Vascular Wound Assessment (Getting to the Heart of the Matter)

Vascular Wound Assessment (Getting to the Heart of the Matter)

January 13, 2009 — Matthew Livingston R.N. C.W.S.

I came across this very insightful post that I thought I would direct your attention to.

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.

Physical vascular assessment includes: peripheral pulses, temperature, presence or absence of hair,
mild to severe pain, rest pain, edema, and gangrene. The vascular assessment should also include:

Pallor: White, pale, blanched color of a limb when in the upright position.

Rubor: Dark purple to bright red color of a limb when in a dependent position.

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

Mottling or mottled skin: Irregular patchy skin coloring. Refers specifically related to blood
vessel changes in the skin which cause the patchy appearance. This may indicate
vascular insufficiency.

Capillary refill: The measurement of the rate of blood refill in empty capillaries . 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 2 seconds.

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