Transcript Silver in wound care
A Palliative Approach to Peripheral Vascular Disease/ Gangrene
Connie Sarvis RN, BN, MN, CON(c),IIWCC, CWS, FCCWS Skin and Wound Consultant Seven Oaks General Hospital
Peripheral Vascular Disease
PAD OR PVD ?
12-15% OF ADULTS OVER 50 (THOSE SEEKING HELP) PAIN OR INFECTION
Prognosis
Symptoms remain stable in about 15/20 cases Symptoms gradually become worse in 4/20 cases Symptoms deteriorate severely in 1/20 cases
RISK FACTORS
Advanced Age Smoking Diabetes
Other Risk Factors
Obesity Sedentary Lifestyle Stress Heredity Diet Hypertension Hyperlipidemia
• Elevated Blood Glucose • Cardiovascular Disease • Cerebrovascular
Disease
CAUSES OF PVD
ATHEROSCLEROSIS INJURY INFECTION
Signs and Symptoms
Symptoms
Claudication Pt feels cramping or pain in the back of the calf when walking As PVD continues to progress, claudication/cramping in the calves occurs even when at rest
Other Pain
If the femoral artery is blocked , then pain may extend up to the thighs and buttocks when walking
Other Signs and Symptoms
Loss of hair growth on entire leg or in patches Absent pedal pulses (later stage) Rubor (later) Elevation Pallor (Later) Cool Feet Delayed capillary refill
ABI’s
Doppler Assessment Measures Vascular Perfusion
How is it Measured?
Blood Pressure (Systolic only taken on both arms Blood Pressure (Systolic only taken on both ankles Doppler is used (8 mgHz) Arm – Brachial pulse is used Legs – Dorsalis Pedis is used
How Do You Get the Number?
Formula (ABI) Ankle Pressure Brachial Pressure
But what do the numbers Mean?
Result of <0.5 = Ischemia Result of 0.5 – 0.8 = Moderate Ischemia Result of 0.8 – 1.0 = Mild Ischemia/Normal Anything over 1.0 is either normal or may indicate calcified arteries in Diabetics.
In this case toe pressures are indicated
Why Might Toe Pressure Numbers Differ?
Microcirculation vs Macrocirculation!
Results
55 mmHg = >0.6 toe brachial index (Low Risk)
40 mmHg = >0.4 toe brachial index (Mod. Risk)
20 mmHg = >0.2 toe brachial index (High Risk) <20 mmHg = < 0.2 toe brachial index (Severe Risk) If trying to heal an ulcer on the heel, then poor vascularization in the toes is not as critical
BUT….
How do we differentiate between ulcers that will heal and those that need palliative care?
Characteristic Location Size Shape/Margins Arterial Usually distal (Top of foot) Small/punched out Round/Smooth Venous Above malleolus Can be quite large Irregular Depth Can become quite deep Usually shallow Wound Bed Base Pale pink – grey Variable – usually beefy red Surrounding Skin Pale Pigmented
What happens to an Arterial Wound?
Remember!
SKIN IS THE TISSUE MOST RESISTANT TO ISCHEMIA AND SO IS USUALLY THE LAST TO UNDERGO NECROSIS!!
Often times the vascular status is discovered only when trauma occurs and there is not enough vascular perfusion to heal the wound
TREATMENT
Depends upon patient’s condition Only curative treatment is surgical intervention Otherwise medical management is preferable
Surgical Procedures
Femoral Popliteal Bypass Angioplasty Plaque excision Stent
OF COURSE SURGERY MAY HAVE ITS’ DRAWBACKS TOO!!
Remember!
IF SURGERY IS UNDERTAKEN – THERE IS A FRESH BLOOD SUPPLY FOR ANY RESIDENT BACTERIA! = INFECTION!!
Conservative Treatment Cadexomer Iodine and Povidine
Other Measures?
Viagara??
Low Dose ASA to prevent clots Statin Medication to lower plaque buildup
GANGRENE
decay of body tissues caused by infection/ischemia/thrombus can be black, brown or green Malodorous!!
Generally associated with Diabetics and Smoking Frostbite
DRY GANGRENE BEGINS AT DISTAL PART OF LIMB DUE TO ISCHEMIA OFTEN IN THE TOES OF ELDERLY PEOPLE SPREADS SLOWLY APPEARS BLACK, SHRUNKEN (MUMMIFIED) PT. HAS DULL ACHE AND SENSATIONS OF COLDNESS IF CAUGHT EARLY AND REVASCULARIZED – SOMETIMES THE LIMB/DIGIT CAN BE SALVAGED
DRY GANGRENE
WET GANGRENE
Generally occurs in moist tissue and organs Tissue is infected by bacteria which have a putrid smell to them Develops quickly due to arterial and/or venous blockage Toxic products of bacteria responsible for sepsis – death.
BUERGER’S DISEASE
LOCAL WOUND CARE
Keep wound Dry Do NOT cleanse with saline first (gangrene) Do not use Eusol, Saline soaks or Hydrogen Peroxide, Gel’s.
Other Comfort Tips
Avoid tight footwear/binding clothing/dressings Hang foot down (at night) Encourage smoking cessation Avoid trauma
Pain
•Fentanyl pre-dressing change •Systemic pain relievers •Gapapentin •Morphine/gel?
Infection Keep gangrenous/arterial area as dry as possible Patients very prone to developing osteomyelitis as ulcers can be quite deep Povidine – Don’t dress until dry Tightly woven dressings better (no loose fibres)