Wounds and Edema Management - Part 2

These flashcards cover essential concepts and terminology related to wounds and edema management, focusing on chronic venous insufficiency, lymphedema, arterial insufficiency, diabetic neuropathy, and wound care practices.

Chronic Venous Insufficiency (CVI)

A condition characterized by impaired drainage of the venous system leading to venous hypertension.

• commonly associated with conditions such as congestive heart failure, obesity, advanced age, trauma etc.

Symptoms of CVI

Common symptoms include varicosities, hemosiderin staining, and edema.

Lymphedema

An abnormal accumulation of lymph fluid due to a disruption in the lymphatic system.

• can occur after cancer treatment or surgeries that involve lymph node removal, leading to swelling in the affected limb.

• tends to be unilateral

• usually not pinning

• tenting = fluids “overflows” to form tent

Arterial Insufficiency

Insufficient blood supply leading to reduced oxygen delivery to cells, tissues, and organs caused by conditions such as atherosclerosis or less commonly trauma .

Intermittent Claudication

Pain that occurs with physical activity but is relieved by rest, often associated with arterial insufficiency.

Edema Classifications (C0-C6)

A grading system used to classify the severity of edema from no signs (C0) to active venous disease (C6).

• C0 - no visible or palpable signs of edema

• C1 - telangiectasia or reticular veins (tiny superficial veins that are blue/red, but not palpable)

• C2 - varicose veins (enlarged veins that can be felt)

• C3 - localized edema without skin changes

• C4 - localized edema with skin changes (such as pigmentation or eczema)

• C5 - localized edema with skin changes and healed ulcers, indicating prior ulceration

• C6 - active venous disease

Diabetic Neuropathy

Nerve damage resulting from prolonged exposure to high blood sugars, affecting sensory, autonomic, and motor functions.

Debridement

The removal of dead tissue and foreign material from the wound bed to promote healing.

Moisture Balance in Wound Care

Maintaining an appropriate level of moisture in a wound to facilitate healing and minimize pain.

Treatment options for CVI

Include compression therapy, elevation, and local wound care.

Ankle-Brachial Index (ABI)

A non-invasive test used to check for peripheral artery disease by comparing the blood pressure at the ankle and the arm. A value less than 0.9 suggests arterial disease.

Venous Leg Ulcers (VLU)

Shallow, irregular-shaped wounds often located near the medial malleolus, typically highly exudative and secondary to CVI.

• tend to recur

Characteristics of Arterial Ulcers

tend to occur over bony prominences, but not weight bearing prominences such as tips of toes or malleoli

• have punched out appearance, pale in colour, produce a little discharge and tend to be painful

Charcot Foot

A complication of diabetic neuropathy characterized by localized inflammation, involving progressive weakening of bones and joint collapse, leading to significant foot bone destruction/deformity.

Autolytic Debridement

A process that uses the body's own enzymes and moisture, often under occlusive dressings, to liquefy and remove non-viable tissue.

Lipodermatosclerosis

A condition resulting from CVI where the skin and subcutaneous fat of the lower leg scar and become hard, inflamed, scaly

• from chronic pressure

CVI etiology: vascular incompetence (venous reflux)

during relaxation, valves closeup to prevent back flow - with this valves are fault and blood pools

CVI etiology: obstructed veins

blood clot obstructs veins - can result from surgical complications, pregnancy, obesity …

CVI etiology: failure of calf muscle pump

Inadequate contraction of the calf muscles during activities can lead to poor venous return, contributing to chronic venous insufficiency.

hemosiderin staining

is a discoloration of the skin resulting from the deposition of hemosiderin, often due to chronic bleeding or venous stasis.

Edema

is an abnormal accumulation of fluid in the interstitial spaces of tissues, leading to swelling. It can result from conditions like heart failure, kidney disease, or venous insufficiency.

gaiter area ulcers (calf area)

are ulcers located around the ankle and lower leg, commonly associated with chronic venous insufficiency. They often appear as shallow, irregularly shaped wounds that can be difficult to heal.

Pinning edema

indent remains in skin after being pressed for a prolonged period, indicating fluid accumulation.

Athersclerotic disease

disruption of oxygenated blood to area

Characteristics for arterial insufficiency

• lower extremities are cool to touch

• pale, shiny, and thin skin

• hair loss on the legs

• dependent rubor

• delayed wound healing, and pain with activity.

• decrease in capillary refill (greater than 2 seconds)

• improves with elevation

neuropathy - sensory

• loss of protective sensation (can feel hot/cold, but can’t detect injury)

• sensory ataxia (misjudge coordination / foot placement

• functional impact

  • increase risk of injury

  • inability to detect and seek treatment for injury (because you only know its there from visuals)

  • failure to comply with treatment due to lack of immediate feedback

neuropathy - autonomic

• sympathetic denervation

• clinical signs

  • anhidrosis (decrease in skin oil)

  • callus

  • cracks/fissures

  • fungal nail

  • dry/yellow cracked nails

  • waxy skin

• functional impact

  • dry, cracked skin more prone to injury

  • callus creates pressure point which can cause injury

neuropathy - motor

• atrophy of intrinsic muscles of foot leading to anatomical changes

• clinical signs

  • claw toes

  • hammer toes

  • muscle weakness

  • pes equinos/pes planus/hallux limitus

  • bunions

• functional impact

  • decreased mobility

  • altered gait pattern

  • altered weight bearing - increased pressure to vulnerable areas

Diabetic foot ulcers

• muscle changes = abnormal weight bearing

• autonomic changes = increased callous formation, dry skin

• sensory changes - impaired response to tissue damage

diabetic (neuropathic) ulcers

• tend to occur on pressure points on plantar surface of foot

• wound base may be covered with char or slough or be pink and bleed easily

• can be deep and even probe to bone

• tend to be pain free

• tend to produce minimal exudate

comprehensive lower extremity assessment: medical history

• cellulitis

• congestive heart failure

  • left sided - back pressure on lung leading to back up of fluid in lungs or pulmonary edema

  • right sided - back pressure on venous system leading to peripheral and / or abdominal edema

• smoking - has big impact on circulation

  • nicotine & CO increase oxidative stress

  • atherosclerosis and cardiovascular disease risk

  • deregulates cardiac function (increases at rest, blunts during exercise)

  • reduced arterial O2

  • increase blood cholesterol leading to plaque build up

  • slows healing

• liver disease - portal hypertension can lead to fluid accumulating in legs or abdomen

comprehensive lower extremity assessment: social history

• mobility - use of gait aids, falls history, social supports, level of independence

• stockings/shoes - pressure gradient stocking history, use of orthotics

comprehensive lower extremity assessment: vascular exam - circulation

• palpation - dorsal pedis, posterior tibial, temperature of foot

• observation - cyanosis, ischemic rubor, capillary refill, skin colour

• ankle brachial index

  • uses ultrasound to compare lower extremity to upper extremity

  • BP in ankle should be equal or slightly higher than arm (calculate day dividing highest ankle pressure by highest brachial pressure)

  • performed after 20-30 minutes of lying down

  • can be falsely elevated in presence of calcified vessels (common in diabetes)

• toe brachial index

  • taken by dividing systolic pressure of great toe by brachial artery pressure

• PPG - photoplethysmography

  • detects changes in blood filling the digit

comprehensive lower extremity assessment: vascular exam - edema

pitting = indent sticks

non-pitting

vascular exam: edema grades

0+ no pitting edema

1+ mild pitting, 2mm depression that disappears rapidly

2+ moderate pitting, 4mm depression that disappears in 10-15 sec

3+ moderately severe pitting, 6mm depression that may last more than 1 minute

4+ severe pitting, 8mm depression that can last more than 2 minutes

comprehensive lower extremity assessment: vascular exam - venous abnormalities

• varicose veins: dilated, twisted veins that are often visible beneath the skin's surface, caused by increased venous pressure.

• spider/reticular veins: small, unsightly veins that appear close to the skin surface, often resembling a spider's web.

comprehensive lower extremity assessment: vascular exam - nail condition

• dry

• cracked

• colour

• length

• thickness

comprehensive lower extremity assessment: vascular exam - skin condition

• presence/absence of hair

• dry/moist

• colour

• shine

• texture

comprehensive lower extremity assessment: foot architecture

• hammer/claw toes

• prominent bones/MTH drop

• drop foot

• Charcot

• hallux limitus

• equinos/pes planus

• amputations

comprehensive lower extremity assessment: sensation

• use of femmes-weinstein monofilament to assess sensory perception in the feet and toes, checking for areas of diminished or absent sensation.

comprehensive lower extremity assessment: wound assessment

• location

• size - length, width, depth

• base - red, yellow, black

• surrounding skin

• edges and undermining

• odour

• drainage - exudate colour and consistency

OT interventions: chronic venous insufficiency

• conservative management

  • elevation

  • salt reduction

  • exercise

• compression therapy

  • temporary tubular compression

  • wraps

  • pressure gradient stockings (long term maintenance)

• local wound care including dressings and debridement

OT interventions: arterial insufficiency

• patient education

  • non-pharmaceutical pain management/positioning

• protection

  • dressings; footwear

OT interventions: neuropathy

• patient education

  • foot inspection

  • callous/nail/skin care

  • footwear

• provision of offloading devices

  • footwear/insoles

  • leg troughs

• provision of gait aids for offloading

• local wound care including dressings and debridement.

Local wound care acronym

DIME

• debridement

• infection and inflammation

• moisture balance

• edge of the wound

debridement

removal of foreign material and devitalized/contaminated tissue from wound bed until surrounding healthy tissue is exposed

• mechanical

• autolytic

• enzymatic

• biological

• sharp/surgical

debridement considerations

• prior to sharps debridement: basic skin/wound assessment; physician order; vascular assessment required to ensure potential wound healing; informed consent given

• contraindications: pain, poor vascularity, non healing wound, anticoagulation

mechanical debridement

use of outside force to remove dead tissue

autolytic debridement

use of moisture retentive dressings to encourage “liquefaction” of necrotic tissue

enzymatic debridement

exogenous enzymes applied to wound bed

biological debridement

use of maggots or leaches to digest necrotic tissue

sharp/surgical debridement

use of scalpel, scissors, tweezers or other sharp instruments to remove necrotic tissue

infection and inflammation

wounds should be assessed regularly for clinical signs and symptoms of infection

• all chronic wounds are colonized by micro-organisms but not all of them are harmful to wound

  • wound healing can be compromised if bacterial burdens are too great

potential indications of infection - NERDS & STONES

• non healing wounds

• exudative wounds

• red and bleeding wounds

• debris

• smell from wound

• size is bigger

• temperature increases

• probes to exposed bone

• new area of breakdown

• erythema/redness

• smell

moisture balance

“not too wet, not too dry: just like the level of moisture in your eye”

• moisture facilities wound healing

• increases rate of re-epithelization

• decrease in pain

• wound exudate delivers growth factors and nutrients

edge of the wound

evaluation and promotion of healthy epithelial edge

• is wound closing

• look for undermining, rolling edges

• what does surrounding skin look like

principles of wound care - healable wounds

• wound cleansing

• debridement

• moisture balance

• elimination of dead space

• provision of thermal insulation

• protection of wound and peri wound area

• inflammation and infection control

principles of wound care - non-healable wounds

• should be kept dry

• goals: comfort, maximizing function, reducing infection risk, prevention of further deterioration

• eschar is not removed

• wound may still heal under eschar

dressings

all have specific purpose: selected with wound assessment in mind

• add moisture

• retain moisture

• remove moisture

• add antimicrobials

• insulate

• eliminate dead space