STGEC ~ Wound Care: Lower Extremity Wounds (2013)

STGEC ~ Wound Care: Lower Extremity Wounds (2013)



in a story just okay we have one more speaker left and before we get to that let me just remind you it's needed in the conference most importantly is the evaluation please be sure to fill this out run back and return to us at the end of this conference today and really read submitting them in the back the next room exchange get the certificates for today also the person in profile again turning back it's completely voluntary but what you do it really helps out in applying teacher conferences through the grants that we get approved so they'll help us out definitely feature and don't forget about the the today's data and DVDs are also available and any order forms that you want for each references for future use that'd be great our next and last speaker is Diane Rudolph she was here this morning and please welcome her back I'm gonna I'm gonna try to objective all right I'm gonna go ahead and try to project again so it's the end of the day so if I start fading just you know kind of throw something at me or get my attention otherwise we're gonna wrap up today with talking about lower extremity wounds and again some of this content kind of overlaps a little bit kind of dovetails together but I think hopefully that's helpful because sometimes hearing hearing the same message in a couple of different ways can be helpful it kind of helps to solidify it back into the gray matter so with that in mind we'll go ahead and get going so basically what we're gonna do is talk about just the lower extremity wounds these are a very very common category of wounds that you find in practice areas in the ambulatory care environment in the acute care and long-term care you see them all over the place so we're going to talk a little bit about prevention and then management we're gonna really focus on kind of the more common garden variety type wounds and we'll talk a little bit about kind of touch on some things that we've also talked about earlier today so in terms of a demographic reality you know I think as we had talked about earlier chronic wounds are usually a symptom of an underlying problem in the population and as our population ages you know we have baby boomers that are now hitting the 65 year mark and we have a lot of in our population we have a lot of vets that are you know in their 70s 80s and beyond as we get older we're more prone to a lot of chronic diseases and as a result of those chronic diseases we can often develop wounds as a consequence of them and and you all know that I'm reaching to the choir it's just a couple of interesting statistics you know 70 percent of pressure ulcers actually occur in the older adult population so although we have pressure ulcers that run the gamut and the age range we see pretty much the largest percentage in individuals over the age of 65 so it's a problem that's not going away if anything it's getting worse about 10% of pressure ulcers occur in the long-term care environment and that's pretty much across the board nationally it runs between 10 and 11 percent at any given time you have older adults that have pressure ulcers you know whether it's in the trunk or the lower extremities 2.5% prevalence of lower extremity ulcers in the population in general that's a pretty significant amount and about 8.9 out of a thousand older adults have lower extremity ulcers so as you can appreciate it's a pretty significant problem and it's not going away I want to start with talking about venous ulcers you've heard a little bit about venous ulcers already but it is a very very common type of vascular ulcer it is probably the most common type of large evety wound that you're going to see in the population and what's probably really critical to keep in mind is that it really accounts for about 70 to 90% of all cases of lower extremity ulcers so one thing to probably keep in mind is that with our diabetic population that that number is probably maybe a little bit lower than the national average because we have such a large percentage of diabetics in our population demographically but it's still a significant issue so the venous officers what do they look like it's kind of one of those things where if you see it and know exactly what it is they most commonly are found in the lower extremity usually in what we call the gaiter area and by data we need we mean between the knee and the ankle those are the most common locations typically we see a lot of emotion Arosa sore hemosiderin staining we see the wounds themselves are very irregular shape almost sometimes looks like a rat women achieve the edges they are highly exudative for the most part and we'll talk a little bit about the pathophysiology and that will make sense some of the other common things that we see are the lipo traumatic sclerosis what does that mean it's again it's another one of those really impressive you know $10 words but lipo means fat they're not all mean skin and sclerosis means hard so what is that it's something that you see with these long-standing chronic venous ulcers where the tissue becomes very firm and very hard almost doughy or woody if you will it just doesn't have that nice normal tissue supplements that you see with with normal tissue sometimes in some of the world these patients that have venous ulcers you kind of end up with what's called an upside-down champagne bottle deformity where the the cap is kind of fat that the ankle kind of gets really skinny and of course we see the vehemence iterance staining that is that that dark discolored hyper pigmented staining that you see it almost looks like somebody had their legs hanging out the window going down the highway and they got a suntan from about the Machine down that is a hyperpigmentation it's a chronic situation that we see with these patients it's a very classic finding and for the most part it really is irreversible so the standard of care for venous ulcers is compression and an appropriate absorptive dressing those are the two main stays of treating these venous ulcers you have got to compress them and you've got to provide some type of a moisture retentive dressing that is absorbent that will again help to wick away that actually they keep that moist environment to allow for those phases of in the wound to be able to automatically debride itself to be able to get itself clean to proliferate and to epithelial lines so when we talk about the pathophysiology and in here talking to you I am walking around but if I stop walking you know I have these these pools my you know your blood vessels are kind of vertical or perpendicular to the earth so you have these columns of fluid and gravity is pulling down on those columns and fluid and again over time you get what's called an increased hydrostatic pressure so pressure builds up in these in these columns in a normal situation if you have somebody who where everything is working as it as it should I'm standing here I'm walking around there's a little bit of blood pooling in my legs but then as I move my fat mechanism my calf muscle is contracting and relaxing and so what it's doing is it is compressing the one-way valves in my legs and it's promoting venous return back up to my heart that's all as it should be and that is why I don't have a diminished legs or discolored legs or venous officers however in a large percentage of the population we end up with what's called venous insufficiency valvular insufficiency so the valves just don't work and they don't work for you number of reasons you can inherit bad veins unfortunately that can be a real big issue if they tend to run in families or they can be acquired so anything that can damage the veins can potentially put you at risk for the development of the venous ulcers being a chronic venous insufficiency so what happens is you have these veins you no longer have the ability of the heart to be able to return that blood you know the the Kapton mechanism to turn the blood back up to the heart so but pools and pools and pools and you get these columns of fluid pressure builds increased hydrostatic pressure and so what happens over time is that that pressure basically translates from the high side of the house we have what are called down you know a high venous pressure system to the low side of the house and so what happens is it causes all these dilated their confidence if you will and so what you see over time are these you know varicose veins and these big dilated tortuous mains sometimes it may not be a really obvious process but this is basically what's occurring so you now have all of this increased pressure eventually that pressure has to to go to somewhere so it causes fluid to leak out into the interstitial tissues into the subcutaneous tissues and you get a Deema you get swelling and as the situation progresses and this isn't something that occurs you know like a pressure ulcer you can develop sometimes in hours or days this is something that takes many many years to occur and so what happens is that you get edema you also get extravasation of the red blood cells out into the tissues and those red blood cells contain hemoglobin and what is what is Neela globin have in it iron and oxygen the iron is is basically a heavy metal and it deposits in the tissues and it causes that hyperpigmentation that we see it's kind of like rust stains if you will so we get that heimo siderosis over time that edema becomes very chronic and it causes a lot of scarring of the subcutaneous tissue so then the tissue starts to get really hard and really and really doughy that's that lipo dramatic analysis so you can appreciate that it's a very it's a very insidious long extended process but ultimately what we have our veins that look like this and can lead to this this is a this is not a textbook case but he looks like a textbook patient this is the gentleman of mine that was from a community nursing home a little elderly gentleman and he has very classic chronic venous insufficiency so you can see that we have this hemosiderin since we've got this this hyper clean lifted the seen again from about mid chin down it just looks like some kind of weird abnormal discoloration but that's your the most entertaining if you were to depress or palpate the skin it would be very firm very very hard he mentioned yes it could be leathery like absolutely they also get because of that chronic swelling of the skin and that chronic inflammation they will often get venous dermatitis or stasis dermatitis which can be very itchy and very uncomfortable as well and we usually manage that with usually post topical steroids to help manage that but you can see here that we have this very classic type of stasis ulcer the margins are very very irregular it's occurring over the lateral malleolus or ankle and that's one of the very common sites are in the medial and ankle bones are very very common sites you can also get them a little bit higher but when we talk about gait your area this is what we're talking about usually in this area right here so that is a very classic type of stasis ulcer and again because you have all that hydrostatic pressure and edema many many times you end up with an open wound and that is sort of like opening up a spigot and that's why they drain so much because it's the path of least resistance and you have fluid flowing out of these rooms here's a close-up just to show you the same kind of situation again you can see that we've got you know a little bit about the field motivation going on here but there's a little granulation but there's also quite a bit of slopping in here the margins are very very irregular and you can see there's a little bit of pressing from some action but that is your very classic venous stasis ulcer here's another example again you can see that in this case we have a very highly extra dating type of the woman and so you can see that we've got you know a couple of these but you can see that we've got quite a bit of maceration here we've got some sloughing going on here we've got some very very tenuous epithelial innovation that's trying to occur but again with the maceration present that is probably going to end up being very compromised tissue but you can see that we also have what are the other things that happens is that this chronic irritation this chronic stasis change also causes something called elephantiasis how many of you have seen that yeah and it seems to be fairly common in our VA population in particular but it's that you start getting these very lumpy bumpy looking tissue and it's called elephantiasis snotra verrucosa and it's a chronic irreversible process that we see not in all patients with stasis officers but with Mandy and you can see he's starting to get some of that down in through here here's another one just just to give you various examples again chronic irregular edges in the lateral malleolus we don't say a whole lot of hemosiderin staining but there is a little bit of hyperpigmentation going on here again just very very classic so we talked about the fact that the standard of therapy for venous ulcers it's compression and absorptive dressings so one of the questions that somebody brought up very astutely earlier was well don't you have to know what their circulation is like before you could put a congressional absolutely and that is why one of the things that we will do is we will send patients we you can actually do this at the bedside if you have a handheld Doppler if you want a more formal extensive evaluation we also have the opportunity to send patients to body to the non-invasive vascular lab to get a full set of non-invasive studies but the ABI is the ankle brachial index and it is a it's a very nice way a non-invasive way to actually get sort of a gross idea of somebody circulatory status and the way that it's basically done is that you measure using a Doppler the brachial systolic pressure and the ankle systolic pressure usually over the dorsalis pedis or it could be the posterior tib and you get those two values and you divide the angle by the brachial value and in a normal situation about 0.9 to 1.2 is considered a normal perfusion that somebody who doesn't have any peripheral vascular disease doesn't really have any kind of circulatory issues then you have 0.6 2.8 we're getting into kind of a gray area and less than point six we've got some fairly significant disease so for somebody who has venous ulcer and you want to put compression on you really want to get an idea of what their perfusion is because you know if you're there's it's probably a gray area in here but you really don't want to compress them usually at less than point eight for the most part you know in some cases you can do a little bit of a modified wrap if you feel comfortable but for the most part for compression therapy to be effective and for it to be safe you really have to do 0.8 or higher as far as their ankle ankle brachial index is concerned now another caveat to that is what happens with a lot of diabetics blood vessels over time they have micro and macro vascular disease but they get a lot of calcification ii don't think so what do you think happens with a calcified vessel if you try to compress it yeah it may be very difficult to compress because you get that met firm calcification so you can't really compress the vessels so you have to be a little bit cautious because in diabetic patients in particular they are prone to having a lot of calcification in their vessels and so if you get an ankle brachial index there is the potential that it could be falsely elevated if you can't compress the vessels you may not be able to get an accurate reading and you may get a reading that's actually in fact a little higher normal so in that case if you have a doubt or you have a question you know you have the option of doing what's called a tow brachial index and this is something that can be done by clinicians who are familiar and if you have the proper equipment to do that but the toe brachial index is actually measuring what we call toe pressures and in the very small vasculature of the toe they generally you don't have as much calcification so you can get a more valid result so a TBI usually a 0.4 0.5 is indicative of peripheral vascular disease so it's kind of helpful to get a good idea of what their perfusion status is before you confront them does that make sense so when we do compression what we're actually talking about is kind of using that whole concept of Laplace's law the ankle is as a narrow narrower radius than the cap so if you have uniform pressure what's going to happen is you're going to have basically the idea is that you're creating this rap to enhance return back up to the heart so the idea or the theory behind compression as you're using about 30 to 40 millimeters from arterial pressure which is considered to be about what is required in order to promote that counter pressure that returned back up to the heart to mimic that path pump mechanism that these patients don't have anymore so there are a variety of different raps on the on the market there are two layer raps there are three layer apps there are four their raps and many of them are very very good i'm not going to promote a particular one this is just kind of feeding you a couple of examples this is the believe this is the Johnson and Johnson rap this is the pro-poor which is very very nice it also comes in a three layer rap called the print for light but the idea is that regardless of what you use and you can also use and aboot is an older technology it's been out since the 1850s it was invented by a German physician and it has also proven itself over time to be very very effective but the idea is that you are a fine after pressure from about the base of the toe all the way up to just below the knee and the idea is that by doing that it creates that counter pressure to promote venous return it also helps with reducing the vascular congestion helping to control edema and edema is a huge enemy to wound healing so controlling that edema becomes very very important there are some other examples and again he looked exactly like some of the veterans like that we often see tonight but you can tell that we also have what's available are the compression stockings and again these come in a variety of different colors and sizes and shapes there's some very very good companies out there jobs you so there's a number of them and the idea is that this is just another option to again provide that support generally when you have a patient who has this stasis ulcer really the the rule of thumb is you really want to try to promote healing and usually you do that with your compression therapy once you've controlled the edema and you've you've got you know near resolution of the room then you want to look at perhaps long-term maintenance with something like this this is a lovely lovely lovely thing do you know what those are what are those those are lymphedema pumps delightful product these are wonderful because for patients who have both chronic lymphedema and chronic venous insufficiency who are prone to a lot of edema this is a lovely way of helping to again promote venous return and typically what folks will do is they will sit with these their legs in these patema pumps and usually it's about an hour once a day is what's recommended you can do it a little more or a little less but if you have patients that are compliant with this it does a fantastic job of helping to increase that venous return and really really helps for the video management and I like to actually use this in compress in conjunction with compression therapy and in some cases I have patients who just cannot tolerate the compression therapy because of some neuropathy issues or because of just being you know just having lots of chronic pain issues osteo and such they don't always tolerate it so as an option or in addition I'll use the lymphedema pumps and they work wonderfully here's another just another example you can see sometimes these can be extremely large and it's not uncommon for these to be around for you know months to years I've had patients who've had States and saucers for twenty thirty years of their lives and they've lived with them which is really kind of devastating when you think about the quality of life issues associated with that but this is a patient you can see again very typical medial malleolus we've got a little bit of crusty with some dried exudate we've got some granulation tissue we've got a lot of fluffing and again those very irregular margins some michael dramatic sclerosis and probably a little bit of states of stomatitis this is about a week later with using move back again just a really nice option and you can see how it has really helped with helping to promote that lovely granulation tissue there so a balloon back is something that you can use in conjunction with compression therapy it's a little bit tricky I think in the ambulatory environment to do that but it is doable so that's kind of a quick down and dirty on venous ulcers venous ulcers chronic pathological condition can be acquired or it can be hereditary and things that can cause venous ulcers to occur any kind of damage to the veins multiple childbirths chronic obesity anything that puts pressure on the venous return on the vena cava any kind of trauma previous surgeries it's not uncommon for I've had you know patients that have had lower extremity bypass and then they get an acquired lymphedema because of the destruction of the lymphatic channels in the women and you know a little bit different animal but they also sometimes can develop a little bhima's insufficiency as well so it could be very very problematic all right so then that's again 72 to 90% of the most of your officers of stasis ulcers standard of care compression therapy and absorptive dress I see any major contraindications for depression the main contraindication for compression would be concurrent peripheral vascular disease so if you do here in our new basis and you have an avi less than point a and ever to get out of it of less than point four then that would be a red flag that you might want to really relocate that compression have to be very careful oh yeah absolutely you know you might be able to get away with sort of a modified rap we have one gentleman who you know has mixed disease and we actually do a very light rap with a little bit of Carl X and a koban but we do it in a very loose way so that and we watch them carefully and he tolerates it and it's not nearly that 30 to 40 millimeters but it does give them a little bit of support and helps to you know promote healing so the next one are the arterial ulcers and these are basically associated also with a lot of your your common classic changes when we think of our tear losses we're thinking again blood supply problems and for the most part unlike the stasis ulcers these tend to occur a little bit more distally they tend to occur over areas of trauma they often can be very difficult if not impossible to heal and often will require some type of surgical interventions if the patient is indeed a surgical candidate a very important thing to keep in mind is if you do have somebody who has no peripheral vascular disease enough in an arterial ulcer if the arterial ulcers have dry gangrene or dry and necrotic tissue or dry eschar the rule of thumb in that kind of a patient is to keep the dry ice far or dry necrotic tissue dry until you can get them to see a vascular specialist you want to do moist wound healing only if the wound is open so let's look at some examples again a lot of those traffic changes a lot of times people that have chronic peripheral vascular disease they tend to have very skinny dry scaly feet and that is because over time what happens is that you have a decreased perfusion to the to the cutaneous tissue so the hair follicles die so you don't have any hair growth anymore because you no longer have blood flow to the hair follicles you no longer have blood flow to some of the the various oil producing glands so the skin becomes very dry and very scaly you no longer have fat you get atrophy of the subcutaneous tissue in the feet so the feet kinda long and skinny looking and then you also will get you know these district nails you get the development of the onychomycosis or the fungal infections and the nails so this is very very very calming and you can see here that we have just an area of minor trauma that again has the potential to develop into something much more serious so again getting these folks to be seen by podiatry or a specialist that is very familiar with managing these and also looking at the vascular piece is going to be very very important there's a couple more examples again you have somebody who's got those classic trophic changes you can see here a lot of recurrent trauma we thought this drawing aquatic tissue here and here you've got those you know elongated thick nails these trophic nails there's no hair growth the skin is very dry and just an area of trauma it could be something as minor as a an ill-fitting pair of shoes you know the Kmart bluelight special where you get that really nice low-cost pair of shoes and you put them on and lo and behold you end up with a pressure point and again in some cases you can lose blood flow to the foot and here we've got an area of gangrene as well and this is more about probably like a an embolic phenomenon in this case here's another arterial ulcer this is again a gentleman with peripheral vascular disease advanced age ninety eight years old and in this case really had a lot of the classic changes that we see with arterial disease most of the time your arterial ulcers you generally see them more distal in the foot but in somebody who is very compromised you may see them a little bit higher as well and this is a this is a patient that was at an outside Hospital where I used to consult and this patient who unfortunately was in extreme denial as you can appreciate ended up with just very very progressive personal vascular disease over time and you can see that we have you know actual mummification of the feet but you know again if we don't see anything until we get to this point and we sure have dropped the ball but it does give you a little bit of an appreciation of how serious these can be tender couldn't potentially become if if ignored so the treatment for the arterial ulcers is basically really evaluating their circulatory status and having them evaluated ideally by both vascular provider and then podiatric or wound care specialist who's comfortable with dealing with arterial ulcers the big thing with those types of wounds is you want to offload pressure to them we want to restore perfusion as best as you can and what would you want to do for some of that dry scaly skin what would be something good that you could use yep and the ointment Vaseline some kind of a nice thicker more emollient a urea type cream is also a good option like hydron anything you know it depends on what you have in your arsenal but a good top of the monument of your base indeed anything like that is very very important because again you have that dry scaly skin and it's dry and scaly and it can definitely previous load that patient to infection cellulitis and other ulcers so the next kind of the these are sort of like the top three perpetrators if you will the venous ulcers they are narrow ulcers and then also what we call are the neuropathic ulcers or the diabetic foot ulcers with these what we typically see is these usually will occur on the plantar surface but you can have them on other ends of the foot when we think about neuropathic ulcers we're really thinking about wounds that occur in individuals who have lost protective sensation and I know Sheree had talked about that earlier but again pain is the gift that no one wants and one of the things that's really critical is that pain is really the the thing that tells us that there's a problem so if you have someone who has significant neuropathy either from poorly controlled diabetes b12 deficiency alcoholic neuropathy or other types of neuropathy they lose that protective sensation so it is not uncommon for them to develop wounds especially on the areas of trauma or areas on the plantar surface the big thing with these is that it's critical to address the underlying disease so if it's a if it's a vitamin deficiency you have to address that if it's diabetes you have to address the diabetes if there's concurrent comorbid conditions like circulatory issues you've gotta address things too you have to address infection as we've talked about before more forcefully and probably the most important thing is to offload pressure off low pressure off blood pressure and again we have podiatry in the back that will definitely you know tell you that you can do the best room here in the world but if you're not offloading pressure to these wounds they're just not going to heal so here's a fairly classic patient again full thickness neuropathic officer one of the things that happens with these wounds especially on the plantar surface is that when you develop these officers you know number one the individual oftentimes they don't even realize that they have a wound on their foot until they see blood or pus in their sock and shoe and by that time it's usually a pretty serious event that they're dealing with but the other thing that the body does is sort of an abnormal compensatory response is that the body builds up this layer of hyper taratata tissue or pallas around the wound and it kind of creates that sort of a doughnut effect you know years ago we used to talk about putting donuts on people's people cipro ulcers thinking that that would offload the pressure and we found out that donuts actually caused more problems and so we we've gotten away from the donuts both the doughnuts that you sit on in the edible kind as much as possible but but in this really creates a donut effect too so you give this ring up I prepare a conduct issue and so what that does is cause even increased pressure on the wound and it makes it worse so a very important principle with the neuropathic ulcers is appropriate moist wound care debris ting the hyper keratotomy shoe and offloading pressure to those areas so this is just a before-and-after again just you know very nicely just kind of shaving off that hyper carry competition of the blade and that way too it allows you the pictures a little bit blurry but it allows you to sort of see what you're dealing with because many times it might be the tip of the iceberg so we have here kind of an opening for making this wound just sort of extends into subcutaneous tissue that certainly something that would be amenable to appropriate care again in another example with a lot of these patients to what happens over time is that they end up losing you know for various reasons they may end up losing parts of their feet they may lose toes they may have rave implications or they may have you know complete receptions of the toes so as you can appreciate that's gonna alter the pressure points and predispose them to new also so again just another example over the metatarsal head that is not an uncommon place either for these ulcers to develop and also on the foot this is just a large ulcer on the heel the fine entire surface of the heel it is you can appreciate it means we got very very big and very very involved what word do you think would be a main concern with ulcers that develop in the feet absolutely why absolutely that's an excellent point so yes absolutely because of the things we talked about before diabetics are not as able to mount a defense so they're more prone to infection they block sensation things can get very serious before they even realize it the other problem also with these particular patients is that I just lost my train of thought oh why would why would this also be an issue because with a lot of these patients with the lack of protective sensation it really really makes it difficult and also because of the anatomy of the foot and the architecture of the foot you know it doesn't take very much depth to get to a full thickness wound and that can very very easily travel across the fascial plains and get into bones so these wounds can develop very quickly into osteomyelitis or sepsis or other types of very very repugnant situations so that was the point I was trying to make Oh again just showing you a way to use the the sentence Weinstein monofilament is a very nice way to check for protective sensation if you're gonna check for a protective sensation in the foot you don't really want to use a pad or a q-tip that might seem like a good idea but it's really not a very sensitive way of doing it you really want to try to use a monofilament that gives you the most appropriate way to check and to do that what you do is you just basically press it and these are some of the key areas that are often shed usually you check about ten different areas on the foot including the front of hard surface and then you from the first and second digit are on the dorsal aspect of the foot and you basically just hold pressure until that monofilament bends and that's enough to indicate whether or not they should be able to if they're intact they should be able to feel that so that's how you basically would do that and of course offloading this is just a couple of basic examples but there are many many options out there and again this is where you know referral to podiatry or to your pet orthotist becomes extremely important to make sure that you have that patient evaluated for appropriate offload and this is absolutely critical because diabetic ulcers are just not going to do anything neuropathic ulcers aren't going to do anything unless you are relieving the causative agent which is that pressure total contact casting is also another option and I just learned recently that that is something that we have available here within the VA and it's a nice way to provide literally a rigid cast that again offloads pressure to that affected wound to enable here enable healing one of the nice things about this is it's a little bit more difficult for them to remove them sometimes you know oona boots or other types of products so that's certainly a very viable option and then finally we have almost finally pressure ulcers and again you've heard we've heard a lot about this but just a couple of things to throw at you with respect to pressure ulcers the inconsistency in staging is always an issue so we need to be very very attuned to that we talked about this earlier if you've seen a chronic tissue it's going to be at least at stage three no matter how small the ulcer stage the wound after you clean it we talked about reverse staging and then the other thing about you know as shariah mentioned is it a pressure ulcer is it something else one of the things you always want to be asking yourself when you're looking at that wound is what is the cause what's the culprit why does this patient have the wound because as you know as you're even hearing now knowing what the cause of the world is going to guide how you treat that wound so again unstageable to stage able and again here's another example of a device related and what's really interesting here this is the patient it was boots of all things and designed offloaded pressure but if you put somebody in a pair of Revlon boots and you cinch them up so tight that they don't get kicked off and they don't go anywhere and you don't check them problems and in this case this is a patient who also has some concurrent peripheral vascular disease so we've got kind of a mixed bag of tricks here the deep tissue injury I'm just going to stick that because we have talked about that again just another option for your for your more non ambulatory patients this is a nice way to offload heal so you also have the multi produce food which can float the heal and it's nice too because it helps to suspend that put in a neutral position to help avoid you know foot drop you also see this this is the knee hug waffle boot it's it's okay it's tends to be a little bit hot and traps the heat but you may see that in some settings and this is just a basically a foam wedge where the the heels are being floated and you have this underneath the cap which again you have to be careful because you still have pressure here that you have to monitor so one of the things that you want to think about is that you you've looked at the wound you've figured out or at least you think you've figured out what it is you are doing all of the appropriate things for that wound including appropriate topical therapy you're managing their comorbidities and you are doing you know everything that's necessary you're making your appropriate referrals to specialists as needed something's still not happening it's just you're still not making progress so just a couple of other you want to think about do you have infection do you have cellulitis again it may not always be obvious and cellulitis may not always occur in the app and the presence of an open frank wound so if you see something like that you certainly want to be a little bit suspicious and you can see here we've got you know this area where you've got quite a bit of Erath them it is changes you've got some open to nuded areas and you've got all this weeping and crusty you know that's pretty suggestive of probably an underlying staph infection that's evolving here we've talked about this a little bit so you'll have it as part of your references so I'm not gonna not going to beat a dead horse so to speak and I apologize if I offended any animal lovers out there but again you just always want to think about is it is it colonized or is it critically colonized or is it infected and you want to address that accordingly the other thing that's always always important if you have a patient who has a chronic mood you know you it looks like a venous ulcer it smells like a venous ulcer it tastes like a venous ulcer if you're really brave and you know you're thinking okay I'm treating this food accordingly and it's not healing and if anything it's getting worse and it doesn't seem like it's a circulatory issue you've looked at everything else just kind of be aware that it is not extremely uncommon for venous ulcers sometimes to convert into malignancy so you can get something called a large or an ulcer that can occur in an open wound so if you have a wound and you're doing everything appropriately and the wound is not responding to proper therapy you might want to consider referring that patient for a possible biopsy that's a very important clinical pearl especially with your lower extremity wounds calcify Laxus again we have we have more than our average share of diabetics in the population and we have more than our average share of diabetic nephropathy as a result so we do see more dialysis patients this is a complication that we sometimes see in dialysis patients it's called calcitriol axis and it's usually a result of an abnormal metabolism of calcium and they basically that the little calcium deposits in the micro vasculature that will actually decrease blood supply to various parts of the tissue and become these large necrotic areas and certainly already need an attention these can occur in the legs the upper thighs really almost anywhere in the body pyoderma again a little bit less common culprit but it is something you can see yes sir I think a lot of times it's going to depend on your clinical judgment but if you're doing everything you here you've addressed the perfusion you've addressed any kind of colonization issues or infection issues you're doing everything appropriately and it's getting worse and you know that there is not a compliance issue you know if I would probably you know it's probably gonna be very dependent on the patient but you're doing everything appropriately it's getting worse you know I would probably have a low threshold it's probably three to four weeks if it's not getting better and three to four weeks you may want to consider biopsy again and that's where you could do either your excisional or your punch biopsy okay does that answer your question okay I adharma it's an autoimmune disease that we often see sometimes to have concurrent Crohn's and inflammatory bowel disease that would be just another potential differential diagnosis to consider again it's one thing that would again be diagnosed with biopsy if your wound is not responding to appropriate therapy the topical therapy you are going to get a little bit more on this but I'll include this in your handout just as a little bit of another reference debridement we've talked about very very important there's a v4 so in terms of wound care pearls getting back to the staging try to master staging as best as you can in terms of topical therapies you know I think one of the things that can be very overwhelming for a lot of folks is they think oh gosh I've got to know all these different products it's kind of like going back to when you learn to pharmacology 101 the best thing is to learn the categories and then know one or two product names within that category and that would really take you far so just instead of learning all product names learn product categories one size doesn't fit all what works for patient a who has the same thing as patient B may not necessarily work for that patient so you always want to be flexible and modify and assess and reassess if you're doing a topical therapy in general and the wound isn't responding I would give it about two weeks and then at that point if the wound is not improving then it's time to think about changing to another topical therapy drainage and moisture again as you heard me say if it's wet dried and if it's if it's dry out a little bit of moisture unless it's dry necrotic eschar in a compromised host moist dressings for all wounds is not appropriate we talked about that a little bit so that's the exception to moisture wound healing some take on the pots I'll establish a goal of wound care what do you want to do when you have this one not every wound is healed but not every wound is going to be complete if you have somebody was so compromised that you're just kind of hoping that the wound doesn't get any worse that may be a reasonable goal especially with some of your palliative care patients so always have a goal through here do you want to heal him you want to maintain them you want to prepare the wound and then send them for surgery have a a good goal in life cause and complicating factors again it it's kind of hard to treat an ulcer or a skin injury that we don't know what's causing it so you always try to figure that out to the best of your ability the other thing this is very important because they see this a lot if you expect a wound to heal faster than it's capable of doing you're gonna keep changing things and changing things and it gets very confusing and it gets very expensive so as I mentioned you know get did something a good solid two-week window and if it looks like it's not healing then you may want to rethink that and many wounds will actually heal if we allow them to and again by supporting the host and by doing good appropriately here there's just a little bit of just to kind of give you side-by-side comparison of venous Arturo and neuropathic again kind of a little take-home reference for you and I think with that in mind if you have any questions I feel like she kind of bit off more than we could chew a little bit with this particular topic there was a lot to digest so I thank you and do I have time for another joke all right just one okay we'll make it quick all right well there are there are these three dogs of course you know if every time you ever hear me I'm always gonna pick on I'm gonna kick on a docks and lawyers but there's these three docks that were really good friends and they just used to do everything together they they just used to hang out they would go play golf together they would go out to eat together there was really really good friends and they decided that they were just going to do something really wild and crazy one day and they decided to book a trip to an exotic deserted island and just have a really good time so they went through the process and they they booked this trip and they found themselves on this beautiful tropical you know desert island just absolutely gorgeous in the South Pacific and there one night they're going for a walk along the beach and they see this kind of funny-looking weird shaped metallic object sticking out of the sand so okay fine so they see this metallic object and they run over to it and they pull it out of the sand and it's this beautiful beautiful elaborate ornate bottle and it's got you know it's just gold and it's just very gorgeous and it's glimmering so they start shining it they're like wow this must be worth a lot of money this looks like an old antiques they start shining it and shining in out of the this bottle comes this Bandini and the genie is like oh wow you know thank you so much I have been in that bottle for years and eons and eons and I I am so appreciative thank you for letting me out of this bottle and in return my three friends I would like to grant each of you a wish so the first doctor who happens he's a family practice doctor he says Jeannie I would like to be 25% smarter than my peers so the genie is always there 25% smarter than your peers so then the second doctor who happens to be a general surgeon it's like well Jeannie I want to be 50% smarter than my peers so the genie goes and he does is hopefully to focus and all of these different you know this and that ooh you're 50% smarter than the payers and the third doctor who's this kind of cocky cardiovascular surgeon kind of has on them a little bit of an ego maybe said Jeannie that's not good enough for me mmm not at all I want to be a hundred percent smarter than my peers Jimmy looks everything's like sure about that and he goes yes I want to be a hundred percent smarter than my peers so now you're a nurse early night just to help me

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