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
• Elevated Blood Glucose
Heredity
• Cardiovascular Disease
Diet
• Cerebrovascular
Disease
Hypertension
Hyperlipidemia
CAUSES OF PVD
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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
Arterial
Venous
Location
Usually distal
(Top of foot)
Above malleolus
Size
Small/punched
out
Can be quite
large
Shape/Margins
Round/Smooth
Irregular
Depth
Can become
quite deep
Usually shallow
Wound Bed Base Pale pink – grey
Variable –
usually beefy
red
Surrounding
Skin
Pigmented
Pale
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
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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?
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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
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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)
GOAL
Prevent Pain!
Prevent Infection!
Prevent Amputation!
Questions?