Exam 2: Week 10, Diabetic/Neuropathic Ulcers Flashcards
Differentiate between type 1 and type 2 diabetes
Type 1: Developed at a young age
Type 2: Developed over time as a teen/adult (Much more common than type 1)
T or F? Individuals with type 2 diabetes are 2-4x more likely to have a heart attack or stroke, 5x more likely to get a foot ulcer/gangrene, and 17x more likely to have kidney disease, and is 8x more likely of going blind (most common cause of blindness)
True
Why are diabetic ulcers the hardest wounds to heal?
Because diabetes affects small arteries (capillaries) and the patient is sometimes unable to feel it
(Note: Arterial affects larger arteries, diabetic affects smaller arteries)
List some facts about diabetes
- 1/4 of people are unaware that they have the disease
- 4% higher mortality rate than those withiut diabetes
- 8% of patients with type II DM have PVD as well
- 50% will have contralateral ulcer within 18 months
- 50% will have second amputation within 3-5 years
- 70% of all amputations are due to DM
List the blood glucose guidelines for patients with diabetes
In General:
- 80-120 mg/dL before meals or when waking up
- 100-140 mg/dL at bedtime
(Note: people with DM may have >200 mg/dL after eating a meal)
List the hemoglobin (HgB) levels of a normal patient, a pre-diabetic patient, and a diabetic patient
Normal: <5.7%
Prediabetes: 5.7-6.4%
Diabetes: >6.5%
What affects does hyperglycemia have on the body?
- Changes RBCs, platelets, and capillaries
- Alters blood flows (micro-circulation)
- Increases microvascular pressure
Describe neuropathic ulcers
- Occurs as a result of nerve damage (neuropathy)
- Plantar aspect of the foot
- May occur under calluses
- May occur in places where pressure and friction are present when wearing inappropriate footwear
- Pain is usually absent/minimal
- Little to no drainage
T or F? Forefoot location accounts for the majority of all ulcers and heal faster than midfoot/heel ulcers, while charcot foot is most common near the midfoot
True
List the risk factor for vascular disease (PVD & accelerated atherosclerosis)
TcPO2/TCOM <30mmHg
List the risk factor for neuropathy
<5.07 monofilament
List the risk factor for abnormal foot function and inadequate footwear
Charcot, claw toes, hammer toes
List the risk factors for impaired healing and immune respone
Thickening of basement membrane (= less O2 delivery)
List some risk factors for neuropathic ulcers
- Inadequate care/education
- Poor vision
Which is more likely to cause a diabetic ulcer? Ischemia or neuropathy
Neuropathy
Describe neuropathy
- Most common complication of diabetes
- Affects 30-40% of type 2 and even more type 1
- May be caused by neural ischemia and segmental demyelination
- Symmetrical, distal
- Increases risk of plantar ulceration >3.5 times
- Affects sensory, motor, and autonomic systems
Why is it not uncommon to see an amputee develop an ulcer on the contralateral limb?
Because all the pressure is now on one limb rather than two
How can individuals with diabetes limit tissue damage?
Monitor/Regulate blood sugars
Where do venous, arterial, and neuropathic/diabetic ulcers form?
Venous: Lower limb
Arterial: Foot
Neuropathic/Diabetic: Foot
List the distribution of ulcers in the forefoot
Top of Big Toe: 8%
Top of Middle Toe: 8%
Bottom of Big Toe: 20%
Bottom of Mid Foot: 22%
Bottom of Middle Toe: 28%
Describe neuropathy
- Most common complication of diabetes
- Affects 30-40% of type 2 diabetics, and affects type 1 even more
- May be caused by neural ischemia (not enough blood to brain), or segmental demyelination
- Typically symmetrical and distal
- Increased risk of plantar ulceration (3.5x risk) because the patient is unable to feel sensation
T or F? Diabetic ulcers have “callused” edges whereas arterial ulcers have “punched out” edges
True
List the 3 types of neuropathy
Sensory Neuropathy:
- Gradual/painless
Motor Neuropathy:
- Leads to muscular atrophy (which increases plantar pressure)
- If patient controls his/her blood sugar, this patient should not get motor neuropathy
Autonomic Neuropathy:
- Sweat, callus, change in blood flow
Describe Sensory Neuropathy
- 50% of patients are unaware they have lost protective sensation
- Parasthesias (burning pain, tingling, aching)
- If patient is unable to feel a 5.07 monofilament test, patient is at risk for ulceration
Describe Motor Neuropathy
- Leads to paralysis/weakness of foot intrinsic muscles as a result of poor blood sugar control
- Decreased foot stability (especially during “stance phase”)
- Leads to deformities (hallux valgus, claw toe, high arch)
- Muscle atrophy increases pressure and shear forces to the foot
Describe Autonomic Neuropathy
- Dry, cracked skin due to increased ability to sweat
- Increased risk of callus formation
- Arteriovenous shunting leads to decreased perfusion (which decreases ability to heal/repair self)
- Uncontrolled vasodilation leads to osteopenia (can lead to charcot foot developing)
List the foot deformities
- PF contracture
- Varus/valgus
- Charcot foot
- Toe deformities
- Bunion
- Calluses
What is charcot foot?
“Rocker bottom” foot as a result of neuropathy that impairs the nerves and causes the bones to abnormally form
Describe Diabetic Neuropathic Osteo-arthropathy (DNO)
Inflammatory response
- Characterized by foot edema, erythema, increases temperature
Bone and Articular destruction occurs
- Leads to multi-joint dislocations and fracture (charcot foot)
Two theories regarding the cause of this
- Neurovascular theory: Uncontrolled vasodilation
- Neurotramatic theory: Patient is unable to feel sensation (which leads to more damage)
T or F? Claw toe deformity is caused by motor neuropathy, muscle atrophy, imbalance of muscles
True
List one cause of ischemic necrosis?
- Narrow shoes
- 2-3 psi buildup over a long period
List one cause of mechanical disruption
- Heat/chemicals or a foreign object
- High pressure could change immediate changes
List one cause of Inflammatory disruption
- Repetitive moderate pressures (40-60 psi)
- Leads to callus/ulcer
List one cause of osteomyelitis
- Moderate force when infection is present (walking)
- Infection pushed into bone
T or F? Poor glycemic control is associated with increased risk of long term complications
(Can be improved with glycemic control)
True
T or F? Diabetes is the leading cause of retinopathy, glaucoma, cataracts
True
Which tests and measures are used for diabetic ulcers?
Sensory Tests
- Monofilament testing (gold standard)
- Vibration testing (tuning fork)
- Pain assessment (0-10)
- Proprioceptive assessment
- Temperature (hot/cold)
Motor Tests
- MMT
- ROM
Autonomic Tests
- Skin check
- Hair/nail check
- Can also use circulation tests (ABI, Rubor, Pulses, Pallor)
Footwear Assessment
- Tracing the foot
Balance Assessment
- Single leg or double leg
- Eyes open or closed
Gait Assessment
T or F? Sensory neuropathy is the leading cause of neuropathic ulcers
True
T or F? Always start with a 5.07 for monofilament testing
True
List the grams produced by each monofilament (4.17, 5.07, 6.10). Explain the interpretation of each (assuming patient is unable to feel)
4.17
- Grams produced: 1g
- Interpretation: Decreased sensation
5.07
- Grams produced: 10g
- Interpretation: Lots of protective sensation
6.10
- Grams produced: 75
- Interpretation: Absent sensation
List the indications for ABI test on patients with neuropathic ulcerations
- Patients with plantar foot ulcerations
- Decreased/absent pulses
- Signs and symptoms of AI
- History of PVD
- History of coronary artery disease
List the indications for a capillary refill test on patients with neuropathic ulcerations
- Ulcer on toe
- Abnormal ABI
- Signs and symptoms of AI
List the indications for a sensory integrity assessment on patients with neuropathic ulcerations
- All neuropathic ulcerations
- Patients with diabetes
- Patients with plantar foot ulcerations
- Patients with neurological injuries
Which scale is used to classify a diabetic ulcer?
Wagner Scale
How can you identify a neuropathic ulcer?
Pain:
- Absent or significantly decreased
Position:
- Plantar aspect of the foot (spots with lots of pressure)
Wound Presentation:
- Round, punched out lesion
- Callus rim
- Little to no drainage (very dry)
- Necrotic base is uncommon
Peri Wound:
- Dry, cracked skin with callus
Pulse:
- Normal
Temperature:
- Normal to increased
Differentiate between a “good” and “poor” neuropathic prognosis ulcer prognosis
“Good” Prognosis:
- Smaller, superficial ulcer (Wagner grade 1)
- Present for <2 months
- Ulcer is decreasing in size within the first 4 weeks of treatment
“Poor” Prognosis:
- Larger size ulcer (Wagner grade 3)
- Ulcer does not decrease size by 20-50% within the first month of treatment
Note: Average healing time is 12-14 weeks (can vary greatly)
T or F? Patients with neuropathic ulcers may not show signs of infection due to decreased inflammatory response/PVD
True
T or F? If no improvement of a neuropathic ulcer is present, this patient should be referred to an MD
True
T or F? Osteomyelitis is usually treated surgically
True
List the signs of hyperglycemia (high blood sugar)
- Fatigue
- Thirst
- Fruity breath
- Increased urination
- Blurred vision
- Dry mouth
- Confusion
- Shortness of breath
List the signs of hypoglycemia (low blood sugar)
- Confusion
- Irritability
- Diaphoresis (excessive sweating)
- Light headedness
List the ways to debride a DM/Neuropathic ulcer with slough and dead tissue
- Autolytic
- Monofilament
- Enzymatic
- Pulse lavage (can also clean biofilms)
- Biological
Do not use these techniques to debride a callus, use sharp
How should you remove a callus/necrotic tissue using sharp debridement?
- Begin in the middle of the ulcer then move out (if the patient does not have PAD)
- Make sure that when you are finished, it is level with the epithelial surface
- Should be done weekly
Is it ok to treat a diabetic/neuropathic patient if he/she has impaired bloodflow?
No
When should you utilize modalities on a diabetic/neuropathic wound?
If the wound has not reduced in size by 50% after 4 weeks
Which biophysical agents (modalities) can be used on diabetic/neuropathic ulcers?
- NPWT (if the wound is not dry)
- Ultrasound (check skin sensation + only use non thermal)
- Estim (check sensation)
- Laser
How should you care for dry feet?
- Can use petroleum to moisturize calluses
- Do not apply moisture between the toes
T or F? Topical growth factors and collagen can be used if the diabetic ulcer is not infected
True
T or F? A patient with a diabetic ulcer should ideally be non weight bearing which means this patient should not use a cane
True
(Note: If patient cannot do non weight bearing, have them partially weight bear with the entire foot on the ground…. greater surface area means less pressure on localized ulcer)
T or F? Modified short leg casts should only be used for grade 1 and 2 ulcers
True
List the contraindications for total contact casts on patients with diabetic/neuropathic ulcers
- Osteomyelitis
- Gangrene
- Fluctuating edema (edema must be controlled before use)
- Infection
- ABI <.5
Who is indicated for a padded ankle foot orthotic?
Low risk patients
T or F? Leather shoes have lots of breathing room and “mold to the foot”
True
How would you educate someone with a diabetic ulcer about shoe recommendations?
- Shoe should be 1/2 inch longer than big toe
- Heels should not be more than an inch off the ground
- Shoe should be made of soft, moldable leather
How should you educate a patient who wants to manage their diabetes and reduce the risk of getting an ulcer?
- Encourage exercise
- Maintain proper diet
- Ensure proper footwear
- Express how important it is to off load and non weight bear
- Tell them about how smoking and vascular complications can impact wound healing
- DO NOT go barefoot and ONLY use white socks without dyes
T or F? ROM, aerobic exercise, and balance activities should be done by the patient after the ulcer has healed
True
What is considered “normal” blood sugar for a diabetic
- 80-120 mg/dL before meals or when waking up
- 100-140 mg/dL at bedtime
What is the average healing time for a diabetic/neuropathic ulcer
12-14 weeks
