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- Optimize perfusion. Refer for surgical evaluation
and consideration of possible revascularization.
- Support moist wound healing. If perfusion
is poor, the wound bed may dry out quickly. If the
patient with an arterial ulcer is not a surgical candidate,
cautious use of moisture-retentive dressings, keeping
dry wounds dry, and close monitoring are important.
- Prevent, treat, and observe for signs of infection.
Consult with physician to determine the need for antibiotic
therapy, debridement, cleansing, and dressing approach.
If gangrene is present, keep the wound dry to avoid
further bacterial growth. Wounds located between the
toes may benefit from cotton or sheepskin placed between
the toes to absorb fluid and protect skin. Following
revascularization, moist wound healing techniques
may be resumed.
- Ambulate as tolerated.
- Control edema, if present.
- Debride when indicated. Method selected is
based upon the condition of the patient and wound.
Debridement may be contraindicated in arterial wounds.
Methods of debridement include autolytic, mechanical,
sharp, and enzymatic.
- Perform daily skin inspection and care. This
may include cleansing, moisturizing, and protective
barriers.
- Provide adequate nutritional intake.
- Manage pain.
- Provide education to patient, family, and caregiver.
Topics include smoking cessation, compliance with
medications, control of diabetes, avoidance of exposure
to friction or trauma, avoidance of extreme temperatures
on skin, limitation of constrictive clothing, leg
crossing, and going barefoot, proper footwear and
nail care, positioning to control pain, close follow-up
with care providers.
- Document assessments and interventions.
- Reassess at regular intervals per agency protocol.
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