a palliative approach to peripheral vascular disease/ gangrene connie sarvis rn, bn, mn,...
TRANSCRIPT
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A Palliative Approach to Peripheral Vascular Disease/ Gangrene
Connie SarvisRN, BN, MN, CON(c),IIWCC, CWS, FCCWS
Skin and Wound ConsultantSeven Oaks General Hospital
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Peripheral Vascular Disease
PAD OR PVD ?
12-15% OF ADULTS OVER 50
(THOSE SEEKING HELP)
PAIN OR INFECTION
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Prognosis
Symptoms remain stable in about 15/20 cases
Symptoms gradually become worse in 4/20 cases
Symptoms deteriorate severely in 1/20 cases
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RISK FACTORS
Advanced Age
Smoking
Diabetes
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Other Risk Factors Obesity
Sedentary Lifestyle
Stress
Heredity
Diet
Hypertension
Hyperlipidemia
• Elevated Blood Glucose
• Cardiovascular Disease
• Cerebrovascular Disease
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CAUSES OF PVD ATHEROSCLEROSIS INJURY INFECTION
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Signs and Symptoms
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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
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Other Pain If the femoral artery is blocked ,
then pain may extend up to the thighs and buttocks when walking
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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
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ABI’s
Doppler Assessme
nt
Measures
Vascular
Perfusion
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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
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How Do You Get the Number?
Formula (ABI)
Ankle Pressure
Brachial Pressure
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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
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Why Might Toe Pressure Numbers Differ?
Microcirculation vs Macrocirculation!
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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
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BUT….
How do we differentiate between ulcers that will heal
and those that need palliative care?
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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
Pale Pigmented
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What happens to an Arterial Wound?
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Remember!
SKIN IS THE TISSUE MOST RESISTANT TO ISCHEMIA AND SO IS USUALLY THE LAST TO
UNDERGO NECROSIS!!
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Often times the vascular status is discovered only when trauma occurs and there is not enough vascular perfusion to heal the
wound
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TREATMENT Depends upon patient’s condition
Only curative treatment is surgical intervention
Otherwise medical management is preferable
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Surgical Procedures Femoral Popliteal Bypass Angioplasty Plaque excision Stent
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OF COURSE SURGERY MAY HAVE ITS’ DRAWBACKS TOO!!
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Remember!IF SURGERY IS UNDERTAKEN –
THERE IS A FRESH BLOOD SUPPLY FOR ANY RESIDENT BACTERIA! = INFECTION!!
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Conservative Treatment
Cadexomer Iodine and Povidine
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Viagara?? Low Dose ASA to prevent
clots Statin Medication to lower
plaque buildup
Other Measures?
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GANGRENE decay of body tissues
caused by infection/ischemia/thrombus
can be black, brown or green
Malodorous!!
Generally associated with Diabetics and Smoking
Frostbite
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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
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DRY GANGRENE
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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.
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BUERGER’S DISEASE
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LOCAL WOUND CAREKeep wound DryDo NOT cleanse with saline first (gangrene)Do not use Eusol, Saline soaks or Hydrogen Peroxide, Gel’s.
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Other Comfort Tips Avoid tight
footwear/binding clothing/dressings
Hang foot down (at night) Encourage smoking
cessation Avoid trauma
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Pain
•Fentanyl pre-dressing change
•Systemic pain relievers
•Gapapentin
•Morphine/gel?
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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)
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GOAL
Prevent Pain!
Prevent Infection!
Prevent Amputation!
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Questions?