Pressure ulcer patient with PAD

[jmn126]

Hi all, i have a pt with a very small pressure ulcer, unstagable due to slough, on his heel, pt has severe PAD, the surgeon put on a duoderm, i took it off after 3 days and area is getting macerated. I am doubting it is ever going to heel with the poor circulation, but..........any other recommendations? Thanks all!!!

[followyourbliss]

Hi jmn126,

When addressing ulcers with an etiology of PAD there are a handful of very important things to address:

1) offloading, offloading dressing, and footwear review with an Orthotist or pedorthist. ( accomodative footwear and orthoses)

2) OT assessment for support surfaces: mattress, assistive devices ie w/c, transfers, offloading etc

3) tight glycemic control if diabetic; smoking cessation if smoker.

4) probing the wound to see if you have bone or covered bone and if so: Bloodwork and xray to query infection re: osteomyelitis etc.

When addressing maceration using a barrier cream to peri wound is needed, secondly more frequent dressing changes, products that absorb while maintaining a moist wound, and protective is key. Frequently the exudate flows to an area of dependence: ie if they sleep on their right, or spend their days in a dependent position.

At the specialized Ulcer clinic that I work in we use offloading dressing with a high success rate and with a lot of efficacy behind the research. In this case a " padded heel " dressing would be appropriate. It consists of 4- 5 layers of products:

a) 1st layer: a broad spectrum antimicrobial such as Iodosorb to address "slough" which absorbs the exudate, gets in all the nooks and crannies, and cleans up the wound.

b) 2nd layer: a small Viscopaste "patch" which is a zinc impregnated gauze which allows fluid/exudate to pass through, is healing, soothing, and is also a protection layer.

c) 3rd layer: a cast padding pillow for offloading, protection, and absorb.

D) a classic pad to absorb and protect, followed by a cast padding wrap around the foot

E) a type of stocking tubing like Blue or Yellow line to secure.

This may sound confusing and complicated, however it is safe, effective, coast efficient, and comfortable. If you are interested in PM'ing me I can find the actual care plan ( somewhere in my files!)

I hope this helps! We see and treat a tremendous amount of ulcers from PAD, PVD, neuropathic, diabetic, venous etc etc....

Wit this type of dressing, and maceration, a dressing change every 2/3 days as per drainage is recommended.

I look forward to your response!

Follow Your Bliss

[mommy.19, MSN, RN, APRN]

Any chance at obtaining a vascular eval? They make be able to offer done endovascular intervention.