Practical #1 Flashcards
What are some causes of arterial insufficiency?
Trauma Acute embolism Diabetes mellitus Rheumatoid arthritis Thromboangiitis (Buerger’s disease) Arteriosclerosis
Most common places for arterial wounds:
Wounds between toes, on tips of toes, dorsal aspect of foot, over phalangeal heads, adjacent to lateral malleolous/ tibia or where subject to trauma , such as shin, distal calf
What arterial wounds look like:
Dry wounds with black/gray necrotic tissue and erythematous halo
Thin dry skin, absence of hair, shiny, smooth, cool
Borders of arterial wounds:
Well defined borders “punched out” smooth edges
Associated illnesses with arterial insufficiency ulcers
Coronary disease CHF COPD Hypertension Diabetes mellitus End-stage renal disease Hypercholesterolemia
Risk factors contributing to AI ulcers
hyperlipidemia and elevated LDL Systemic process Smoking Diabetes Hypertension Trauma Advanced Age
Tests and Measures for AI
Pulses Capillary Refill Rubor of Dependency Venous Filling Time Ankle-Brachial Index Doppler Ultrasound TBI- Toe pressures TCPO2- Transcutaneous oxygen Plethysmography Duplex scanning Arteriography
Common causes of venous insufficiency
Common causes of venous insufficiency
Risk factors contributing to VI ulcers
Vein dysfunction Calf muscle pump failure Trauma Previous VI ulcer Advanced Age Diabetes
PT Tests and Measures for VI
Clinical Assessment for DVT
Ankle-Brachial Index
Trendelenburg Test
Venous Filling Time
C0
asyptomatic
C1
telangiactasias or spider veins <3mm
C2
varicose veins>/= 3mm
C3
leg edema
C4
skin and subcutaneou tissue change
C4A
hemosideran deposition
C4B
lipodermatosclerosis
C5
healed venous ulcer
C6
current venous ulcer
Venous signs:
Eschar or slough, wet, yellow fibrous
Moderate to heavy exudate
Tortuous veins
Edematous leg
Wound edges in VI:
Shallow wounds
Irregular wound edges
Location of VI insufficiency:
Superior to Malleoli, usually medial
Surrounding skin dry and scaly
ABI results >1 (.1.3)
Calcified vessels if diabetic- requires further evaluation. Do not exceed 250 mmHg, is non-compressible and may damage artery
ABI 1-.95:
No significant Arterial Disease
ABI .95-.8:
Mild disease- Compression with caution
ABI: .8-.5:
claudication- compression contraindicated (usually symptomatic with claudication @.7)
ABI less than .6
debridement contraindicated by ANY means. Inadequate circulation, exposing debrided tissue to infection
ABI less than .5
compression contraindicated –resting pain .5-.4
ABI less than or equal to .3:
tissue loss
Risk Factors Contributing
to Pressure Ulcers
Shear Excessive moisture Impaired mobility Malnutrition Impaired sensation Advanced age History of pressure ulcer
Stage I PU:
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
Area may be painful, warmer, cooler, firmer, softer than surrounding tissue
Tissues involved in stage I:
May be superficial
May be first sign of deeper tissue involvement
Stage II PU:
Superficial ulcer
Shallow crater without slough or bruising
May be ruptured or intact blister
Tissues Involved in Stage II:
Partial thickness (epidermis, dermis, or both)
Stage III PU:
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Tissues involved in Stage III PU:
Full thickness (epidermis, dermis, subcutaneous tissue) Bone/tendon not visible
Stage IV PU:
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
Deep ulcer with extensive necrosis
Tissues involved in Stage IV PU:
Full thickness
Underlying deep tissue exposed
Unstageable PU:
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
Tissues involved in unstageable PU:
Full thickness
Will be category III or IV
Superficial Burns
First-degree burns”/Integumentary Pattern B
Dry, bright red, or pink skin that blanches upon pressure
No dermal vessel damage
Types of superficial burns:
Sunburn, minor flash burn
Erythema, significant pain, lack of blisters, sunburn
Superficial Partial-Thickness Burns
Superficial second-degree burns”/Integumentary Pattern C
Painful, moist, weeping, blistered skin with local erythema and edema
Blanches to pressure with immediate capillary refill
Examples of Superficial Partial-Thickness Burns
Brief contact burns, flash burns, brief contact with dilute chemicals
Deep Partial-Thickness Burns
Deep second-degree burns”/Integumentary Pattern C
Mottled areas of red with white eschar, blistering possible, may have areas of insensitivity/reduced sensation
Blanches to pressure with slow capillary refill
Scarring, pigment changes, contractures possible
Examples of Deep Partial-Thickness Burns
Severe sunburn, scald, flash burn, brief contact with dilute chemicals
Full-Thickness Burns
Third-degree burns”/Integumentary Pattern D
Initially look red then become mottled white/black, dry, leathery eschar, very painful
Burned areas insensate to light touch
Scarring and contractures likely
Most require surgical debridement and grafting
What layers affected with full-thickness burn:
Epidermis, Dermis, and complete destruction to subcutaneous fat
Subdermal Burns
Fourth-degree burns”/Integumentary Pattern E
Charred, mummified appearance
Exposed deep tissues
Burned areas insensate to light touch
May have permanent nerve damage
Require surgery (fasciotomy, escharotomy, grafting) and possible amputation
NU Wound edges:
even, well defined, with and without undermining
Diabetic Risk Factors Contributing Delayed Healing and Neuropathic Ulcers
Vascular disease Neuropathy Mechanical stress Abnormal foot function and inadequate footwear Impaired healing and immune response Poor vision
PT Tests and Measures
for Neuropathic Ulcers
Circulation
Sensory integrity
Grade 0 Wagner:
No open lesions
May have deformity or cellulitis
Grade 1 Wagner:
Superficial ulcer
Grade 2 Wagner:
Deep ulcer to tendon, capsule, bone
Grade 3 Wagner:
Deep ulcer with abcess, osteomyelitis, or joint sepsis
Grade 4 Wagner:
Localized gangrene
Grade 5 Wagner:
Gangrene of the entire foot
NU Position
Plantar foot
Plantar aspect of metatarsal heads
Plantar aspect of midfoot if Charcot deformity
May occur under calluses
May occur in areas of pressure/friction from inappropriate footwear
NU Presentation
Round, punched-out lesions
Callused rim
Minimal drainage unless infected
Eschar or necrotic material uncommon unless infected
