- monitor skin closely during treatments
- place devices on properly i.e SCD’s
- help with preventative measures and support surfaces adherence
How to treat general infection
-if active signs of ing=fection, call physician to report status of wound if: patient not on PO or IV antibiotics. Or has been on PO or IV antibiotics 3-4+ days and not improving
- consider having patient evaluated by a physician
- Document your communication with physician
VLU leg appearance
Firm edema Dilated superficial veins Dry, thin scaly skin Evidence of healed ulcers Leg hyperpigmentation
VLU periwound appearance
Leg edema Dermatitis Mace ration Hyperkeratotic tissue Atrophied Blanche Lipodermatoschelrosis
