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Fall 2024: Integumentary Systems > Exam 2: Week 10, Diabetic/Neuropathic Ulcers > Flashcards

Exam 2: Week 10, Diabetic/Neuropathic Ulcers Flashcards

1
Q

Differentiate between type 1 and type 2 diabetes

A

Type 1: Developed at a young age

Type 2: Developed over time as a teen/adult (Much more common than type 1)

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2
Q

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)

A

True

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3
Q

Why are diabetic ulcers the hardest wounds to heal?

A

Because diabetes affects small arteries (capillaries) and the patient is sometimes unable to feel it

(Note: Arterial affects larger arteries, diabetic affects smaller arteries)

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4
Q

List some facts about diabetes

A
  • 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
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5
Q

List the blood glucose guidelines for patients with diabetes

A

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)

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6
Q

List the hemoglobin (HgB) levels of a normal patient, a pre-diabetic patient, and a diabetic patient

A

Normal: <5.7%
Prediabetes: 5.7-6.4%
Diabetes: >6.5%

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7
Q

What affects does hyperglycemia have on the body?

A
  • Changes RBCs, platelets, and capillaries
  • Alters blood flows (micro-circulation)
  • Increases microvascular pressure
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8
Q

Describe neuropathic ulcers

A
  • 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
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9
Q

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

A

True

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10
Q

List the risk factor for vascular disease (PVD & accelerated atherosclerosis)

A

TcPO2/TCOM <30mmHg

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11
Q

List the risk factor for neuropathy

A

<5.07 monofilament

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12
Q

List the risk factor for abnormal foot function and inadequate footwear

A

Charcot, claw toes, hammer toes

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13
Q

List the risk factors for impaired healing and immune respone

A

Thickening of basement membrane (= less O2 delivery)

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14
Q

List some risk factors for neuropathic ulcers

A
  • Inadequate care/education
  • Poor vision
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15
Q

Which is more likely to cause a diabetic ulcer? Ischemia or neuropathy

A

Neuropathy

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16
Q

Describe neuropathy

A
  • 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
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17
Q

Why is it not uncommon to see an amputee develop an ulcer on the contralateral limb?

A

Because all the pressure is now on one limb rather than two

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18
Q

How can individuals with diabetes limit tissue damage?

A

Monitor/Regulate blood sugars

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19
Q

Where do venous, arterial, and neuropathic/diabetic ulcers form?

A

Venous: Lower limb
Arterial: Foot
Neuropathic/Diabetic: Foot

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20
Q

List the distribution of ulcers in the forefoot

A

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%

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21
Q

Describe neuropathy

A
  • 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
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22
Q

T or F? Diabetic ulcers have “callused” edges whereas arterial ulcers have “punched out” edges

A

True

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23
Q

List the 3 types of neuropathy

A

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

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24
Q

Describe Sensory Neuropathy

A
  • 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
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25
Q

Describe Motor Neuropathy

A
  • 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
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26
Q

Describe Autonomic Neuropathy

A
  • 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)
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27
Q

List the foot deformities

A
  • PF contracture
  • Varus/valgus
  • Charcot foot
  • Toe deformities
  • Bunion
  • Calluses
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28
Q

What is charcot foot?

A

“Rocker bottom” foot as a result of neuropathy that impairs the nerves and causes the bones to abnormally form

29
Q

Describe Diabetic Neuropathic Osteo-arthropathy (DNO)

A

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)

30
Q

T or F? Claw toe deformity is caused by motor neuropathy, muscle atrophy, imbalance of muscles

A

True

31
Q

List one cause of ischemic necrosis?

A
  • Narrow shoes
  • 2-3 psi buildup over a long period
32
Q

List one cause of mechanical disruption

A
  • Heat/chemicals or a foreign object
  • High pressure could change immediate changes
33
Q

List one cause of Inflammatory disruption

A
  • Repetitive moderate pressures (40-60 psi)
  • Leads to callus/ulcer
34
Q

List one cause of osteomyelitis

A
  • Moderate force when infection is present (walking)
  • Infection pushed into bone
35
Q

T or F? Poor glycemic control is associated with increased risk of long term complications

(Can be improved with glycemic control)

A

True

36
Q

T or F? Diabetes is the leading cause of retinopathy, glaucoma, cataracts

A

True

37
Q

Which tests and measures are used for diabetic ulcers?

A

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

38
Q

T or F? Sensory neuropathy is the leading cause of neuropathic ulcers

A

True

39
Q

T or F? Always start with a 5.07 for monofilament testing

A

True

40
Q

List the grams produced by each monofilament (4.17, 5.07, 6.10). Explain the interpretation of each (assuming patient is unable to feel)

A

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

41
Q

List the indications for ABI test on patients with neuropathic ulcerations

A
  • Patients with plantar foot ulcerations
  • Decreased/absent pulses
  • Signs and symptoms of AI
  • History of PVD
  • History of coronary artery disease
42
Q

List the indications for a capillary refill test on patients with neuropathic ulcerations

A
  • Ulcer on toe
  • Abnormal ABI
  • Signs and symptoms of AI
43
Q

List the indications for a sensory integrity assessment on patients with neuropathic ulcerations

A
  • All neuropathic ulcerations
  • Patients with diabetes
  • Patients with plantar foot ulcerations
  • Patients with neurological injuries
44
Q

Which scale is used to classify a diabetic ulcer?

A

Wagner Scale

45
Q

How can you identify a neuropathic ulcer?

A

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

46
Q

Differentiate between a “good” and “poor” neuropathic prognosis ulcer prognosis

A

“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)

47
Q

T or F? Patients with neuropathic ulcers may not show signs of infection due to decreased inflammatory response/PVD

A

True

48
Q

T or F? If no improvement of a neuropathic ulcer is present, this patient should be referred to an MD

A

True

49
Q

T or F? Osteomyelitis is usually treated surgically

A

True

50
Q

List the signs of hyperglycemia (high blood sugar)

A
  • Fatigue
  • Thirst
  • Fruity breath
  • Increased urination
  • Blurred vision
  • Dry mouth
  • Confusion
  • Shortness of breath
51
Q

List the signs of hypoglycemia (low blood sugar)

A
  • Confusion
  • Irritability
  • Diaphoresis (excessive sweating)
  • Light headedness
52
Q

List the ways to debride a DM/Neuropathic ulcer with slough and dead tissue

A
  • Autolytic
  • Monofilament
  • Enzymatic
  • Pulse lavage (can also clean biofilms)
  • Biological

Do not use these techniques to debride a callus, use sharp

53
Q

How should you remove a callus/necrotic tissue using sharp debridement?

A
  • 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
54
Q

Is it ok to treat a diabetic/neuropathic patient if he/she has impaired bloodflow?

A

No

55
Q

When should you utilize modalities on a diabetic/neuropathic wound?

A

If the wound has not reduced in size by 50% after 4 weeks

56
Q

Which biophysical agents (modalities) can be used on diabetic/neuropathic ulcers?

A
  • NPWT (if the wound is not dry)
  • Ultrasound (check skin sensation + only use non thermal)
  • Estim (check sensation)
  • Laser
57
Q

How should you care for dry feet?

A
  • Can use petroleum to moisturize calluses
  • Do not apply moisture between the toes
58
Q

T or F? Topical growth factors and collagen can be used if the diabetic ulcer is not infected

A

True

59
Q

T or F? A patient with a diabetic ulcer should ideally be non weight bearing which means this patient should not use a cane

A

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)

60
Q

T or F? Modified short leg casts should only be used for grade 1 and 2 ulcers

A

True

61
Q

List the contraindications for total contact casts on patients with diabetic/neuropathic ulcers

A
  • Osteomyelitis
  • Gangrene
  • Fluctuating edema (edema must be controlled before use)
  • Infection
  • ABI <.5
62
Q

Who is indicated for a padded ankle foot orthotic?

A

Low risk patients

63
Q

T or F? Leather shoes have lots of breathing room and “mold to the foot”

A

True

64
Q

How would you educate someone with a diabetic ulcer about shoe recommendations?

A
  • 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
65
Q

How should you educate a patient who wants to manage their diabetes and reduce the risk of getting an ulcer?

A
  • 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
66
Q
A
67
Q

T or F? ROM, aerobic exercise, and balance activities should be done by the patient after the ulcer has healed

A

True

68
Q

What is considered “normal” blood sugar for a diabetic

A
  • 80-120 mg/dL before meals or when waking up
  • 100-140 mg/dL at bedtime
69
Q

What is the average healing time for a diabetic/neuropathic ulcer

A

12-14 weeks

Fall 2024: Integumentary Systems (11 decks)

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