Lower Leg & ankle wound wound care and TX

Question 1

Amkle brachial index ABI

Answer 1

• 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

Question 2

Predisposing factors Venous Leg Ulcers

Answer 2

• 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

Question 3

Pathophysiology of venous disease

3common components

Answer 3

• valve incompetence causng reflux
• venous obstruction
• calf muscle weakness causing insufficient venous return

–causes venous hypertension. leakage into tissue edema.

Question 4

inflammation as a result of venous disease causes….

Answer 4

-increased capillary permeability, leading to fibrotic changes and hyperpigmentation

Question 5

venous muscle pump

Answer 5

• involves venous valves and calf muscles
• compresses veins to force blood flow to heart
• most effective with unobstructed veins ad normal valves

Question 6

typical VLU presentation

Answer 6

• located in gaiter area
• wound with red granulation tissue and/or cellular debris or crust
• irregular wound margins
• periwound skin color changes

Question 7

venous disease Wound appearance key findings

Answer 7

• granulation tissue
• Fibrin
• Slough
• Crusted areas
• non granular tissue
• irregular wound margins
• superficial wound
• minimal to moderate pain
• moderate to heavy exudate

Question 8

Treating venous disease by..

Answer 8

• 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

Question 9

arterial leg ulcers Predisposing factors

Answer 9

• PVD
  -smoking
  Diabetes
  -advanced age
  -male gender
  -hypertension

Question 10

Arterial ulcers leg appearance

Answer 10

• 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

Question 11

arterial ulcers anatomic location

Answer 11

• between toes
• tips of toes
• pressure points
• sites of trauma or footwear rubbing
• typically distal to ankle

Question 12

Arterial ulcers - common wound characteristics

Answer 12

• well-defined wound margins: punched out?
• pale or necrotic wound bed
• gangrene may be present
• minimal exudate
• painful
• infection common
• blanched or pupuric pwriwound

Question 13

types of traumatic wounds

Answer 13

• contusion
• abrasion
• laceration
• bite
• puncture
• impalement
• avulsion/degloving
• crash injury
• burn
• post-surgical

Question 14

how to treat a surgical site infection

Answer 14

• 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

Question 15

how to treat a pressure injury

Answer 15

• 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

Question 16

How to treat general infection

Answer 16

-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

Question 17

VLU leg appearance

Answer 17

Firm edema
Dilated superficial veins
Dry, thin scaly skin
Evidence of healed ulcers
Leg hyperpigmentation

Question 18

VLU periwound appearance

Answer 18

Leg edema
Dermatitis
Mace ration
Hyperkeratotic tissue
Atrophied Blanche
Lipodermatoschelrosis