Neuropathic Flashcards

1
Q

High blood sugars cause ____

A
  1. nerve damage
  2. arterial damage
    - large and small vessels
    - large = coronary arteries and large LE arteries
    - small = arterioles, capillaries, venules; damage to eyes and kidneys, most vulnerable
    - even though ABI may be considered normal, the foot may be functionally ischemic
  3. lead to endothelial dysfunction - Vessels can’t dilate in response to injury resulting in decreased blood flow and oxygen/nutrient transport
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2
Q

What are the causes of foot ulceration?

A
  1. Sensory neuropathy- 50% of patients unaware they have lost protective sensation (unable to feel 5.07 monofilament)
  2. Autonomic neuropathy - Dry, cracked, fissured skin due to decreased ability to sweat
    Increased rate of callus formation
  3. Motor neuropathy - Intrinsic muscle weakness/atrophy; Decreased foot stability; Leads to deformities; Increased pressure/shear forces to the foot
  4. Mechanical stress on the foot - Abnormal or excessive forces predispose to ulceration
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3
Q

Current recommendation is checking diabetic patients at least ___
5.07 monofilament = grams of pressure
Tuning fork may also be used at

A

4x/year
10
128hz

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4
Q

What is the classification on the Wagner classification system?

A

0 - no open lesion; may have deformity or cellulitis
1 - superficial ulcer
2 - deep ulcer tendon, capsule, boe
3 - deep ulcer with abscess, osteomyelitis, or joint sepsis
4 - localized gangrene
5 - gangrene of the entire foot

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5
Q

What are the characteristics of a diabetic ulcer?

A
  1. Predominantly on the plantar foot - Usually over a bony prominence; May be anywhere below the knee
  2. Dry, minimal exudate unless infected - usually has callused periwound
  3. Pale wound bed - Necrotic tissue uncommon unless infected
  4. Round punched out appearance
  5. Painless
  6. Pulses and temperature are normal
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6
Q

What are the most common locations of diabetic ulcer? best dressing for it?

A

heel , ball of foot, big toe

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7
Q

abnormal callus formation; Callus is a thick layer of dead tissue that builds up due to increased pressure/friction; Always remove

A

Hyperkeratosis

- make sure pts know not to remove themselves

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8
Q

What foot deformities are sene with peroneal nerve damage?

A
  1. equinovarus

2. increased forefoot pressure

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9
Q

What foot deformities are sene with tibial nerve damage?

A
  1. calcaneovalgus
  2. increased heel pressure
  3. if subtalar joint subluxes leads to Charcot foot
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10
Q

a condition causing weakening of the bones in the foot that can occur in people who have significant nerve damage (neuropathy); The bones are weakened enough to fracture, and with continued walking the foot eventually changes shape; As the disorder progresses, the joints collapse and the foot takes on an abnormal shape, such as a rocker-bottom appearance

A

Charcot foot

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11
Q

What are the key points to teach pt’s for proper foot care?

A
  1. Daily foot inspection is a must!
  2. Always wear shoes to prevent trauma - No sandals; Cotton or wool socks
  3. Properly fitted shoes - Custom shoes are necessary if deformities are present; Medicare allows one pair of custom shoes and 3 inserts per year
  4. Regular podiatry visits to remove calluses and trim nails
  5. Keep skin moisturized - Avoid lotion between toes; Dry between toes after shower
  6. Never soak feet - Will cause maceration and lead to increased risk of infection
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12
Q

What factors optimize healing?

A
  1. Maintenance of normal blood sugars - A1c of 6 or less (mean glucose of 126 over past 3 months)
  2. Eliminate sources of trauma with proper footwear
  3. Offload pressure - 92% heal with offloading alone; Don’t feel pain so don’t want to stay off of it
  4. Reduce bioburden with antimicrobial dressings
  5. Moist wound healing
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13
Q

What is the role of a dietitian in diabetic wound healing?

A
  1. Dietician is crucial with all non-healing diabetic wounds
  2. Get lab results - Prealbumin, total protein, Hgb
  3. Is a supplement needed? - Vitamin C, Zinc, Vitamin A, Iron, Amino Acids
  4. Look at hydration
  5. Calorie intake
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14
Q

Consequence of high blood sugars and small vessel disease; Poor glucose control leads to impairment of WBC function and ability to fight infection; Most common reason for hospital admission for diabetic patients; Precursor for most amputations; Streptococcus + is most common organism

A

infection

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15
Q

Gold standard for off loading a diabetic ulcer; Modified short leg cast used for Wagner grade 1 or 2 ulcers; Assists wound healing

A

Total contact casting

  • Immobilizes foot and ankle dispersing weight-bearing forces over large area
  • Cast rigidity controls edema
  • Immobilization of foot protects from trauma
  • Assists with patient compliance
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16
Q

What are contraindications for total contact casting?

A
  1. Untreated osteomyelitis
  2. Dermatitis
  3. Fluctuating/unpredictable edema
  4. Active infection
  5. ABI less than 0.5
  6. Claustrophobia
17
Q

What are some alternative offloading methods to a total contact cast?

A
  1. Orthowedge healing shoe
  2. Darco shoe inserts
  3. Molded shoes/shoe inserts
  • Provides safe ambulation, pressure reduction, room for bandages
18
Q

What are some adjunct therapy used for wound healing

A
  1. Growth factors – Regranex
  2. E-stim - Underwater/immersion
  3. Hyperbaric oxygen
  4. Pulsed lavage/wound cleansing - 4-15 PSI’s is range needed to wash bacteria out and not harm healthy tissue
19
Q

what are some things to consider when doing gait and mobility training with a pt with diabetic ulcers

A
  1. PWB gait with assistive device - beeper boot

2. Alter gait pattern to decrease plantar pressure - Step-to pattern; Slower steps

20
Q

What are therapeutic exercises used in pts with diabetic ulcers?

A
  1. ROM Exercises - Assess/address great toe extension, talocrural dorsiflexion, and subtalar joint motion; Joint mobilizations may be helpful
  2. Aerobic Exercise - Assists with glycemic control; Assists with weight loss (5-10% body weight makes a huge difference)
21
Q

What things should be considered when getting permanent/ custom footwear?

A
  1. Conforms to foot, soft and moldable
  2. Should be ~½ inch longer than the longest toe with snug heel fit
  3. Toe box deep/wide enough for toe spread and clearance
  4. 1st MTP joint widest part of shoe
  5. Heel height < 1 inch
  6. Adjustable lace/straps
  7. Soft inserts may decrease pressure
  8. Fit shoes in the middle of the day
  9. Break in shoes gradually
  10. Patients with severe foot deformities or amputations should be referred to an orthotist`
22
Q

Diabetes statistics:
23 million are currently diagnosed
- Up to __% will get a foot ulcer in their lifetime
__ million are undiagnosed
__% of all amputations start with a foot ulcer

A

25%
7
85%