Wound Care Flashcards
Venous ulcer
- Around ankle and lower third of leg
- Nil to mild
- Pitting oedema usually present
- Ragged edge, often superficial, ooze +++
- Varicosities, leg warm, varicose dermatitis, haemosiderin deposits
- Limb oedema, past DVT, failed graft
- ABI >0.9
Arterial ulcer
- Distal to ankle
- Over pressure points on toes
- Usually more moderate to severe
- Usually absent
- Punched out, often deep, involving deep fascia, dry
- Cold extremities, ischaemic changes, diminished or absent peripheral pulses, thin/shiny skin
- PVD (claudication, rest pain), diabetes, smoker
- ABI <0.5-0.7
Treatment - venous ulcer
Compression therapy
Leg elevation
Surgical management
Treatment - Arterial ulcer
Revascularisation
Anti-platelet medications
Management of risk factors
Treatment - neuropathic diabetic
Off-loading of pressure
Topical growth factors
Treatment - pressure ulcer
Off-loading of pressure
Reduction of excessive moisture, shear and friction
Adequate nutrition
Framework for ulcer and wound management
History
- Medications, smoking, alcohol
- Precipitating factors
- Impact on patient
Examination
Investigations
- Pathology
- Wound swab
- Biopsy
- Imaging
- Vascular assessment
Diagnosis
Implementation of care
- Correct pathophysiology
- Manage symptoms
- Address lifestyle and behavioural issues
- Manage factors that impair wound healing
** Refer to page 267 of GP Study Notes
64M, Aboriginal, sustained a small ulcer from bushwalking 2/52 ago. Has been growing and worsening with no sign of
healing. Denies pain or discomfort. PHx T2DM, HTN, OA. Med metformin, gliclazide, ramipril, simvastatin and
meloxicam.
- What are the FOUR questions in his history that will assist you with further treatment of the wound?
- What are the SIX key steps in physical examination of his foot?
- Patient fails to respond to initial management and now the wound is slightly larger. What is your next key investigation
to identify the cause of this ulcer? - You have concerns that Mike is not compliant with his treatment plan and medications. What are your FIVE possible
options to improve his involvement in his care?
What are the FOUR questions in his history that will assist you with further treatment of the wound?
● Smoking status
● Tetanus immunisation status
● Reduced sensation in feet
● Claudication
● Compliance with medications
● Systemic symptoms
What are the SIX key steps in physical examination of his foot?
● Assess for signs of infection
● Inspect for cutaneous signs of peripheral vascular/arterial disease
● Assess foot sensation
● Check peripheral pulses
● Assess footwear
● Assess gait
● Assess for joint deformity/Charcot joint
Patient fails to respond to initial management and now the wound is slightly larger. What is your next key investigation
to identify the cause of this ulcer?
Arterial doppler ultrasound of both legs
You have concerns that Mike is not compliant with his treatment plan and medications. What are your FIVE possible
options to improve his involvement in his care?
● Involve the aboriginal health care worker
● Arrange a Webster pack
● Educate about the possible outcomes of poor compliance
● Organise home medication review
● Assure he has access to subsidised medications through CTG scheme
● Involve diabetic nurse educator
Nursing home, painful ulcers. Hx of 40 pack year, recent pain in feet overnight. PHx of cardiac stenting 15 years ago.
O/E: punched out lesions over medial malleolus.
What is the diagnosis?
Arterial ulcer
Ankle-brachial index
** An ABI <0.8 warrants caution in applying any compression; <0.4 demands urgent referral
Normal - 0.91 - 1.3
Normal - > 0.9
Ischaemic - <0.5
Claudicant - 0.5-0.9
Venous ulcer (features, signs of insufficiency, management)
Clinical features: ● Shallow and non-tender ● Medial more common than lateral ● Slow to heal without compression Signs of chronic venous insufficiency: ● Oedema ● Visible varicose veins ● Lipodermatosclerosis ● Haemosiderin staining of the skin Optimal management: ● Prevention and control of infection (antibiotics only if there is cellulitis) ● Firm elastic compression bandage (use minimal stretch bandage from base of toes to just below the knee) ● Bed rest with elevation ● Early ambulation and exercise ● Appropriate lifestyle modification (weight reduction, smoking cessation) ● Be aware of drugs that can adversely affect healing (smoking, corticosteroids, cytotoxic agents, NSAIDs, antibiotics, beta blockers)
20M, MVA, recovery complicated by DVT. Presenting with a non-healing leg ulcer. Experiences a dull ache but not too painful.
What is the likely diagnosis?
Venous ulcer
Pressure wound - stages
Stage I —intact skin with nonblanchable erythema. In
patients with dark skin the pressure injury may be a different colour from the surrounding skin.
Stage II —partial thickness loss of dermis. A shallow wound with a red/pink wound bed but no slough or bruising. Can also present as an intact or ruptured serum-filled blister.
Stage III —full thickness tissue loss. Subcutaneous fat may be visible, but bone, muscle or tendon is not visible or palpable. Slough (if present) does not obscure the depth of tissue loss.
Undermining or tunnelling can be present.
Stage IV —full thickness tissue loss with exposed or palpable bone, muscle or tendon. May have slough or eschar on areas of the wound bed. Undermining or tunnelling is often present.
Unstageable (depth unknown) —full thickness tissue loss where the wound bed is covered by nonviable tissue (slough, necrosis, eschar) that obscures the depth of the wound. Until
enough nonviable tissue is removed, the stage of the pressure injury cannot be determined
Suspected deep tissue injury (depth unknown) —an area of intact skin, purple or maroon in colour, or a blood-filled blister. Indicates damage to underlying soft tissue from pressure or
shear. Deep tissue injury can be difficult to detect in patients with dark skin tones.
Pressure wounds - prevention
● Regular repositioning
● Using slide sheets and materials to decrease friction
● Regular skin inspection
● Implementing a continence management plan
● Using barrier creams and ointments
● Using prophylactic dressings
Diabetic wounds (cause, management)
Cause: neuropathic (pressure damage) or ischaemic (loss of peripheral arterial circulation)
Management: monitoring and dressing. Do not start antibiotics unless it is infected.
