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Integ Fall 2024 > Pressure Injuries & Neuro ulcers > Flashcards

Pressure Injuries & Neuro ulcers Flashcards

1
Q

What is a pressure injury?

A
  • localized area of tissue necrosis that develops when soft tissue is compressed between a firm surface and underlying bony prominence
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2
Q

What is the inverse pressure-time relationship?

A

increased pressure = decreased time for injury

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3
Q

What do individual hemodynamic factors do for healing time?

A

impacts the time it takes for injury to heal
- increases it

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4
Q

What patients experience the most pressure injuries?

A
  • bed-bound individuals
  • pts with improperly fitted casts or splints
  • pts who sit for prolonged periods
  • neonates
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5
Q

What are some major risk factors for pressure injuries?

A
  • pressure time relationship
  • shear and friction
  • moisture
  • impaired mobility
  • malnutrition
  • impaired sensation
  • advanced age (>62)
  • history of previous pressure injury
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6
Q

What is the major concept to treating pressure injuries?

A

PREVENTION

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7
Q

What is the pain like for a pressure injury?

A
  • painful/tender
  • no pain if SCI, peripheral neuropathy, sedation
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8
Q

What is the position of pressure injuries?

A
  • over bony prominences
  • areas of outside pressure (casts, IV/catheter tubing, shoes)
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9
Q

What is the presentation of pressure injuries?

A
  • descriptors per NPUAP injury classification
  • stage 1-4, unstageable
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10
Q

How is the periwound and extrinsic tissues of pressure injuries?

A
  • surrounded by ring of erythema
  • localized warmth
  • fibrosis and induration
  • dermatitis common
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11
Q

How are the pulses with pressure injuries?

A
  • normal unless concomitant arterial disease in the foot
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12
Q

What is the temperature like in pressure injuries?

A
  • usually warm if reactive hyperemia
  • usually cold if an area of ischemia
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13
Q

what scale is used most for classifying pressure injuries?

A

NPUAP pressure injury staging system

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14
Q

What is the criteria for a stage 1 pressure injury?

A
  • nonbanchable erythema of intact skin
  • area may be painful, warmer, cooler, firmer, and softer
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15
Q

What is the criteria for a stage 2 pressure injury?

A
  • superficial ulcer that presents as a shallow crater w/o slough, eschar, or bruising
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16
Q

What is the criteria for a stage 3 pressure injury?

A
  • deep ulcer that presents as a deep crater; may have undermining or tunneling
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17
Q

What is the criteria for a stage 4 pressure injury?

A
  • deep ulcer with extensive necrosis; often has undermining or sinus tracts
  • often showing underlying tendon/bone
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18
Q

What is the criteria for an unstageable pressure injury?

A
  • the base of the pressure injury is obscured by eschar or slough
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19
Q

What is the Pressure Ulcer Scale for Healing? (PUSH)

A
  • for healing potential
  • takes <5 minutes after training
  • score 8-24(higher score = more severe ulcer)
  • 3 subscales (surface area, exudate amount, wound appearance)
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20
Q

What are the 5 components to preventing pressure ulcers?

A
  • education
  • positioning
  • mobility
  • nutrition
  • management of incontinence
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21
Q

How should patients be positioned to prevent pressure ulcers?

A
  • at risk patients should be positioned at a 30 degree angle
  • use pillows and foam pads
  • head of bed should be at lowest degree of elevation
  • bed linens should be free of wrinkles
  • remove lift sheets and slings when finished lifting patient
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22
Q

What kind of mobility should be used when preventing pressure injuries?

A
  • Lift, shift, lower do not drag
  • linens loose enough so patient can move
  • PT to assist with mobility
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23
Q

What does NO ULCERS SKIN mean?

A

Nutrition and fluid status
Observe the skin
Up and walking or assist position changes
Lift don’t drag
Clean skin and continence care
Elevate heels
Risk assessment
Support surfaces

Surface selection
Keep turning
Incontinence management
Nutrition

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24
Q

What are some risk management factors to prevent pressure injuries?

A
  • hyperglycemia
  • anemia
  • malnutrition
  • incontinence
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25
Q

What is the prognosis of pressure injuries?

A

Heal very slow
Expected healing time:
- stage 1: 1-3 weeks
- stage 2: averages 23 days
- stage 3-4: 8-13 weeks

full-thickness injuries more likely to be infected which increases healing time
- should be reassessed if injuries do not decrease in size w/in 2 weeks

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26
Q

What are some PT management techniques for pressure injuries?

A

Coordinate care with other practitioners:
- wound care nurses
- vascular (foot wounds)
- surgeons
- dietician
Address underlying etiology & risk factors
Education

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27
Q

What is the goal of local wound care?

A
  • create warm, moist, granular wound bed with healthy surrounding tissue to promote wound closure
  • protect surrounding tissue from chapping/chafing, excessive moisture, and strong adhesives
  • debride necrotic tissue
  • treat infection if present
  • address cause of pressure injury
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28
Q

What are some PT interventions for preventing pressure injuries?

A
  • functional mobility training
  • pelvic floor exercises for incontinence
  • aerobic exercise (increases BF)
  • strength training to promote mobility
  • Remind staff to lift vs slide
  • pressure relieving devices/recommendations
  • wound management
  • biophysical agents (e-stim, UV, US)
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29
Q

What are some pressure relief mandates?

A

takes 2 full minutes of pressure relief to re-perfuse tissue
Sitting:
- every 10-15 minutes adjust
- cushions/recliners

In bed:
- reposition at least every 2 hours
- float the heels
- support surfaces

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30
Q

Should you debride stable, hard, dry, eschar-covered wounds in ischemic limbs?

A

NO
- leave it, let it do its thing

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31
Q

What does erythema look like in darker skin complexions?

A
  • purple/bluish discoloration
32
Q

About how many people don’t know they are diagnosed with diabetes?

A
  • almost 1 in 5 don’t know they are diagnosed with diabetes
33
Q

What is the 8th leading cause of death?

A
  • diabetes
    leading cause for amputation
34
Q

What are the mortality rates for those people that have amputations w/ diabetes after 5 years?

A

Toe: 41%
Below Knee: 63%
Above knee: 86%

35
Q

What is type 1 diabetes?

A

beta cells in pancreas are destroyed and cannot produce insulin

36
Q

What is type 2 diabetes?

A

body is insulin resistant
- impaired secretion or alteration of insulin
- body doesn’t make enough insulin to support the body

91% of those with diabetes have this

37
Q

What are pre-diabetic and diabetic numbers for A1c and fasting blood glucose levels?

A

A1c:
- pre-diabetic: 5.7-6.4%
- Diabetic: >6.5%

FBG:
- Pre-diabetic: 100-125 mg/dL
- Diabetic: 126 mg/dL and above

38
Q

What are some diabetes related tissue damage theories

A
  • hyperglycemia: alters BF, increases microvascular pressure
  • glycosylated proteins cause tissue trauma
  • accumulation of sorbitol, due to breakdown of glucose, results in tissue destruction
    tissue damage can be caused by any of these or a combination
39
Q

What are some risk factors for neuropathic ulcers?

A
  • Vascular disease
  • Neuropathy (affects sensory, autonomic, and motor): stocking glove dis.
  • Mechanical stress/abnormal foot function (foot changes shape)
  • Inadequate footwear
  • Impaired healing and immune response
  • Poor vision (increase risk for hitting things/falling/trauma): retinopathy
40
Q

What are some risk factors for delayed healing in diabetes?

A
  • Ulcer characteristics
  • Disease characteristics: impacts kidneys & eyes
  • Inadequate care and education
41
Q

About how many patients experience sensory neuropathy?

A
  • 50% of patients w/ neuropathy are unaware they have lost protective sensation
  • experience parathesis
42
Q

What is the main cause of charcot foot?

A
  • diabetic neuropathic osteoarthropathy
43
Q

What is diabetic neuropathic osteoarthropathy?

A
  • inflammatory phase characterized by foot edema, erythema, and increased temperature
  • bone and articular destruction ensure, progressing to multi-joint dislocations and fractures
  • requires immobilization and limited weight-bearing
44
Q

What are 2 theories of diabetic neuropathy osteoarthropathy?

A

Neurovascular theory:
- hyperemia increases pressure in foot from autonomic neuropathy leads to deep tissue ischemia -> causes inflammation and bone break down

Neurotraumatic theory:
- trauma is undetected due to sensory neuropathy leads to progressive deformity

45
Q

What are some foot changes that occur with diabetic neuropathy?

A

Impaired ROM:
- great toe EXT, DF, subtalar joint = increased forefoot pressure
- increases vertical pressure and horizontal shear
Foot deformities:
- pes aquinas, hallux valgus, hammer toes, Charcot foot
Prior amputation

46
Q

How is the pain with a diabetic ulcer?

A
  • typically none (no protective sensation)
47
Q

Where are diabetic ulcers normally positioned?

A

Plantar aspect foot:
- midfoot w/ Charcot foot
- forefoot under calluses, heel, friction areas
- tips of toes, medial 1st and lateral 5th MTP

48
Q

What is the presentation of a diabetic ulcer?

A
  • round, punched-out
  • callused rim
  • minimal drainage unless infected
  • eschar or necrotic base is uncommon usually pink
49
Q

How is the periwound and structure around a diabetic ulcer?

A
  • dry, cracked skin
  • callus
  • foot structural deformities
50
Q

How are the pulses and temperature with diabetic ulcers?

A

Pulse:
- normal or bounding (from arthrosclerosis)

Temp:
- normal or increased

51
Q

What are the test for classifying, testing circulation, and sensory integrity for neuropathic ulcers?

A

Classifying:
- Wagner scale
Circulation:
- pulses, capillary refill, doppler ultrasound, ABI, TBI
Sensory Integrity:
- Monofilament testing

52
Q

What are the characteristics for a Wagner grade 0 of a diabetic ulcer?

A
  • no open lesions, may have deformity or cellulitis

none, superficial, partial-thickness wound

53
Q

What are the characteristics for a Wagner grade 1 of a diabetic ulcer?

A
  • superficial ulcer

partial or full-thickness wound

54
Q

What are the characteristics for a Wagner grade 2 of a diabetic ulcer?

A
  • Deep ulcer to tendon, capsule, or bone

full-thickness wound

55
Q

What are the characteristics for a Wagner grade 3 of a diabetic ulcer?

A
  • Deep ulcer with abscess, osteomyelitis, or joint sepsis

full-thickness wound

56
Q

What are the characteristics for a Wagner grade 4 of a diabetic ulcer?

A
  • Localized gangrene

full-thickness wound

57
Q

What are the characteristics for a Wagner grade 5 of a diabetic ulcer?

A
  • Gangrene of the entire foot

full-thickness wound

58
Q

What is a common ABI score for those with diabetes?

A
  • an ABI score of greater than 1 due to arthrosclerosis
59
Q

Why would you do a pulse examination on patients with neuropathic ulcerations?

A
  • they have open wounds on their LE
60
Q

Why would you do an ABI on patients with neuropathic ulcerations?

A
  • plantar foot ulceration is present
  • decreased or absent pulse
  • signs and symptoms of arterial insufficiency
  • history of PAD or coronary artery disease
61
Q

Why would you do a capillary refill examination on patients with neuropathic ulcerations?

A
  • digital ulcer is present
  • abnormal ABI
62
Q

Why would you do a sensory integrity exam on patients with neuropathic ulcerations?

A

ALL PATIENTS WITH:
- neuropathic ulcerations
- diabetes
- plantar foot ulcers
- neurological injuries

63
Q

What are some important steps for monofilament testing?

A
  • occlude patients vision
  • begin with 5.07 monofilament
  • avoid calloused areas
  • each location tested randomly 3 times
64
Q

What is the interpretation of monofilament testing?

A

4.17: decreased sensation
5.07: loss of protective sensation
6.10: absent sensation

65
Q

What are some medical interventions in those with diabetic neuropathic ulcers?

A
  • managing DM and other co-morbidities (decreasing A1c levels)
  • debridement of necrotic tissue
  • revascularization
  • amputation
66
Q

What is the prognosis for neuropathic ulcer healing?

A

Large variability in healing
- average is 12-14 weeks
- up to 90% healing with conservative management of local wound care, unloading, and treating infection

forefoot ulcers heal faster than heel ulcers

67
Q

Which ulcers have good prognosis vs poor prognosis?

A

Good:
- Wagner 1or 2
- Present for <2 months
- Better glycemic control
- higher ABI w/ good BF

Poor:
- larger size
- infected (increases risk of amputation by 154%)
- wagner > 3 increases amputation risk
- smoking

68
Q

What are the three main types of PT management for neuropathic ulcers?

A
  • Team approach
  • Education
  • Wound observation
69
Q

What are some wound care guidelines?

A
  • off loading (be cautious of damaging the other limb)
  • pare callus flush with epithelial surface
  • petroleum-based moisturizer daily
  • toe spacers if enclosing shoes in dressing
  • possible use of US, e-stim, etc if doesn’t by 50% in first month
70
Q

What is a total contact cast used for?

A

Walking short leg cast
- for Wagner grade 1 or 2 ulcers
- assists with wound healing
- controls edema, disperses weight, protects against microtraumas

71
Q

What are some contraindications for total contact casts?

A
  • osteomyelitis
  • gangrene
  • fluctuating edema
  • active infection
  • ABI <.45
72
Q

What kind of interventions can be done for mobility in those with neuropathic ulcers?

A

Don’t traumatize other foot
PWB with AD
Alter gait pattern to decrease plantar pressure
- step to pattern decreases pressures up to 53% for ulcers on forefoot and great toe
- slower gait decreases pressures
Temporary footwear
Balance assessments
- TUG, Berg, FGA

73
Q

What PT interventions can be done for those with neuropathic ulcers?

A

ROM exercises
- address great toe EXT, talocrual DF, and subtalar joint motion
Strengthening:
- Hip EXT rotators & ankle inverters to decrease pronation
Aerobic exercise:
- assists w/ glycemic control and weight loss

74
Q

What are some considerations for those with permanent footwear?

A
  • those with severe foot deformities and ampuataions should be referred to a skilled shoemaker/orthotist
  • must protect foot and minimize plantar pressures and shear forces
  • shoes should be half and inch longer than the longest toe with snug heel fit
  • extra-depth toe box
  • heel height < 1 inch
  • laces better than slip-ons
75
Q

When would you refer someone with a neuropathic ulcer?

A
  • ABI <.8
  • failure to respond to treatment
  • suspect infection
  • exposed bone/capsule

Integ Fall 2024 (5 decks)

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