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
2
Q
What is the inverse pressure-time relationship?
A
increased pressure = decreased time for injury
3
Q
What do individual hemodynamic factors do for healing time?
A
impacts the time it takes for injury to heal
- increases it
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
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
6
Q
What is the major concept to treating pressure injuries?
A
PREVENTION
7
Q
What is the pain like for a pressure injury?
A
- painful/tender
- no pain if SCI, peripheral neuropathy, sedation
8
Q
What is the position of pressure injuries?
A
- over bony prominences
- areas of outside pressure (casts, IV/catheter tubing, shoes)
9
Q
What is the presentation of pressure injuries?
A
- descriptors per NPUAP injury classification
- stage 1-4, unstageable
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
11
Q
How are the pulses with pressure injuries?
A
- normal unless concomitant arterial disease in the foot
12
Q
What is the temperature like in pressure injuries?
A
- usually warm if reactive hyperemia
- usually cold if an area of ischemia
13
Q
what scale is used most for classifying pressure injuries?
A
NPUAP pressure injury staging system
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
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
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
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
18
Q
What is the criteria for an unstageable pressure injury?
A
- the base of the pressure injury is obscured by eschar or slough
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)
20
Q
What are the 5 components to preventing pressure ulcers?
A
- education
- positioning
- mobility
- nutrition
- management of incontinence
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
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
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
24
Q
What are some risk management factors to prevent pressure injuries?
A
- hyperglycemia
- anemia
- malnutrition
- incontinence
25
What is the prognosis of pressure injuries?
*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
26
What are some PT management techniques for pressure injuries?
Coordinate care with other practitioners:
- wound care nurses
- vascular (foot wounds)
- surgeons
- dietician
Address underlying etiology & risk factors
Education
27
What is the goal of local wound care?
- 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
28
What are some PT interventions for preventing pressure injuries?
- 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)
29
What are some pressure relief mandates?
*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
30
Should you debride stable, hard, dry, eschar-covered wounds in ischemic limbs?
NO
- leave it, let it do its thing
31
What does erythema look like in darker skin complexions?
- purple/bluish discoloration
32
About how many people don't know they are diagnosed with diabetes?
- almost 1 in 5 don't know they are diagnosed with diabetes
33
What is the 8th leading cause of death?
- diabetes
*leading cause for amputation*
34
What are the mortality rates for those people that have amputations w/ diabetes after 5 years?
Toe: 41%
Below Knee: 63%
Above knee: 86%
35
What is type 1 diabetes?
beta cells in pancreas are destroyed and cannot produce insulin
36
What is type 2 diabetes?
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
What are pre-diabetic and diabetic numbers for A1c and fasting blood glucose levels?
A1c:
- pre-diabetic: 5.7-6.4%
- Diabetic: >6.5%
FBG:
- Pre-diabetic: 100-125 mg/dL
- Diabetic: 126 mg/dL and above
38
What are some diabetes related tissue damage theories
- 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
What are some risk factors for neuropathic ulcers?
- 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
What are some risk factors for delayed healing in diabetes?
- Ulcer characteristics
- Disease characteristics: impacts kidneys & eyes
- Inadequate care and education
41
About how many patients experience sensory neuropathy?
- 50% of patients w/ neuropathy are unaware they have lost protective sensation
- experience parathesis
42
What is the main cause of charcot foot?
- diabetic neuropathic osteoarthropathy
43
What is diabetic neuropathic osteoarthropathy?
- 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
What are 2 theories of diabetic neuropathy osteoarthropathy?
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
What are some foot changes that occur with diabetic neuropathy?
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
How is the pain with a diabetic ulcer?
- typically none (no protective sensation)
47
Where are diabetic ulcers normally positioned?
Plantar aspect foot:
- midfoot w/ Charcot foot
- forefoot under calluses, heel, friction areas
- tips of toes, medial 1st and lateral 5th MTP
48
What is the presentation of a diabetic ulcer?
- round, punched-out
- callused rim
- minimal drainage unless infected
- eschar or necrotic base is uncommon *usually pink*
49
How is the periwound and structure around a diabetic ulcer?
- dry, cracked skin
- callus
- foot structural deformities
50
How are the pulses and temperature with diabetic ulcers?
Pulse:
- normal or bounding (from arthrosclerosis)
Temp:
- normal or increased
51
What are the test for classifying, testing circulation, and sensory integrity for neuropathic ulcers?
Classifying:
- Wagner scale
Circulation:
- pulses, capillary refill, doppler ultrasound, ABI, TBI
Sensory Integrity:
- Monofilament testing
52
What are the characteristics for a Wagner grade 0 of a diabetic ulcer?
- no open lesions, may have deformity or cellulitis
*none, superficial, partial-thickness wound*
53
What are the characteristics for a Wagner grade 1 of a diabetic ulcer?
- superficial ulcer
*partial or full-thickness wound*
54
What are the characteristics for a Wagner grade 2 of a diabetic ulcer?
- Deep ulcer to tendon, capsule, or bone
*full-thickness wound*
55
What are the characteristics for a Wagner grade 3 of a diabetic ulcer?
- Deep ulcer with abscess, osteomyelitis, or joint sepsis
*full-thickness wound*
56
What are the characteristics for a Wagner grade 4 of a diabetic ulcer?
- Localized gangrene
*full-thickness wound*
57
What are the characteristics for a Wagner grade 5 of a diabetic ulcer?
- Gangrene of the entire foot
*full-thickness wound*
58
What is a common ABI score for those with diabetes?
- an ABI score of greater than 1 due to arthrosclerosis
59
Why would you do a pulse examination on patients with neuropathic ulcerations?
- they have open wounds on their LE
60
Why would you do an ABI on patients with neuropathic ulcerations?
- plantar foot ulceration is present
- decreased or absent pulse
- signs and symptoms of arterial insufficiency
- history of PAD or coronary artery disease
61
Why would you do a capillary refill examination on patients with neuropathic ulcerations?
- digital ulcer is present
- abnormal ABI
62
Why would you do a sensory integrity exam on patients with neuropathic ulcerations?
ALL PATIENTS WITH:
- neuropathic ulcerations
- diabetes
- plantar foot ulcers
- neurological injuries
63
What are some important steps for monofilament testing?
- occlude patients vision
- begin with 5.07 monofilament
- avoid calloused areas
- each location tested randomly 3 times
64
What is the interpretation of monofilament testing?
4.17: decreased sensation
5.07: loss of protective sensation
6.10: absent sensation
65
What are some medical interventions in those with diabetic neuropathic ulcers?
- managing DM and other co-morbidities (decreasing A1c levels)
- debridement of necrotic tissue
- revascularization
- amputation
66
What is the prognosis for neuropathic ulcer healing?
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
Which ulcers have good prognosis vs poor prognosis?
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
What are the three main types of PT management for neuropathic ulcers?
- Team approach
- Education
- Wound observation
69
What are some wound care guidelines?
- 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
What is a total contact cast used for?
Walking short leg cast
- for Wagner grade 1 or 2 ulcers
- assists with wound healing
- controls edema, disperses weight, protects against microtraumas
71
What are some contraindications for total contact casts?
- osteomyelitis
- gangrene
- fluctuating edema
- active infection
- ABI <.45
72
What kind of interventions can be done for mobility in those with neuropathic ulcers?
*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
What PT interventions can be done for those with neuropathic ulcers?
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
What are some considerations for those with permanent footwear?
- 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
When would you refer someone with a neuropathic ulcer?
- ABI <.8
- failure to respond to treatment
- suspect infection
- exposed bone/capsule
