Exam 1 Flashcards
What does it mean that the patient has tight, hairless, and shiny skin starting at mid shin level and extending to the toes?
Arterial insufficiency
When does arterial insufficiency occur?
Occurs when the blood flow in the arteries is not sufficient to meet the needs of the skin, muscles, and
nerves.
Leads to an arterial ulcer
What causes arterial insufficiency?
Cholesterol deposits, blood clots that obstruct blood flow, or damaged, diseased, or weak vessels
What is a C & S test?
Culture and Sensitivity test
Culture is a done to find out what kind of organism (usually bacteria) is causing an illness or infection
Sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection
Why is a C & S test important?
To select the best medicine to treat the illness or infection
How would you test for light touch?
Use a brush, cotton ball, monofilament
How would you test for pressure?
Use blunt end of your finger or thumb and press into patient’s skin
How would you test for pain?
neurological pin, paper clip, or safety pin
What nerve endings are responsible for carrying sensations of touch, pressure, and temperature?
Free nerve endings
If a patient has low levels of albumin would could this mean?
Could signal that there is inflammation, shock, or malnutrition
What are some ways to apply compression therapy?
Static compression
Intermittent pneumatic compression pumps
Single chamber, sequential multi-chamber devices
Compression bandages and garments
What does a compression application assist with?
Laying down of collagen in organized manner
Controlling scarring and preventing keloids
Reshaping of residual limb following amputation (stump wrapping)
What are some indications for compression?
Chronic edema
Lymphedema
Prevention of DVT
Stabilization of wound bed
What causes edema?
Imbalance in hydrostatic forces
Improper diet, reduced fluid intake
Trauma, burns, infection
Prolonged sitting and reduced air pressure long distance travel
Pregnancy
Chronic medical conditions ie- CHF, renal disease, diabetes
Venous insufficiency
What causes lymphedema?
Chronic infections- filariasis
Surgery that damages lymphatic vessels or nodes
Decreased activity
Reduced plasma proteins
Congenital malformation of lymphatic system
What may cause the formation of a thrombus in high risk individuals?
Immobilization causes stasis of blood flow, pooling of fluids in interstitial tissues and formation of thrombus
Compression is effective as __________.
Anti-coagulant medications
How can compression assist w/ venous stasis ulcers?
Normalization of venous circulation
Reduced venous pooling and reflux
Improve tissue oxygenation
Altered white cell adhesion and reduced edema
Which type of compression is effective in healing venous stasis ulcers?
Multi-layered compression
Would you use compression with arterial insufficiency ulcers?
NO compression may further compromise arterial circulation
What are contraindications for compression use?
Heart failure or pulmonary edema
Recent or acute DV T, thrombophlebitis or pulmonary embolism
Obstructed lymphatic or venous return
Severe PAD or ulcers resulting from arterial insufficiency
ABI .8 – nml compression (30-40mmHG)
ABI btw .5 and .8 – reduce compression levels (23-37 mmHG)
Acute, local skin infection
Significant hypoproteinemia (protein levels <2gm/dL)
Acute fracture or trauma
Arterial revascularization
Neuropathy (CAUTION-patient may not recognize ischemia)
Impaired sensation or mentation
Uncontrolled hypertension
Cancer
Stroke or significant cerebrovascular insufficiency
Superficial peripheral nerves
List the application techniques for compression bandaging?
Long stretch Short stretch Unna’s boot Multilayered bandage system (Profore) Anti-embolism stockings Fitted compression garments Velcro-closure devices Intermittent pneumatic compression pump
Describe a complete decongestive therapy program for lymphedema?
Skin and nail care
Lymphedema massage
Compression garment
Active and light resisted exercise
Use of intermittent pneumatic compression??
Lower pressures may be safer and more effective for the treatment of lymphedema – 30 mmHG – on the low end of the UE range or 40 mmHG on the low end of the LE range
What interventions would you use with pre-prosthetic patients?
Residual limb shaping
Ther ex – focus on strength, endurance, balance. Stretching for areas that may develop contracture, eg. hip and knee flexors
Transfer and gait training
Functional activity training
What is the most common type of vascular ulcer?
Venous ulcers
*Generally have the best prognosis
Where is peripheral vascular insufficiency most common?
In the distal LE
What may Lower extremity vascular disease (LEVD) cause?
Pain, tissue loss, and changes in appearance and function
What is peripheral insufficiency?
Inadequate return of venous blood from periphery
Generally caused by poor venous valve function
What percentage of people over the age of 66 have lower extremity arterial disease?
30%
*At any given time, one person in every 1000 in the United States has an unhealed venous ulcer
Lower extremity ulcers may be caused by _______, _______ , or ______.
Arterial insufficiency, venous insufficiency, or mixed vascular disease
What is arterial insufficiency?
Lack of sufficient blood flow in arteries to the extremities
What are causes of arterial insufficiency?
Cholesterol deposits (atherosclerosis) or clots Damaged, diseased, or weak vessels
What are the 3 layers of arteries?
tunica intima
tunica media
tunica adventitia
Describe the vascular anatomy of arteries?
Elastic, strong, muscular contractile vessels that convey blood from the heart to the periphery
How is normal venous function characterized?
High standing/ resting pressures
Low walking pressures
Deep veins of the legs are surrounded by skeletal muscles that contract and relax during ambulation and other activities
Describe venous blood flow?
from the periphery back to the heart
What causes 90% of arterial problems in the legs?
Atherosclerosis
What are risk factors for arterial ulcers?
Smoking Diabetes Hyperlipidemia Hypertension Obesity Physical inactivity Male gender Advanced age Strong family history
Arterial ulcers do not heal unless tissue ______ is restored.
perfusion
What percentage of patients w/ a venous ulcer have some degree of coexisting arterial disease?
21% to 25%
What are risk factors for venous vascular ulcers?
Thrombophilia DVT Trauma Obesity Sedentary lifestyle and occupation Advanced age High # of pregnancies Varicose veisn Family history of venous disease
What is ABI and what does it mean?
Ankle-Brachial index
is the ratio of the systolic pressure in the ankle relative to the systolic pressure in the brachial artery in the arm
What is the Toe-Brachial index?
substituting the systolic pressure in the great or second toe for the ankle pressure
What are musculoskeletal tests and measures for vascular ulcers?
ROM and muscle performance is assessed
What are neuromuscular tests and measure for vascular ulcers?
The Six P's Pain Pulselessness Pallor Poikilothermy (body temp that varies w/ environmental temp) Paresthesia Paralysis
What are cardiopulmonary tests and measures of vascular ulcers?
Examine circulation- color and temp of involved area
Palpation of LE pulse sites
ABI & TBI readings
Transcutaneous partial pressure of oxygen measurement
Venous and capillary refill time
What does it mean if venous filling time is faster than normal?
It may indicate venous insufficiency
Retrograde flow will cause veins to fill more rapidly
What may a more than 3 second delay in capillary refill indicate?
Arterial insufficiency
List the indicators of arterial insufficiency?
trophic changes, such as thickened toenails, loss or thinning of hair, and shiny skin and absent or diminished pulses along with a low ABI and TBI
What are the integumentary tests and measures?
wound location; dimensions
wound bed characteristics, appearance, and color; drainage; undermining, tracts, or tunnels; and the status of the wound edges
What are other indicators of venous insufficiency?
lower extremity edema, hemosiderosis, venous dermatitis, ankle flare, and lipodermatosclerosis
When is culturing of the wound bed warranted?
Wound fails to heal There is deterioration Spreading erythema Increase in the amount of drainage Onset of purulent drainage Increasing pain Increased odor
If a patient has poor calf muscle function what would this impair?
It would impair the function of the calf muscle pump thus reducing peripheral venous return
What determines the patient’s prognosis for healing from a vascular ulcer?
The type and severity of the vascular compromise
What percent of chronic wounds are associated with malignancy
33%
Which preferred practice patterns can these wounds be classified in?
7A 7B 7C 7D 7E
Which preferred practice pattern refers to Impaired integumentary integrity associated with partial-thickness skin involvement and scar formation ?
7C
This preferred practice pattern refers to Primary prevention/risk reduction for integumentary disorders?
7A
Which preferred practice pattern refers to Impaired integumentary integrity associated with skin involvement extending into fascia, muscle, or bone and scar formation?
7E
Impaired integumentary integrity associated with skin involvement extending into fascia, muscle, or bone and scar formation is which preferred practice pattern?
7B
This preferred practice pattern refers to Impaired integumentary integrity associated with full-thickness skin involvement and scar formation?
7D
What are the priorities in wound management intervention?
Determining and correcting etiological factors
Addressing systemic factors
Providing appropriate topical therapy
What determines the interventions used for patients w/ arterial ulcers and LE arterial disease?
Based on the severity, stage, and symptoms of arterial disease; patient’s general medical status; goals of therapy; and expected outcome or prognosis
What type of dressing would you use for arterial ulcers/ LE arterial disease?
Nonadherent dressings
*this type of dressing keeps the wound moist
When would you perform a debridement of arterial ulcers?
only if there is adequate perfusion or when the wound is infected
What is the primary focus of interventions for arterial ulcers/ LE arterial disease?
Increase blood flow
Diminish pain
What is the most critical component for patients with venous insufficiency with or w/o ulceration?
Compression
Which type of compression has been shown to accelerate the healing of venous ulcers?
Static elastic compression
What is a contraindication for ALL forms of compression?
Symptomatic heart failure and patients with a thrombus
Why would you use a intermittent pneumatic compression pump?
To provide additional dynamic compression beyond static compression
What is the most common surgical option for venous ulcers?
Subfascial endoscopic perforator surgery (SEPS)
What interventions should you use for patient’s w/ venous ulcers?
Education Debridement Dressings Skin substitutes—bioengineered skin equivalents Exercise, gait training, and positioning Pain management Ultrasound and electrotherapy Nutrition Surgical options - most common is subfascial endoscopic perforator surgery (SEPS)
What surgical options would you use for patients with arterial ulcers?
revascularization, debridement, amputation
What interventions would you use for patients w/ arterial ulcers/ LE arterial disease?
Pain management Exercise and activity Electrotherapy Intermittent pneumatic (dynamic) compression Hyperbaric oxygen therapy Nutrition Surgical options - revascularization, debridement, amputation Education
When you not apply compression for venous and arterial disease?
Compression therapy should not be instituted if the ABI is less than 0.5
When you should avoid interventions in patients w/ venous and arterial disease?
If the patient has moderate arterial insufficiency and there is edema caused by venous insufficiency or dependent positioning, a trial of modified- or low-pressure compression of 23-30 mm Hg at the ankle may be used
Which of the following are risk factors for pressure ulcer formation? A. Friction B. Shear C. Pressure D. Moisture E. All of the above
E. all of the above
During the proliferation phase of healing, which cells are responsible for producing the collagen that forms connective tissue?
Fibroblasts
Tissue anoxia and resulting cell death can occur if the external pressure is greater than the capillary closing pressure. What is capillary closing pressure?
Capillary closing pressure is defined as the pressure that occludes the smallest blood vessels
How does moisture from urinary incontinence contributes to pressure ulcer formation?
Changing the pH of the skin
Increasing bacterial load of an existing skin lesion
Increasing tissue destruction from shear and friction
Corticosteroids can interfere with wound healing by which mechanism?
Interfering with cellular and chemical activity responsible for the inflammatory response to injury
Thick necrotic drainage often accompanied by a foul odor is termed?
Purulence
The fan-shaped subcutaneous wound extension that is the result of destruction of the connective tissue between the dermis and subcutaneous tissue is termed?
Undermining
Alleviating causative factors by altering seating and bed surfaces, protecting the skin, and frequently changing the patient’s position are part of what?
Standard precautions of care for all pressure ulcers
A stage IV sacral ulcer has a large amount of necrotic tissue and a minimum-moderate amount of exudate on the old dressings. The patient has no fever, chills, or other signs of systemic infection. The most appropriate adjunct modality to facilitate wound healing at this point would be?
Pulsed lavage w/ suction
Vacuum-assisted closure facilitates wound healing by which mechanisms?
Reducing the bacterial load.
Effectively managing exudates and thereby preventing further periwound skin damage.
Increasing the amount of granulation tissue in the wound bed.
What is a noninvasive test therapists may use to screen for lower extremity arterial compromise?
Ankle brachial index
How much pressure is considered “standard” for compression to treat venous insufficiency?
30 to 40 mm Hg
Infection may NOT be obvious in patients with arterial compromise because of which of?
Reduce perfusion
Successful treatment of leg ulcers requires attention to?
Adequate blood flow
Prevention of infection
Controlling systemic factors
The most important aspect of venous ulcer intervention is?
Compression therapy
What is the ABI value associated with lower extremity intermittent claudication?
0.5
Venous ulcers tend to be ____ and ___?
Shallow and wet
Leg pain that increases with lower extremity elevation is associated with?
Arterial insufficiency
Venous insufficiency may be a complication for?
A seated occupation
Valvular incompetence
Obesity
What is the most common cause of venous ulcer recurrence?
Nonadherence to compression therapy
Treatment of SEVERE arterial insufficiency usually involves?
Surgical intervention
What are neuropathic ulcers assoicated with?
Sensory and autonomic neuropathies
Poorly fitting shoes with inadequate distribution of pressure during the gait cycle
Diabetes
What is Charcot foot?
Collapse of the foot arch resulting in a rocker sole
What can ROM limitations in a diabetic patient’s feet cause?
ROM limitations may cause abnormal peak pressures during gait and thereby contribute to ulcer formation
What type of patient is at highest risk for neuropathic ulcers?
Peripheral neuropathy w/ loss of sensation
Where to neuropathic ulcers usually occur?
- On the distal digits
- On the weight-bearing surfaces of the foot
- On the dorsal IP joints
What type of exercise is appropriate for a patient with a neuropathic ulcer?
Bicycle
What is the purpose of any off-loading device for a patient with a neuropathic ulcer?
To distribute the plantar foot pressure and reduce stress at the wound site
What should you inspect in patients w/ neuropathic foot ulcers?
Skin
Nails
Shoes and socks
What should instructions for a patient w/ neuropathic ulcers include?
Foot and skin protection
How do partial thickness burns differ from superficial burns?
Partial thickness burns affect the dermis, and superficial burns affect the epidermis
What would you expect to happen during the first few weeks after a full thickness burn injury?
patient will be treated with intravenous fluids, wound care, and physical therapy and be scheduled for skin grafting surgery.
What is the most likely cause of weakness in a 53 y/o patient 2 weeks following a 22% total body surface area (TBSA) burn injury?
Disuse and increased catabolism secondary to the burn injury
What is a common etiology of a burn injury?
Flame
Chemical
Contact
Scald
In what position should a patient’s shoulder rest after an axillary burn?
90 to 110 degrees of shoulder abduction with slight horizontal flexion
For which type of patient is anticontracture positioning recommended for?
Any patient w/ a contracting scar
In which phase of healing is ROM for scar tissue lengthening thought to be most beneficial
Proliferation and remodeling phase
Ambulation training is often started as soon as a burn patient is medically stable and able to follow directions to help achieve which outcomes?
Improved strength
Increased ROM
Edema control
Improved aerobic capacity
Where do pressure ulcers usually occur?
over bony prominences where the weight of the body is distributed over a small area, thereby producing high local pressure
What are the 5 stages of acute wound healing?
Hemostasis Inflammation Proliferation Epitheilalization Remodeling
What occurs during epithelialization?
epithelial cells migrate across the wound bed and produce a single-cell thick layer to cover the granulation tissue
What happens during the proliferation phase?
visible hallmark is granulation tissue, made up of new capillaries and connective tissue
In which phase does collagen in the dermal layer is reorganized to optimize tissue strength, maximize tissue mobility, and minimize scarring occur?
Remodeling
What happens during hemostasis?
begins as soon as tissue destruction occurs; lasts for about 30 minutes after the initial injury and prevents excessive bleeding, edema, and further tissue damage
What phase is described as complex sequence of events involving numerous cells and chemicals lasts 3-7 days and begins with phagocytosis?
Inflammation
What are chronic wounds?
Failure to progress through a normal, orderly, and timely sequence of repair or wounds that pass through the repair process without restoring anatomic and functional results
What are the causes of pressure ulcers?
shear
pressure
friction
moisture
Which cause of pressure ulcers occurs b/c of prolonged exposure of the skin to excessive moisture macerates the epidermis and increases the susceptibility of tissue to destruction from shear and friction?
Moisture
How does pressure cause pressure ulcers?
when external pressure applied to tissue exceeds the capillary closing pressure in that tissue, the capillaries become occluded, preventing blood flow and causing tissue hypoxia or anoxia and eventual cell death
How does friction cause pressure ulcers?
destroys the superficial layers of the skin when two surfaces rub against each other
How does shear cause pressure ulcers?
forces that compress, distort, or tear cutaneous and subcutaneous capillaries, resulting in tissue ischemia
In a typical patient examination for pressure ulcers what should be assessed?
Focused on the causes of wound formation including onset, medical history, and functional status
Nutritional status and psychosocial issues are often assessed
What are the risk assessment scales used to assess pressure ulcers
Norton Scale and Braden Scale
Minimum Data Set
Outcomes and Assessment Information Set
Spinal Cord Injury Pressure Ulcer Scale
What tests and measures should be used for pressure ulcers?
Tissue description Drainage Periwound skin color Edema Wound size and edges Clinical test; serum albumin, prealbumin, BMI, ABI, blood glucose levels Sensations; touch, temp, pressure, vibration and proprioception Pain levels
What are the factors that can prevent PUs or facilitate wound healing?
Caregiver education Use of support surfaces Positioning Moisture control Adequate nutrition
What are support surfaces?
Including wheelchair cushions, bed overlays, and specialty mattresses
Distribute pressure to decrease the amount of pressure over a body part at risk for PU formation
What are positioners?
support devices used to off-load bony prominences and to maintain optimal position of a body part, thereby reducing the risk of ulceration or promoting healing of an existing ulcer
What are protectors?
soft devices that use foam, gel, air, fiber, or other pressure absorbing materials to protect bony prominences from shear and friction
What is the ideal sitting position for prevention of PUs?
One that distributes the body weight to non bony ares and that off loads bony prominences
What are alternative positions for bed bound patients?
30 degrees and 150 degrees sidelying
What are the goals of nutrition interventions for patients w/ PUs?
Provide sufficient calories, protein, fluid, vitamins to facilitate wound healing and closure
What interventions would you use for moisture management?
Bladder training
Prompt voiding
Absorbent underpants
Where are primary dressings applied?
directly to the wound bed
Why are secondary dressings applied?
to anchor or contain the primary dressings
Appropriate wound dressing will keep the wound bed _______ while keeping the periwound skin ______.
Moist
Dry
What is the removal of nonviable tissue and foreign bodies from the wound bed, is an important part of wound-bed preparation?
Debridement
What adjunctive therapies can be used along side tissue off loading, debridement, and provision of a moist wound environment?
Pulsed lavage with suction Vacuum-assisted closure Electrical stimulation Ultraviolet C Ultrasound
To manage moisture tissue loads what should type of bed surface should you select?
Increase support area Low moisture retention Reduced heat accumulation Shear and pressure reduction Dynamic properties Cost per day Check for "bottoming out" *foam and egg crates are cheap but can bottom out
In sitting, what must you keep in mind when managing tissue loads?
proper postural alignment
distribution of weight, balance, stability
continuous pressure relief
prescribed cushions /positioning devices
written plan: reposition at least every hour, shift weight every 15 minutes
What would a complete treatment plan for pressure ulcer care include?
Nutritional support and hydration
Management of tissue loads, friction and shear
Ulcer care: managing bacteria colonization and infection
Maximizing wound healing
Caregiver education
Select dressing that keeps the wound bed ____ moist and the surrounding tissues ____.
Moist
Dry
What are selective forms of debridement?
Sharp, autolytic, and enzymatic
What are non selective forms of debridement?
Mechanical
Surgical
What is surgical debridement?
Performed by a Physician, podiatrist, or PA
Removes all necrotic tissues and even some viable tissues
What is sharp debridement?
Selective removal of necrotic, infected, or foreign tissue w/ sterile instruments
Performed at an outpatient clinic
What is a mechanical debridement?
Non-selective removal of devitalized tissues from the wound and periwound areas using friction or pressure
May be painful
Used for loose debris or exudate
Includes moist to damp dressing, abrasion, syringe irrigation, or whirlpool
What is autolytic debridement?
Phagocytosis of necrotic tissue by WBC
Facilitated by moisture retentive dressings
Selective and pain free
Effective for superficial eschar/ not for large amounts of eschar
What is enzymatic debridement?
Application of enzymes in a topical ointment to facilitate liquefaction and digestion of non-viable wound tissues
Selective and pain-free
Helpful adjunct to sharp or autolytic debridement
What are two topical ointments for enzymatic debridement?
Collagenase
Paparin urea based combinations
Sensory neuropathy can be cause by damage to _____ and prevent patients from feeling ______.
small nerve fibers
pressure of a callus or foreign body
Describe a motor neuropathy?
Caused by damage to the large fibers
Intrinsic muscles of the foot atrophy and weaken
Force imbalances in the foot and lower extremity cause the tendons to pull in deviated alignment
Structural deformities develop
Describe an autonomic neuropathy?
Caused by damage to the large nerve fibers and the sympathetic ganglia
Decreases the production of sweat and oil in the skin, causing it to become dry and inelastic
What are the two most common complications in patients w/ hyperglycemia?
Impaired wound healing and suppressed immune responses
What pathology is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion and/or action?
Diabetes mellitus
Which type of diabetes is caused by progressive autoimmune destruction of the insulin secreting beta cells in the pancreas?
Type 1
Which type of diabetes is the Most common form of diabetes in older adults
Generally caused by a combination of insulin resistance and beta-cell failure
Excess circulating glucose causes tissue and organ damage?
Type 2
What are musculoskeletal tests and measures for patients w/ diabetes
Decreased soft tissue extensibility and joint capsule mobility causes decreased ROM and interfere with functional activities
Multiple changes in the form and function of the foot and lower extremity
ROM of the foot and ankle should be measured in patients with NUs because limited joint mobility in these areas can lead to increased plantar pressures and may be a risk factor for foot ulceration
What are neuromuscular tests and measures for patients w/ diabetes
Diminished reflexes occur in patients with diabetic neuropathy because of large motor nerve involvement
Sensation is tested using nylon monofilaments for
pressure and a tuning fork for vibration
Graded tuning forks or the 128 Hz tuning fork can be used to test vibratory sense and identify diabetic peripheral neuropathy
Measurement of plantar skin temperature is recommended to help locate infection, inflammation, or the fracture of an acute Charcot neuroarthropathy
What are cardiovascular tests and measures for patients w/ diabetes
Pedal pulses are usually the first screening test for poor peripheral circulation
Faint or absent pulses are confirmed with a Doppler test
PT will often evaluate arterial circulation by measurement of the ABI
Capillary refill test
Venous filling time
Rubor of dependency test
Great toe pressure
Transcutaneous oxygen tension
Systemic blood pressure
What are integumentary tests and measures for patients w/ diabetes
Traumatic wounds and incision sites should be observed for signs of complications with healing
Areas of special concern include:
Between the toes where maceration is common
Under the metatarsal heads where callus formation is common
Any areas of erythema or warmth
Cracks or fissures in the plantar heel
Thorough wound assessment (including measurements, location, tissue type, and drainage) should be performed
What is the simplest and most frequently used diagnostic scale for NUs?
The wagner scale
The University of Texas foot classification system?
provides more detailed information and may be preferable in multidisciplinary diabetic foot clinics and in multicenter research
What grade on the Wagner Scale is given to a deep ulceration, infection w/ cellulitis, osteomyelitis, or abscess formation?
Grade 3
What is the characteristics of a grade 5 neuropathic ulcer on the Wagner Scale?
Full foot gangrene
What grade on the Wagner Scale is given to a bone deformities, calluses, skin changes that are at risk for developing wounds, or postulceration that has healed?
Grade 0
What grade on the Wagner Scale is given to subcutaneous tissue involvement, infection, no bone involvement?
Grade 2
What are the characteristics of a grade 4 neuropathic ulcer on the Wagner Scale?
Partial foot gangrene or necrosis
What grade on the Wagner Scale is given to full thickness skin loss w/ no infection, usually of neuropathic etiology?
Grade 1
What is shown to be the best clinical measure for detecting patients at risk for new ulcers?
Neuropathic disability score (NDS)
What interventions used for patient’s w/ diabetes w/ neuropathic ulcers?
Patient education on foot care
Blood glucose control
Exericse to help reduce blood glucose levels
Ankle foot orthosis w/ peripheral motor neuropathy to cause foot drop
Properly fitting footwear
Treatment of neuropathic wound
What is the best treatment for off loading of neuropathic wounds?
Total contact cast (TCC)
At what grade on the Wagner Scale is the TCC indicated?
Grade 1 or 2
At what grade on the Wagner Scale is the TCC contraindicated?
Grades 3-5
What is the most common problem w/ TCC?
is the formation of NUs over pressure points if the cast is not properly fitted and padded
When are surgical dressings removed postoperatively?
The first or second day
The wound is ________ to remove as much of the postoperative bleeding as possible.
irrigated
In the post healing foot what percentage of the time should therapeutic shoes be worn to be effective?
at least 60% of the time
What bill mandates reimbursement for 80% of the cost of footwear and orthotics for patients with diabetes and associated foot problems?
Medicare Therapeutic Shoe Bill
What do studies suggest may help distribute the plantar pressures along the plantar surface of the foot?
wearing socks w/ shoes
What are the goals for rehab of burn injuries?
Care of the burn wound Managing edema Preserving and increasing mobility and strength Improving function Controlling scar formation
What is criteria for burn severity base on?
burn depth and size, the age of the patient, the anatomical area burned, and associated injuries
What causes scald burns?
Hot liquids
*most common in pediatric burns
Following acute burn shock, the body is in a state of ______ and ___________.
hypermetabolism and protein catabolism
What type of burn may have surface burns because of an associated flash, as well as entrance and exit wounds where the current entered and exited the patient?
electrical burn
What type of burn occurs when contact is made with a hot object or when contact is made with a rapidly moving object?
Contact burn
This type of burn result from direct contact with flaming objects or clothing that has been ignited with a flame?
Flame burns
This type of burn tends to be deep and is related to industrial accidents?
Chemical burns
How is edema measured after burns?
using volumetry, circumference measurements, or figure-of-eight measurements
What causes restrictions of ROM in patients w/ burns?
Wound contraction, edema, and pain
Strength testing is done via?
Manual muscle testing
Why do patients w/ burns often have decreased strength?
Loss of lean body mass caused by catabolism of muscle protein associated w/ burn trauma and healing
How is pain caused by a burn generally described?
burning, severe, acute
What generally replaces the pain after the burn wound has healed?
pruritis (itching)
What type of burns are very painful and certain care procedures including dressing changes and some exercise can increase pain?
Superficial burns
What is the most common neurological complication after a burn injury?
Peripheral neuropathy
What responses to a burn injury are mainly related to fluid moving from blood vessels to the interstitium?
Direct cardiovascular and pulmonary
What are always checked in patients w/ burns?
BP and body temp
What is associated w/ decreased cardiac output?
Burn shock
Patients with burns and an associated _______ injury have a much higher mortality rate
inhalation
What determines the depth of the burn?
Temp and duration of the tissue exposure to extreme heat
What do partial thickness burns involve?
damage to the dermis and may be separated into subclassifications of superficial or deep partial-thickness burns
Characterized by blister formation
What do full thickness burns involve?
complete destruction of the epidermis and dermis
What are the two most common methods use to estimate burn size?
The rule of nines and the Lund & Browder chart
What is one of the most problematic late morbidities associated w/ burn injury and wound healing?
Scarring
What are the most common variables to quantify and document findings from the examination of a scar?
the level of hypertrophy (height), the amount of redness or inflammation (vascularity), level of extensibility (pliability), and the amount of contraction
What preferred practice patterns are used?
7B, 7C, 7D
If there aren’t any complications how long would it take for a partial thickness burn to heal?
14 days
How are superficial burns typically treated?
with a lotion
Partial thickness burns are ____ and should be kept ____.
moist
moist
Deep partial-thickness and full-thickness burns have the best outcome when treated?
surgically (skin graft)
How can burn related edema be treated?
positioning programs or overlapping layers of compression
What is the most common type of behavioral pain control strategy used in PT?
Reinforcement
What are cognitive techniques frequently used to manage procedural burn pain?
Distraction and reappraisal
What can be used to prevent deformity from contracture, to maintain or increase ROM, and to protect a fragile area of tissue?
Splinting
In burn patients how should ROM exercises be performed?
in anatomical planes and focus on opposing the direction of wound and scar tissue contraction forces
In burn patients, when can ambulation training begin?
once the patient is medically stable, alert, and able to follow directions
What should you apply over a scar to minimize hypertrophic scarring?
Compression garments or bandages
Aerobic conditioning should include?
focus on large muscle groups and rhythmic activities such as cycling, walking, or running
What are the effects of UV radiation?
Erythema Production – redness caused by superficial blood vessel dilation. Tanning Epidermal Hyperplasia Vitamin D Synthesis Bactericidal Effects Effects on immune system
What is UV-C?
bactericidal; but usually filtered out by the ozone layer; short-wave UV
What is UV-B?
sunburn, Vitamin D – effect on the skin is tanning and epidermal hyperplasia
What is UV-A?
florescence, long wave UV
What influences the absorption of UV?
Medications
Limited absorption: just in the first few mm depth of skin
When when should you use UV?
Acne, psoriasis
Wound care for bactericidal effects of UV-C
Osteoporosis UV of all types will help hold Vitamin D
What are safety considerations w/ UV?
Eye protection for both you and the patient
Do not look directly at light source
Do not apply to unprotected eyes if treating the face
Long term exposure to UV-A and UV-B is carcinogenic and actinic (ages the appearance of the skin) PT will be limited, not intended to last for months!
Burning (superficial and superficial partial thickness) can occur with incorrect dose
How do we know if we have reached the correct exposure time for the treatment goals?
SED – suberythemal dose – no change in skin redness in 24 hours after UV exposture (not enough for treatment goals)
MED – minimal erythemal – smallest exposure time that produces erythema within 8 hours that disappears within 24 hours
Exposure time will change with the medical problem; could by 2 – 3 x MED
What is First degree erythema?
Definite redness with some mild desquamation appears within 6 hours and lasts for 1 to 3 days. Dose generally 2.5 times MED.
What is second degree erythema?
Intense erythema with edema, peeling and pigmentation appears within 2 hours or less and is like severe sunburn. Dose generally 5 times MED.
What is third degree erythema?
Erythema with severe blistering, peeling, and exudation. Dose generally 10 times MED.
What is the UV treatment technique?
Determine MED on day before treatment is to begin
MED: minimal erythemal dose
Physician recommendation may be for 2 or 3 x the MED
With each visit, increase treatment time by 10% to 50% with max time of 5 minutes. 5sec time frequently sufficient.
Keep treatment height constant (inverse square law applies) 60-80 cm
Keep light source perpendicular to the treating surface
Which UV ray penetrates deeper?
UVA penetrates deeper than UVB or UVC
Which UV rays are almost entirely absorbed in the superficial layers of the skin?
UV-B and UV-C
When is UV radiation less deep?
On thicker or darker pigmentation
What are contraindications for UV?
Eyes – never expose the eyes to light radiation
Conditions adversely affected by UV radiation: Skin CA, fever, pulmonary tuberculosis, cardiac conditions, liver or kidney diseases, SLE
What are precautions for UV?
Use of photosensitizing meds: antibiotics, Ag-based arthritis meds, some cardiac meds, phenothiazines, psoralens for psoriasis
Photosensitive patients
Recent Radiation therapy
Do not treat again with UV until the effects of the prior treatment have gone
Buoyancy
force that works in the opposite direction to gravity
gravity pulls downward, buoyancy pushes upward from the bottom
when object placed in water, displacement occurs because of upward pressure of buoyancy
amount of displacement (Archimedes)- immersed body will experience and upward thrust equal to the weight of the liquid displaced
larger objects = greater buoyant forces due to more water displacement. Smaller objects = less buoyancy.
Why does buoyancy matter?
Body submersion decreases stress on joints, muscles and connective tissues.
Helps raise weakened body parts against gravity.
Assists the therapist in supporting the weight of patient’s body during therapeutic activities.
What is hydrostatic pressure?
Pressure exerted by water on an object immersed in water
What is Pascal’s law?
pressure of a liquid is exerted equally on an object at a given depth and the object will experience pressure that is proportional to the depth of immersion
Specific gravity of a person increases when there is _____ in bone mass and muscle mass
increase
Specific gravity of a person is ______ when there is greater amounts of adipose tissue?
decreases
Specific gravity less than 1 will ____ and great than 1 will ____.
less than floats
great than sinks
What is the specific gravity of the body?
.87-.97
What provides resistance to motion of a body in water?
viscosity
The resistance is ______ the direction of movement and ________ in proportion to speed of body’s motion and the frontal area of body part in contact with water.
opposite
increases
What is specific heat?
Amount of heat, in calories required to raise the temperature of 1 gram of a substance by 1 degree C
Specific heat of water and air is?
Water = 4.19 J/gm/C Air = 1.01 J/gm/C
Arthritis benefits from ____ water.
warmer
What is product of several forces acting on an object immersed in water?
Turbulence
What is horizontal flow of water passing over a body part in motion that creates drag?
Laminar flow
What inhibits movement by resisting forward motion?
Drag
What is encountered initially as a body moves through the water, creating a positive pressure?
Frontal resistance
What are the cardiovascular effects of hydrotherapy
increased venous circulation
Increased cardiac output
Increased cardiac volume
Decreased heart rate, systolic blood pressure, and VO2 response to exercise
What are the respiratory effects of hydrotherapy?
Decreased vital capacity
Increased work of breathing
Decreased exercise-induced asthma
What are the musculoskeletal effects of hydrotherapy?
Decreased Wt Bearing
Strengthening
Effects on bone density loss
Less fat loss than with similar land based exercise
What are the cleansing effects of hydrotherapy?
Pressure to remove debris
Dissolved surfactants and antimicrobials to assist with cleaning.
How does hydrotherapy control pain?
Studies show decreased pain in patients with OA and fibromyalgia.
Thought to stimulate peripheral mechanoreceptors to gate transmission of pain signals to spinal cord
More stim=less pain (e.g. higher temp w/ increase H2O agitation).
Cold water for reducing acute inflammation
How does hydrotherapy control edema?
Used with lymphatic insufficiency, renal dysfunction, and post-op inflammation. Uses cold water to cause vasodilation in conjuction with effect of hydrostatic pressure. Contrast baths (switching between warm and cold water) to create pumping action thru alternating vasodilation and vasoconstriction.
Whirlpool for wound care?
Has decreased in use over the last 5-10 years.
Was used to cleanse wound, assist with debridement of necrotic tissue and to increase circulation in area via warm water to assist with healing.
Concerns: potential for wound infection from bacteria, cytotoxic effect of cleansing additives, and soft tissue damage due to inability to control fluid pressures.
What do turbines do?
Mix air and water to provide agitation and turbulence to the water in tank
Mechanical stimulation from agitation to skin receptors may promote analgesic effect
More air that is mixed with water, more turbulence
How much psi should non immersion irrigation devices deliver to remove debris w/o damaging tissue?
4 to 15 psi
Why would you use a hubbard tank?
Hubbard tanks are whirpool tanks to accommodate supine position and allow ROM in both UE and LE with support from the water
Hubbards are used for patients who cannot be transferred into a low boy or who have too large a surface area for treatment
Hubbards have lifting devices to transfer-usually hydraulically controlled
Contrast bath
Alternately immersing extremity in warm/hot and then in cool/cold water.
For: 1/edema; 2/pain control; 3/desensitization.
20-25 min tx duration; 3-4 min warm; 30sec-1min cold; for a total of 5 to 6 repetitions.
What are contraindication for local immersion forms of hydrotherapy
maceration around a wound
bleeding
What are precautions for local immersion forms of hydrotherapy
Impaired thermal sensation in the area
Infection in the area
Confusion or impaired cognition
Recent skin grafts
What are contraindication for full body immersion forms hot of hydrotherapy
Pregnancy
MS
Poor thermal regulation
What do venous ulcers look like?
wet, pain free, deep red color, on the medial side
What do arterial ulcers look like?
dry, painful, pale, yellow, black, on the lateral side
What are the stages of a pressure ulcer?
Stage 1- Non blanchable erythema Stage 2- Break in skin Stage 3- Partial thickness Stage 4- Full thickness Stage 5- Bone exposure
What are the %’s given to the body parts of an adult burn victim using the rule of 9s?
Head 4.5% Front & 4.5% Back
Truck 18% Front & 18% Back
Arms 4.5% Front & 4.5% Back (per arm)
Legs 9% Front & 9% Back (per leg)
Intermittent pneumatic compression
Increases blood flow by mimicking calf muscle pump during ambulation
Alternating compression and release of compression every few seconds
Treatment last 45 min to 3 hours
Mostly used for venous insufficiency
Can be used w/ intermittent claudication and limb threatening PAD
Who is Intermittent pneumatic compression a contraindication for?
Severe arterial disease in which ABI < 0.5
Peripheral edema cause by CHF
