WOUND BLOG by Matthew Livingston RN

VASCULAR ASSESSMENT

The vascular assessment will answer the question “Does the wound have enough blood supply to heal?”
Healthy tissue is bright, beefy red, shiny, and granular with a velvety appearance. Tissue with poor
vascular supply is pale pink or blanched to dull, dusky red color.

The physical vascular assessment includes palpating lower extremity pulses.  If unable to palpate a pulse use a doppler to assess for a pulse.  Notify a physician if you and a second clinician are unable to doppler a pulse.

Check for a capillary refill ( the measurement of the rate of blood refill in empty capillaries) which is measured
by pressing a nail bed or area of tissue until it turns white and then timing until the return of color once the pressure is released. Normal refill time is less than 3 seconds.Press the skin in several areas around the foot to insure uniform capillary refill and that there is not an area of regional ischemia.

Palpate the foot and leg temperature (the colder the extremity the more you should be concerned).

Absence of lower extremity hair may be an indicator of chronic arterial insufficiency.

For patient with wounds the wound edges will often appear as if the were punched out (i.e. the skin edges drop down to the wound bed) and the patient often identifies severe pain at the wound bed. These symptoms would lead to orders for diagnostics to rule out arterial insufficiency.

A mixture of these vascular symptoms with edema of the lower extremities may indicate a mixed venous – arterial component to the extremity. Complete an ABI study to insure if compression is appropriate for the patient.

Gangrene indicates cellular death buy occlusion (either micro or macro occlusive).

Pallor  (white, pale, blanched color) may be noted when the lower extremity is in upright position.

Rubor (dark purple to bright red color) may be noted when the lower extremityis in a dependent position.

Intermittent claudication includes symptoms of cramping or fatigue of major muscle groups in one or both lower extremities that is reproducible upon walking a  specific distance. These symptoms suggests intermittent claudication and is caused by muscle ischemia.

Mottling or mottled skin ( irregular patchy skin coloring) may be noted. Mottling  is related to blood
vessel changes in the skin which cause the patchy appearance. This may indicate vascular insufficiency.

Diagnostic studies for vascular assessment:
Transcutaneous oxygen measurement (TCOM)
Ankle brachial index (ABI)
Arterial duplex scan
Arteriogram
Magnetic Resonance Arteriogram (MRA)