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Jane E. Carmel, MSN, RN, CWOCN
Statement of Clinical Problem: Arterial ulcers are the result of insufficient arterial perfusion to the tissue that leads to ischemic and necrosis. Ulcers with adequate blood supply are expected to heal. However, without adequate arterial perfusion the ulcers will progress to necrosis and gangrene. Arterial ulcers are best managed by surgical interventions to promote better perfusion to the extremities. Unfortunately, there are many people that have severe arterial occlusion of extremities that are not a candidate for surgery.
Objective: To provide palliative care for extensive ischemic ulcers by recommending treatment that will address managing sloughing necrotic tissue with strong odor and drainage along with comfort measures and support for patient and caregivers.
Clinical Approach: Three cases are presented; A ninety-two year old woman with extensive arterial occlusion to both extremities, eighty year old and eighty -eight year old gentlemen with arterial ulcers confined to one foot. All three cases are on Hospice service and non-ambulatory. Two reside at home with supportive family and the other person resides in a long term care facility. These cases started with dry, stable eschar of toes, however due to their severe arterial insufficiency these wounds started to extend to the entire foot, one patient has sloughing wet gangrene tissue of the entire plantar surface.
The goal was to manage odor, drainage and protect the areas from trauma. Pain management was critical initially but once necrosis and gangrene extended, pain was not significant in all three cases. Family and care givers had to be prepared that the toes would self amputated as they became very brittle.
Conclusion: Ischemic, arterial wounds that cannot be treated by surgical intervention of either re-perfusion or amputation are devastating for the patient and care givers. The clinician needs to assess and recommend palliative treatment as the condition deteriorates.