Posts Tagged ‘wounds’

Lower Extremity Ulcers: Go With the Flow

Wednesday, October 21st, 2015

Lower Extremity Ulcer - Is this Pressure?

Imagine, if you will, the following scene: a wound care clinician is asked to weigh in on a lower extremity ulcer consultation, and upon arrival is told that it’s a pressure ulcer. So she seeks more information about blood flow:

Clinician #1: Tell me about the blood flow to the lower extremity.

Clinician #2: It seems okay because pulses are palpable on the foot.

Clinician #1: Are there recent Ankle Brachial Index (ABI) assessments in order to obtain a much more reliable assessment of blood flow?

Clinician #2: Um … no.

Here’s the truth

Unfortunately, this kind of conversation happens all the time, so let’s set the record straight: palpation of pulses is not a reliable assessment of blood flow to the foot. They can be misleading and leave you hanging – without the information you need to properly and safely manage the wound.  An ABI will reveal what you need to know about the blood flow to the lower extremity, and give you vital clues to the underlying disease process causing the ulcer. Only when this information has been gathered can you properly develop a plan of care that will help, and not hurt, the patient.

The 2014 International Pressure Ulcer Guidelines mentions performing a vascular assessment on every lower extremity ulcer.  That means, at a minimum, we need to check pulses and toe measurements, and perform an ABI. This will assist in identifying the true cause of the wound, whether it be pressure, venous, arterial, or mixed venous/arterial.

What’s this about an ABI?

An ABI is considered the gold standard of tests that can be easily performed at bedside – all you need is a blood pressure cuff and a hand-held Doppler. It is also the most useful test to assess lower extremity arterial perfusion, and compares the systolic blood pressure of the ankle to that of the arm (brachial). When should you perform ABI?

  • When pulses aren’t clearly palpable or are weak
  • On all patients with lower extremity ulcers
  • When the ulcer is not healing
  • Always before starting compression therapy

Compression therapy is the standard of care for the treatment of venous stasis ulcers.  ABI results will help identify significant arterial disease and determine the amount of compression (if any) that can be applied safely. You never want to compress a lower extremity that has significant arterial flow compromise, for fear of cutting off all blood flow and causing harm to your patient.

Blood flow assessment is a must

Earlier, we used the example of a patient who has a possible “pressure ulcer.” When we are not sure of the type of wound we are treating, we need to ask some serious questions:

  • Could there be arterial blood flow compromise that will make healing problematic or even unrealistic?
  • Is there venous disease complicating the clinical picture that could benefit from appropriate levels of compression?
  • Or is this strictly a pressure ulcer where the treatment plan will require off-loading interventions first and foremost?

The bottom line

When assessing a lower extremity ulcer, it is vital to determine the assessment of blood flow.  Without the information obtained from an ABI, your care plan can be inappropriate, your goal setting can be unrealistic, and your patient could be harmed.

What do you think?

We want to know about your experiences with this topic. When do you typically obtain an ABI in practice? In long-term care settings, how often do you obtain ABI measurements? If you’re not obtaining ABIs, what are you using? Please share your experiences below.

 

I Stage, II Stage, III Stage , IV…. Making Pressure Ulcer Staging a Little Easier

Friday, June 6th, 2014

There has to be a way to get everyone on the same page.  You would think that over the last 6-7 years since the National Pressure Ulcer Advisory Panel (NPUAP) had released the updated staging guidelines we would have gotten better at this.  Not necessarily the case. blog
Lets try to make pressure ulcer staging as simple as possible.  We will take out the all the extra verbiage; you can read that later on.  We will break staging down to some user-friendly terms.  Now remember, we are talking about pressure ulcers, so all of these skin injuries pressure had to be present, sure – friction and shearing can contribute, but pressure must be present. They are usually located over a bony prominence but we know they don’t have to be; they will be located anywhere the skin has had unrelieved pressure.  If they are related to a device they will take on the shape of the device that has caused the injury to the skin.

Stage I.  This is an area of non-blanchable area of erythema (redness) of intact skin.  That’s what it is. Period.  Intact red skin.  Non-blanchable is when we push on the skin it stays red; it doesn’t turn white or blanch.  So, intact, non-blanchable area of erythema, a stage I pressure ulcer.

Stage II.  This is a superficial or shallow open area.  We say it is pink, partial and painful.  The damage is into the dermis here so the tissue we see will always be smooth pink/dark pink, not granulation tissue.  Never will we see any necrotic tissue here; your wound won’t have yellow, black brown colors in it.  It also may be an intact serum (clear fluid) blister. So there you have it; a stage II is a superficial open area with NO necrotic tissue or it can be an intact or ruptured serum filled blister.

Stage III. This stage is easy.  Damage is now into the subcutaneous tissue, but not through the subcutaneous layer.  So this is the start of full thickness tissue injury.  Now here is where we can start see slough, eschar, and granulation tissue in the wound bed.  Tunneling and undermining may also be present in the full thickness pressure ulcer.  In the stage III pressure ulcer we may see healthy subcutaneous tissue, necrotic tissue or granulation tissue.  What we WON’T see in the stage III is muscle, tendon, ligament or bone, ever.

Stage IV.  This is full thickness tissue damage where we now see muscle, tendon, ligament, or bone in the wound bed.  The definition also states “palpable” so if we can feel tendon or bone here, we would stage it as a stage IV.   Cartilage in the wound bed would be included in the stage IV pressure ulcer.  We can have granulation tissue or necrotic tissue present in the wound bed as well.  Undermining and tunneling may be present in a stage IV, but what I MUST see or feel are those underlying structures – muscle, tendon, ligament and / or bone present to say it’s a “stage IV”.

Unstageable pressure ulcer is a stage we use to classify the pressure ulcer that has enough necrotic tissue present to make the clinician uncertain whether the pressure ulcer is a stage III or stage IV.  So until enough necrotic tissue can be removed we place it in the “unstageable” category.  Once that necrotic tissue is removed and we can evaluate the actual level of tissue destruction in the wound bed, that is when we will stage it and it will either be a stage III or a stage IV.

Suspected Deep Tissue Injury (SDTI).  To be a SDTI the skin must be intact, it must be purple or maroon in color or an INTACT BLOOD filled blister.  Once this intact SDTI pressure ulcer opens up, we would then reclassify it based on our assessment or tissue type in the wound bed.

We need to use the staging definitions set out by the National Pressure Ulcer Advisory Panel (NPUAP) correctly, and all clinicians who assess skin need to have a good understanding of these definitions in order to properly stage pressure ulcers.  What was discussed about above is just a summary, there is more reading we need to do, but this will give us a good place to start with the staging.  We need to start staging consistently across the healthcare continuum; it really just comes down to good wound assessment skills, knowing the tissue type that lies before your eyes and identifying the level of tissue destruction and applying them to the NPUAP staging definitions. Lets get this right!

Thank You Veterans!

Saturday, May 23rd, 2009

Memorial Day USA

Over the years in my nursing practice, I have had the opportunity to care for the wounds of countless numbers of veterans.  I am sad that I cannot remember all of their names.  However, there  is one common thread I do remember, if not for each one of these veterans I would not have the choice to be a nurse, the choice to practice wound care, or even the choice to write this blog.   Today, myself, Nancy and all of the staff at the Wound Care Education Institute want to say “Thank you” to each and every veteran and member of the US military forces for your courage and the sacrifices you have made for our country.  We also thank the families of the military for sharing their loved ones with us.  Our gracious thanks,….

Welcome to the Wound Care Education Institute blog!

Monday, March 9th, 2009

 

A few weeks ago while out in California for a seminar, Nancy took me out for a treat, my first visit to an IN-N-OUT Burger. Now if you have never been to an IN-N-OUT burger, the big secret is the simplicity of choices you have to make, there are only 3.  You can order a Number 1, a Number 2 or a Number 3, that’s it, no more options.  While sitting there eating my number 3, I was thinking how much easier it would be if wound care only had three choices, Treatment number 1 for necrotic wounds, treatment number 2 for infected wounds, and treatment number 3 for clean wounds.

Unfortunately choosing wound treatments is much more complicated. Each wound has its own attributes and is attached to a patient that has their own unique characteristics.  Add to that, the thousands of dressing options, tapes, cleansers, ointments, lotions, equipment, fillers, barriers, protectors, wraps, modalities . . . there is just no way these could ever be simplified down to 3 options. 

At WCEI, we realize the challenges faced by healthcare professionals in navigating through a maze of wound care products and regulations, all the while trying to make informed treatment recommendations.  We cannot narrow the options down to three choices for you, but it is our hope that this wound care blog will offer ideas and information that will keep you up to date with the latest and greatest wound management technologies and industry trends.

At WCEI, wound and skin care is our passion!  We live and breathe wound care 24/7!  If you feel like us, follow our blog and join us as we explore the WOUNDerful world of skin and wound care!

Donna Sardina

 

Nancy Morgan and Donna Sardina

Nancy Morgan and Donna Sardina