Past Topics
Growth Factors: Role and Function in Chronic Wound Care
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Debridement
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Wound Healing and Cellular Communication
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Proteases and the Chronic Wound
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Bacterial Loads - Contamination, Colonization & Infection
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Friend or Foe? The Role of Inflammation in Wound Healing
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This Month

Perfusion - the Lifeline for Wound Healing

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Challenges with OASIS and Wound Assessment
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Assessment and Documentation Issues in Wound Care
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The Environment of the Patient and The Healing Process
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Examining the Environments of Wound Healing


Perfusion- the Lifeline for Wound Healing



Without adequate perfusion, the wound healing will be difficult. Perfusion is most often compromised in the lower extremities, and may include peripheral arterial disease (PAD), microperfusion compromise or both. With inadequate arterial flow to the wounded area, attention to improve flow and keep the wound clean and dry to avoid infection are primary goals of management and treatment.

Assessing Lower Extremity Arterial Flow

On a visual examination, the skin of the patient with compromised arterial flow will usually be pale, dry, cool, shiny and hairless. Diminished or absent dorsalis pedis and posterior tibial pulses may be noted. When the limb is elevated to 45-degree angle pallor is noted, while positioning the limb in a dependent position results in rubor (discoloration). The patient may report leg pain or heaviness that occurs with walking (intermittent claudication). The presence of nocturnal or resting leg pain most notably when the patient lies flat is also indicative of arterial disease.

The Ankle brachial index (ABI) is utilized to assess patients for the extent of their disease. This is a measurement of the brachial and ankle systolic pressures. A numerical index is formed by dividing the ankle doppler systolic pressure by the brachial doppler systolic. An ABI of less than 0.8 may indicate peripheral arterial disease and an ABI of 0.5 or less confirms serious arterial disease. It is important to note that if an ABI is below .08, applying compression systems or garments may be contraindicated.

For diabetics the ABI is often falsely elevated due to calcification and a toe pressure measurement utilizing photo plethysmography may be indicated. A systolic toe pressure of below 30 is associated with PAD. Segmental dopplers offer useful information, but are also affected by calcification. A transcutaneous oxygen measurement below 20mmHg in the area of the wound is associated with failure to heal as marked ischemia is most likely present.

A vascular surgeon should evaluate a patient where arterial disease and a wound co-exist. Appropriate evaluation and treatment may be indicated. If revascularization is not indicated at this time, appropriate measures of assessment, pain control, and measures to improve the patient’s quality of life should be implemented.

Nursing Implications

Utilizing assessment data, it is possible to make informed decisions regarding the care plan and any necessity for referrals to vascular and wound healing specialists. This is one area where a nursing action performed without adequate knowledge could be truly limb- or life- threatening. If high compression devices are utilized on a limb with less than 0.6 ABI, for instance, consequences could be dire. If someone with gangrene or critical limb ischemia is not urgently referred, an amputation may be needed that may have been preventable with bypass surgery. It is recommended to all agencies that the Wound Ostomy Continence Nurses Society “Guideline for Management of Wounds in Patients with Lower-Extremity Arterial Disease” be incorporated into policy, in order to give nurses clear parameters to work with. This may be ordered by calling 1 (888) 224-9626.

If there is mild to moderate decrease in flow, nursing interventions can maximize the perfusion to the wound. Optimal nutrition may include such supplements as L-arginine, a precursor to endothelial-derived nitric oxide, a potent vasodilator.

Pain control is an essential part of the nursing care rendered to a patient with PAD. Wounds and ensuing wound care will be very painful for the patient and measures should be taken to ensure patient comfort, as best as possible. Medication, for example, may be administered 30 minutes prior to performing a wound assessment and dressing treatment. Pain causes release of potent vasoconstrictors and worsens flow to the skin. By choosing a dressing that provides warmth, such as a foam, and reducing the frequency of dressing changes, it is possible to prevent hypothermia at the wound site, which slows healing.

Cilostazol may be prescribed as it may improve walking distances for patients with intermittent claudication. Other medications that may be prescribed include antithrombotic agents to reduce platelet aggregation, and analgesics to reduce pain and improve the quality of life for the patient.

When an oxygen challenge (breathing 100% pure oxygen) raises transcutaneous oxygen pressures near the wound to near 100 mmHg, hyperbaric oxygen treatments may be useful. Vacuum Assisted Closure (VAC) therapy may also be considered. This device causes negative pressure in the wound bed and may draw blood cells to the wound.

Link those who use tobacco to a cessation class. Provide information about safety issues, such as avoiding trauma if they have known PAD, since healing may not be possible after injury. Just as for the diabetic with neuropathy, teach them to avoid self-treating corns, calluses and dystrophic toenails. Heating pads, hot soaks and friction may cause damage more quickly than with well-perfused skin. It is important for the patient not to go barefoot, cross their legs or wear constrictive clothing or stockings.

Inadequate arterial or microperfusion may result in failure to heal. A thorough assessment and comprehensive care plan by the nurse may make the difference between saving or losing a limb. Implementing research-based interventions may improve a person’s chance of healing even in the presence of impaired perfusion.

This article was written by Joan Jurkin, RN MSN CWOCN

The Wound & Skin Care Center is possible thanks to the generous support of Johnson and Johnson Wound Management Worldwide.


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