Determining the Etiology of Wounds: Pressure Versus Vascular
Presented by Jeri Ann Lundgren, RN, BSN, PHN, CWS, CWCN Pathway
Health Services
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Training Objectives Describe etiologies of Pressure Ulcers
Discuss the pressure versus other causes of wounds Demonstrate how
to determine vascular wounds from pressure ulcers
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Pressure Ulcers A pressure ulcer is localized injury to the
skin and/or underlying tissue usually over a bony prominence, as a
result of pressure, or pressure in combination with shear and/or
friction Copyright: NPUAP 2007
Extremity becomes pale/pallor with elevation and has dependent
rubor Skin: shiny, taut, thin, dry, hair loss of lower extremities,
atrophy of subcutaneous tissue Increased pain with activity and/or
elevation (intermittent claudication, resting, nocturnal and
positional)
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Arterial Insufficiency Perfusion Skin Temperature:
Cold/decreased Capillary Refill Delayed more than 3 seconds
Peripheral Pulses Absent or Diminished
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Arterial Insufficiency Tests Ankle Brachial Index (Doppler)
< 0.8 Systolic Toe Pressure (Doppler) TP < 30 Transcutaneous
Oxygen Pressure Measurements (TcPo 2 ) TcPo 2 < 40 mm Hg
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Arterial Insufficiency Ulcers Location Toe tips and/or web
spaces Phalangeal heads around lateral malleolus Areas exposed to
pressure or repetitive trauma (shoe, cast, brace, etc.)
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Arterial Insufficiency
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Venous Insufficiency
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Lower Leg characteristics Edema Pitting or non-pitting Venous
Dermatitis (erythema, scaling, edema and weeping) Hemosiderin
Staining Brown staining (hyperpigmentation) Active Cellulitis
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Venous Insufficiency Pain Minimal unless infected or desiccated
Peripheral Pulses Present/palpable Capillary Refill Normal-less
than 3 seconds
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Venous Insufficiency Ulcers Location Medial aspect of the lower
leg and ankle Superior to medial malleolus
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Venous Insufficiency
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Peripheral Neuropathy/Diabetic History Diabetes Spinal cord
injury Hypertension Smoking Alcoholism Hansens Disease Trauma to
lower extremity Family history ***Please note that there are over
100 known causes
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Peripheral Neuropathy/Diabetic Relief of pain with ambulation
Parasthesia of extremities Altered gait Orthopedic deformities
Reflexes diminished Altered sensation (numbness, prickling,
tingling)
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Peripheral Neuropathy/Diabetic Intolerance to touch (e.g., bed
sheets touching legs) Presence of calluses Fissures/cracks,
especially the heels Arterial insufficiency commonly co-exists with
peripheral neuropathy!
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Peripheral Neuropathy/Diabetic Light pressure using a
Semmes-Weinstein Monofilament Exam Vibratory sense using a tuning
fork Deep tendon reflexes of ankle and knee Recommend an ABI as
arterial insufficiency commonly co-exists
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Peripheral Neuropathy/Diabetic Plantar aspect of the foot
Metatarsal heads Heels Altered pressure points Sites of painless
trauma and/or repetitive stress
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Peripheral Neuropathy/Diabetic
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Moisture-Not Pressure
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Intertrigo
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Wounds NOT Caused by Pressure
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Resources Available Resources and Web Sites: www.wocn.org
(Wound, Ostomy & Continence Nurse Society) www.ahrq.gov (Agency
for Health Care Research and Quality, formally AHCPR) www.aawm.org
(American Academy of Wound Management) www.npuap.org (National
Pressure Ulcer Advisory Panel) www.woundsource.com (Great source to
find wound care products)
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Thanks for your participation!!! Jeri Lundgren, RN, BSN, PHN,
CWS, CWCN Pathway Health Services [email protected]
Cell: 612-805-9703 This material was prepared by Stratis Health,
the Quality Improvement Organization for Minnesota, under a
contract with the Centers for Medicare & Medicaid Services
(CMS), an agency of the US Department of Health and Human Services.
The contents presented do not necessarily reflect CMS policy.
10SOW-MN-C7-11-39 011012
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