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A Palliative Approach to Peripheral Vascular Disease/ Gangrene Connie Sarvis RN, BN, MN, CON(c),IIWCC, CWS, FCCWS Skin and Wound Consultant Seven Oaks.

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Presentation on theme: "A Palliative Approach to Peripheral Vascular Disease/ Gangrene Connie Sarvis RN, BN, MN, CON(c),IIWCC, CWS, FCCWS Skin and Wound Consultant Seven Oaks."— Presentation transcript:

1 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

2 Peripheral Vascular Disease PAD OR PVD ? 12-15% OF ADULTS OVER 50 (THOSE SEEKING HELP) PAIN OR INFECTION

3 Prognosis Symptoms remain stable in about 15/20 cases Symptoms gradually become worse in 4/20 cases Symptoms deteriorate severely in 1/20 cases

4 RISK FACTORS Advanced Age Smoking Diabetes

5 Other Risk Factors Obesity Sedentary Lifestyle Stress Heredity Diet Hypertension Hyperlipidemia Elevated Blood Glucose Cardiovascular Disease Cerebrovascular Disease

6 CAUSES OF PVD ATHEROSCLEROSIS INJURY INFECTION

7

8 Signs and Symptoms

9 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

10 Other Pain If the femoral artery is blocked, then pain may extend up to the thighs and buttocks when walking

11 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

12 ABIs Doppler Assessment Measures Vascular Perfusion

13 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

14 How Do You Get the Number? Formula (ABI) Ankle Pressure Brachial Pressure

15 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

16 Why Might Toe Pressure Numbers Differ? Microcirculation vs Macrocirculation!

17 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

18 BUT…. How do we differentiate between ulcers that will heal and those that need palliative care?

19 CharacteristicArterialVenous LocationUsually distal (Top of foot) Above malleolus SizeSmall/punched out Can be quite large Shape/MarginsRound/SmoothIrregular DepthCan become quite deep Usually shallow Wound Bed BasePale pink – greyVariable – usually beefy red Surrounding Skin PalePigmented

20 What happens to an Arterial Wound?

21 Remember! SKIN IS THE TISSUE MOST RESISTANT TO ISCHEMIA AND SO IS USUALLY THE LAST TO UNDERGO NECROSIS!!

22 Often times the vascular status is discovered only when trauma occurs and there is not enough vascular perfusion to heal the wound

23 TREATMENT Depends upon patients condition Only curative treatment is surgical intervention Otherwise medical management is preferable

24 Surgical Procedures Femoral Popliteal Bypass Angioplasty Plaque excision Stent

25 OF COURSE SURGERY MAY HAVE ITS DRAWBACKS TOO!!

26 Remember! IF SURGERY IS UNDERTAKEN – THERE IS A FRESH BLOOD SUPPLY FOR ANY RESIDENT BACTERIA! = INFECTION!!

27 Conservative Treatment Cadexomer Iodine and Povidine

28 Viagara?? Low Dose ASA to prevent clots Statin Medication to lower plaque buildup Other Measures?

29 GANGRENE decay of body tissues caused by infection/ischemia/thrombus can be black, brown or green Malodorous!! Generally associated with Diabetics and Smoking Frostbite

30 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

31 DRY GANGRENE

32 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.

33

34 BUERGERS DISEASE

35 LOCAL WOUND CARE Keep wound Dry Do NOT cleanse with saline first (gangrene) Do not use Eusol, Saline soaks or Hydrogen Peroxide, Gels.

36 Other Comfort Tips Avoid tight footwear/binding clothing/dressings Hang foot down (at night) Encourage smoking cessation Avoid trauma

37 Pain Fentanyl pre-dressing change Systemic pain relievers Gapapentin Morphine/gel?

38 Infection Keep gangrenous/arterial area as dry as possible Patients very prone to developing osteomyelitis as ulcers can be quite deep Povidine – Dont dress until dry Tightly woven dressings better (no loose fibres)

39 GOAL Prevent Pain! Prevent Infection! Prevent Amputation!

40 Questions?


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