WK2-Wound Etiologies Part 1 Flashcards
What is the general pathophysiological mechanism of arterial insufficiency ?
AI wound is one that results from a lack of blood flow which deprives a certain area of oxygen
Can be due to: Trauma, acute embolisms, diabetes mellitus, rheumatoid arthritis, thromboangiitis ( Buerger’s disease), Arteriosclerosis and atherosclerosis.
What is the organization scheme of arteries from large arteries to vessels that actually permeate tissues ? and what are the 3 layers to the smallest organization of arteries ?
arteries > arterioles > capillaries
capillaries from outer most to innermost: tunica adventitia, tunica media, tunica intima
What is intermittent claudication ?
Intermittent claudication is pain due to poor tissue perfusion during activity, it typically stops within 1-5 minutes of ceasing activity, ~50% stenosis will result in claudication
the pain is usually distal to site of occlusion
What is ischemic rest pain ?
a step above intermittent claudication in where there is a burning pain at rest exacerbated with elevation.
What are the general characteristics of a wound caused by AI ?
severe pain unless masked by some comorbidity
found on the LE, distal toes, dorsal foot, areas of trauma
pale granulation tissue, shiny, loss of hair in area, anhydrous skin, yellow nails, no drainage, decreased pulse, cool temperature
What is the first line of testing for AI and VI ?
ABI, ankle brachial index
mmHg LE/mmHg UE
At what ABI should debridement begin to be clinically judged ?
.7
What is the general pathophysiological mechanism of venous insufficiency ?
condition where the veins, particularly in the LE have difficulties sending blood back to the heart,
due to sustained venous hypertension that can be due to incompetent veins, bicuspid valves failing to close, valve damage as in varicose veins
What are the two theories that describe how venous hypertension causes tissue damage
WBC trapping theory: WBCs gather in area and release things that damage walls due to high venous pressure
Fibrin cuff theory: distension makes veins leaky, leading to edema in intersitium
What are the general characteristics of VI ulcers ?
mild to moderate pain unless masked
found on medial malleolus, medial leg, or areas of trauma
irregular shape, glossy, coating, red ruddy wound bed, copious drainage
edema, hemosiderin staining
normal pulse, or decreased
normal to mild warmth
What is the general treatment for VI ulcers ?
Compression unless ABI is under .5
What is the average healing time of VI ulcers ?
8 weeks
How many weeks in should a referral for a VI ulcer be referred out ?
4 weeks
For VI ulcers, what ABI is a contraindication to compression ?
<0.5
How does a pressure injury occur ?
a pressure injury occurs due to excess pressure on the skin causing a breakage, typically over a bony prominence
can be common in those with spinal cord injuries, hospitalized patients, individuals in long term care facilities
What are the general characteristics of a pressure injury ?
Pain and tenderness if nervous system is intact, no pain if medical conditions mask it
typically over bony prominences
presentation described and staged by NPUAP
dermatitis and erythema common on surrounding tissue, localized warmth
normal pulse
temp may be increased
Within how many weeks should a pressure injury that does not decrease in size be reassessed ?
two weeks
What is the average healing time for pressure injuries that are stage 1-4 ?
stage 1: 1-3 weeks
stage 2: 23 days
stages 3-4: 8-13 weeks.
Your patient presents with an ulcer near his lateral malleolus that is covered with adherent yellow slough. Pedal pulses are absent on the affected side. You are unable to perform an ABI because the patient complains of severe pain when the cuff is inflated more than 30 mmHg.
a. Why is performing the ABI painful?
b. What other tests and measures might you perform to assist in your examination? Why?
A. Performing the ABI is painful because inflation
of the cuff further occludes the patient’s circulation,
causing ischemic pain.
b. A Doppler ultrasound should be performed
to assess distal pulses. The rubor of dependency
test and venous filling time would provide
additional information regarding the
patient’s arterial circulation without causing
undue discomfort.
Your patient presents with ulcers on the dorsal aspect of his left fourth and fifth toes. The ulcers are dry with a pale base. On examining his lower leg, you notice the skin is pale and fragile and there is a loss of hair growth.
a. Is this patient’s presentation consistent with an arterial insufficiency ulcer? Why or why not?
b. Describe at least three additional pieces of information you would like to gather to more accurately
assess the etiology of this patient’s wound.
a. The patient’s presentation is consistent with
arterial insufficiency in position, presentation,
and periwound condition.
b. The examiner should perform a pulse examination,
palpate the affected area for temperature
differences, and question the patient about
pain at rest and in varying positions. Additional
information that would help to clarify the
wound’s etiology includes the patient’s past
medical history as well as some additional tests
and measures, such as an ABI and sensation.
Your patient with arterial insufficiency complains that her feet are cold and asks if she should use a
heating pad to warm them. What is your response and why?
Direct heat to arterial insufficient limbs can cause
significant tissue damage. You should tell the
patient not to use a heating pad or soak her feet in
warm water. Alternatively, you should advise her
to wear warm socks.
Your patient presents with an arterial insufficiency ulcer on his left foot. The ulcer has a pale, granular base and measures .8x.6x.2 There is no wound drainage. The surrounding tissue is anhydrous, mildly pale, slightly cool to the touch, and edematous. Pedal pulses are decreased and his ABI is 0.6. The patient has been dressing the wound with a moisture-retentive dressing and an elastic compression bandage. Given your examination findings, do you agree with the current dressing? Why or why not?
The use of a moisture-retentive dressing is appropriate.
However, compression is contraindicated
with low ABIs, as the elastic compression wrap
will further compromise the patient’s circulation.
Based on your present knowledge of venous blood flow, describe two types of therapeutic exercises
that can enhance venous return.
Inspiratory spirometry or diaphragmatic breathing
exercises will enhance the effect of the respiratory
pump on venous return. Repeated active
ankle dorsiflexion and plantar flexion and walking
will enhance the effect of the calf muscle pump on
venous return.
Local wound care for your patient with a venous insufficiency ulcer consists of once-weekly application
of moisturizing lotion to the intact skin, an amorphous hydrogel, and gauze covered with a
compression wrap. You notice the edges of his wound are white and friable, causing a slight increase
in wound size. What is your response and why?
The periwound is too moist, causing maceration
and increasing the size of the wound. You should
discontinue the amorphous hydrogel and apply a
skin sealant to the periwound. In addition, you
should consider either using a more absorptive
dressing, such as a semipermeable foam, hydrocolloid,
or alginate, or increasing the frequency of
dressing changes to twice weekly to better control
the wound drainage.
Which bandage will provide the greatest amount of compression: an 8-cm, 10-cm, or 15-cm shortstretch
compression wrap? Why?
Based on Laplace’s law, assuming all other variables
are equal, the smaller the bandage width, the
more compression it will provide. Therefore, the
8-cm bandage will provide the greatest amount of
compression.
You have been treating a patient with a venous insufficiency ulcer with a paste bandage weekly for
2 weeks. There has been a minimal decrease in wound size as well as edema. The patient’s calf is
warmer, redder, and itchy. What is your response and why?
The patient seems to have developed a sensitization
to the paste bandage. You should initiate
another form of compression therapy that is less
likely to cause a reaction, such as a multilayer
compression bandage system or CircAid. You
should also contact the physician about the use of
a topical glucocorticoid ointment to decrease erythema
and pruritus.
Why do the guidelines state that patients should change positions every 2 hours when lying down,
but every 15 minutes when sitting up?
Patients have less contact with the support surface
when seated than when supine. Because pressure is
defined as force per unit area, contact pressures are
higher when patients are seated. The inverse relationship
between pressure and time means that
patients may develop pressure ulcers in less time if
subjected to higher pressures. Therefore, patients
must reposition more often when seated than supine
to reduce the risk of pressure ulcer formation.
What is the most common location for a pressure ulcer on a patient with a spinal cord injury? Why
might this be so?
Due to the increased time spent sitting in a wheelchair
and impaired sensation below the level of
injury, the most common location for pressure
ulcers in patients with spinal cord injuries is over
the ischium.
You are trying to decide upon the most appropriate wheelchair cushion for your patient, Ms. B, who
has multiple sclerosis. Ms. B is obese, transfers independently but with some difficulty, and is incontinent
of urine. She works 2 hours a day delivering documents, which requires her to transfer in and
out of her car often. What type of wheelchair cushion do you think is most appropriate? Support
your rationale.
Although the lighter weight of foam would make
wheelchair mobility and lifting her cushion in and
out of the car easier, Ms. B is likely to bottom out on
foam due to her increased body weight, and the
foam cushion would be soiled by incontinence. An
air-filled cushion would make transfers more difficult
for Ms. B. A gel-filled cushion would be most
likely to prevent bottoming out, withstand repeated
episodes of incontinence, and allow ease of transfers
