Test 5- Lymphedema, Prosthetics, Wound Care, Pressure ulcers Flashcards
1
Q
Is primary or secondary lymphedema more common?
A
Secondary
2
Q
Most common cause of secondary lymphedema?
A
Comprehensive cancer management
*also, Surgical dissection of lymph nodes, infection and inflammation, obstruction or fibrosis, or combined venous lymphatic dysfunction
3
Q
Clinical manifestations of lymphatic disorders:
A
Lymphedema Increased size of limb Sensory disturbances Stiffness and limited ROM Decreased resistance to infection
4
Q
Primary cause of amputation in US
A
Peripheral vascular disease
*Second leading cause is trauma
5
Q
2/3 of all lower extremity amputations in the US related to:
A
Diabetes mellitus
6
Q
Name some factors that can affect blood flow in the deep veins and increase the risk for developing blood clots:
A
Increasing age, personal or family history of DVT or pulmonary embolism, certain types of malignant cancers, varicose veins, smoking, birth control pills, pregnancy, obesity, a broken hip or leg or major surgery on hip, knee, or lower leg
7
Q
In some cases a pulmonary embolism may be the first sign of DVT. Symptoms of pulmonary embolism include:
A
Shortness of breath, sudden onset of chest pain, coughing, spitting up or vomiting blood
8
Q
Wells Clinical Assessment for DVT:
If score is equal to or greater than 3 there is a 75% probability that the patient does have a DVT and should have _____ _____ performed.
A
Venous US
9
Q
Levels of amputation: Partial toe Toe disarticulation Ankle disarticulation (Syme’s) Transtibial Transfemoral Etc. What does it mean if it’s a disarticulation?
A
They don’t cut through bone they cut at the joint space
10
Q
Foot amputation levels (proximal to distal) :
A
Symes (ankle disarticulation)
Chopart
LisFranc
Transmetatarsal
11
Q
Surgical approaches (amputations)
Myoplasty- ____ to _____
Myofascial- muscle to _____
My odes is- muscle to _______
A
Muscle to muscle
Muscle to fascia
Muscle to periosteum/bone
12
Q
What is the most important factor in determining a good prosthetic candidate?
A
Patient’s prior level of activity
*Unilateral transtibial usually makes for a good candidate, bilateral transfemoral if person is in good health
13
Q
Studies have shown that from 9% to 20% of people with diabetes who had already experienced an amputation underwent a second amputation within ___ months of first surgery.
A
12 months
14
Q
An elastic wrap or shrinker application is for _____ control and ______ of limb.
A
Volume control and shaping
15
Q
A monofilament exam, also known as a Semmes-Weinstein monofilament can be used to identify a high risk of _____ _____.
A
Foot ulceration
16
Q
-
-
A
Rigid
IPOP (Immediate post op prosthesis)
Soft (elastic wraps, shrinkers)
17
Q
3 post op dressings for volume control:
A
Soft gauze w/ ACE
Rigid Plaster to keep knee in extension and control edema
IPOP, plaster cast with pylon and foot
18
Q
Have patient start putting pressure and sensations through limb to prepare for prothesis.
This is called:
A
Desensitization
19
Q
What is important to remember about positioning for contracture prevention when it comes to amputees?
A
You want to keep the knee extension.
If elevating to prevent Edema make sure knee is kept in extension
20
Q
Ther Ex for amputees:
- ROM/ stretching to prevent/correct ______ of LE’s
- Strengthening of ___’s and contralateral LE
- Strengthening of residual limb
A
Contracture
UE’s
21
Q
Goals of Pre-Prosthetic phase:
Healing of residual limb Independent transfers and mobility Positioning Pain mgt Strengthening ROM Shaping Limb Pt Ed Psychological adjustment
A
Boop
22
Q
Def: Feeling that absent body part is still present
A
Phantom Limb Sensation
23
Q
Phantom limb pain- sensations of cramping, ______, shooting, ______ pain
A
Burning, stabbing
24
Q
Treatment options for phantom pain/sensations:
A
Pharmacology (opioids, Botox, E Stim (TENS), anti-convulsives) US Dry needling Compression Surgery-neuroma removal VR Mirror therapy
25
Def: A rare congenital deformity in which the hands or feet are attached close to the trunk, the listing grossly under developed or absence. This condition was a side effect of the drug Thalidomide taken during early pregnancy
Phocomelia
26
Def: Birth defect where part or all of the fibular bone is missing, as well as Associated limb length discrepancy, for deformities, and knee deformity’s. It is a very rare disorder occurring in only 1 in 40,000 births
Fibular Hemimelia
27
UE prosthetic devices:
Myoelectric
Body-powered
Terminal devices
28
Def: Amount of fluid transported
Lymphatic load
29
Def: The amount of fluid the lymphatic system can transport
Transport capacity
30
The main components of lymphatic fluid are ___ and ____ found in the extracellular spaces. In a normal state the lymphatic system transports this fluid back to the _____ circulation.
Water and protein
Venous
31
Primary Lymphedema is less common and is due to _______ _______.
Structural malformation
32
Stages of lymphedema:
Stage 0- _____ Stage
-No outward swelling noted
Stage 1- _____ Stage
-Elevation reduces swelling, no tissue fibrosis, swelling is soft or pitting
Stage 2- _____ Stage
- Fibrosis of tissue; brawny, hard swelling/no longer pitting, positive Stemmer sign, frequent infections
Stage 3- ______ Stage
-Positive Stemmer sign, Significant increase in limb volume, typical skin changes noted, bacterial and fungal infections of skin and nails more common
0–Latency stage
1–Reversible stage
2–Spontaneously irreversible
3-Lymphostatic elephantiasis
33
_____ Edema: Pressure on the edematous tissues With the fingertips causes an indentation of the skin that persists for several seconds after the pressure is removed. This reflects significant but short duration edema with little or no fibrotic changes in skin.
Pitting Edema
34
_____ edema: Pressure on the edematous areas feels hard with palpation. This reflects a more severe form of interstitial swelling with progressive, fibrotic changes in subcutaneous tissues.
Brawny Edema
35
_____ edema: This represents the most severe and long-duration form of lymphedema. Fluids leak from cuts or sores; wound healing is significantly impaired. Lymphedema of this severity occurs almost exclusively in the lower extremities.
Weeping edema
36
What are some comprehensive regimens and components for management of lymphedema? (4)
Manual lymphatic drainage
Exercise
Compression therapy
Skin care and hygiene
37
Reducing risk of lymphedema:
- Keep _____. Sitting or standing for long periods of time can cause pooling of fluid in legs. Don’t sit with legs crossed
- ______ involved limb and perform pumping ex. frequently
- Be cautious about performing vigorous, _______ activities
- Wear compressive garments while exercising
- Monitor diet to maintain an ideal weight and minimize _____ intake
- If possible have BP, needle sticks and blood draws performed on uninvolved extremity
Moving
Elevate
Repetitive
Sodium
38
Skin care with lymphedema:
- Keep skin clean and supple; use moisturizer and sunscreen, but avoid ______ lotions
- Immediately attend to skin abrasions or cuts, insect bites, burns
- Protect hands and feet with socks, shoes, gloves, etc
- Use an electric razor when shaving
- Avoid ____ baths, whirlpools, and saunas that ______ the body’s core temperature
Perfumed lotion
| Avoid hot baths that elevate core temp
39
Manual Lymphatic Drainage (MLD) components:
- Very light, slow, _____ strokes/massage
- Proximal congestion of trunk, _____, buttock, or _____ cleared first to make room for ____ fluid
- Direction: ______ to _____
- After proximal congestion, clear involved limb ____ portion first then working _____
Circular
Groin, axilla; distal fluid
Distal to proximal direction
(After prox congestion) Proximal portion first then working distally
40
Exercises for lymphatic drainage: principles and rationale
- Contraction of muscles pumps fluids by direct _______ of the collecting lymphatic vessels
- Exercise strengthens and prevents _____ of muscles of the limbs, which improves the efficiency of the lymphatic pump
- Exercise should be sequenced to clear the _____ lymphatic reservoirs before the ______ areas
- Ex. with compression bandaging enhances lymph flow and ____ resorption more efficiently than without
Compression
Atrophy
Central, peripheral
Protein
41
```
Start an upper or lower extremity regimen for lymphedema with these exercises (Clearing centrally) :
-
-
-
-
```
Deep breathing exercises
Posterior pelvic tilts and partial curl ups
Cervical ROM
Bilateral scapular movements
42
Surgical interventions for lymphedema:
-
-
-
Lymphovenous bypass
Lymph node transplant
Liposuction
43
Components of exercise regimens for management of lymphedema:
- Deep breathing exercises
- ______ exercises
- _______ and muscular _____ exercises
- ______ conditioning exercises
- Lymphatic _____ exercises
Flexibility
Strengthening and muscular endurance
Cardiovascular conditioning
Lymphatic drainage
44
UE ex for Lymphedema (in sequence):
- Active circumduction with involved arm elevated while supine
- Bilateral active movements of arms while supine
- Bilateral hand press while supine to sitting
- Shoulder stretches while standing
- Seated active exercises of elbow,forearm, wrist and fingers while UE elevated
- Bilateral horizontal AB/ADD of sho
- Overhead wall press
- Finger ex.
- Partial curl ups
- Rest with involved UE elevated for 30 min
Have fun remembering that
45
LE Ex. for Lymphedema (in sequence)
- Alternate knee to chest
- Bilateral knees to chest
- Glute sets and posterior pelvic tilt
- SKTC w/ involved LE
- ER of hips while supine w/ both legs elevated resting on wall
- Active knee flexion of involved LE
- Active PF/DF/Circum of ankles while supine and LEs elevated
- Active hip/knee flexion with ER and elevated
- Active cycling and scissoring while elevated
- Bilateral KTC ex, then partial curl ups
- Rest w/ LEs elevated
Fun stuff
46
During a wound assessment you look at what 4 things:
1) Location
2) Size, depth, shape
3) Tunneling, undermining
4) Exudate/drainage
47
Attributes preventing healing of wounds:
- ______ tissue
- _____
- Periwound erythema and _____
- Edges _____ (not connected)
Necrotic
Hemorrhage
Edema
Undermined
48
Attributes characteristic of a wound healing:
- _______ tissue
- New ______
- _______ wound edges
Granulation
Epithelium
Attached
49
Types of Exudates:
______: Thin, bright red
_____: Thin, watery, pale red to pink
_____: Thin, watery, clear
_____: Thin or thick, opaque tan to yellow
_____: Thick, opaque yellow to green with offensive odor
```
Bloody
Serosanguineous
Serous
Purulent
Foul Purulent
```
50
Rating scale maybe used to quantify the amount of exudates:
1- None, dry
2- Scant, tissue moist, no exudates
3- Small, drainage <25%
4- Moderate, Tissue saturated, Drainage may or may not be evenly distributed, drainage >25% to <75% of wound dressing
5- Large, Tissues bathed in fluid, drainage >75% of wound dressing
Might need to know? Who knows.
51
Indications for wound culture:
| Signs of local infection-
- Edema
- Erythema or skin discoloration
- Purulent or foul smelling drainage
- Increased pain
- Induration (harden)
- Heat around wound
52
Indications for wound culture:
| Signs of systemic infection-
- Elevated temperature (fever)
- Elevated white blood cell count (leukocytosis)
- Confusion or agitation in older adults
- Red streaks from wound
53
Other indications for wound culture are:
- _____ involvement: Full thickness wound at increased risk for osteomyelitis
- ____-healing wounds
Bone
| Non-healing
54
The function of a ________ is to:
- Prevent additional wound contamination
- Keep micro organisms in the wound from infecting other sites
- Prevent further injury to the wound
- Apply pressure to control hemorrhage
- Absorb wound drainage
- Assist wound healing
Dressing
55
The function of a ________ is to:
- Keep the dressing in place
- Maintain a barrier between dressing and environment
- Provide external pressure to control swelling
- Provide support or stability to an area
- Hold splints in place
Bandage
56
General principles for dressing and bandaging:
- Don’t touch open wound
- Possibly limit skin of toes from touching
- Dressings should always be applied securely to prevent ______ or _____ over wound
- Always ____ and ____ wound before applying bandage
- Place the part in a _____ position
- When applying pressure bandage, do not _____ blood flow
Slippage or friction
Clean and dry
Functional
Constrict
57
More Dressing principles:
- Pressure bandage must have even _____
- ______ part frequently, leave finger tips and toes exposed
- Clips, clamps, pins, should be applied ____ from wound
Overlaps
Observe
Away
58
____-______ Dressings: Permeable to gas, bacteria, fluid; good for wounds with significant drainage, infected wound
Ex. Dry dressing- Enough drainage where it won’t adhere to the wound, gauze, ABD pad
Impregnated Gauze/Petroleum Gauze
Non-Occlusive
59
______ Dressings: different types chosen to keep wound bed at optimal environment; barrier to germs, limit scab formation, can be left on for 3 to 10 days.
-Promotes autolytic debridement
Occlusive Dressings
60
Of the occlusive dressings, only ____ and _____ are used with infection.
Alginates and hydrofibers
61
Non-occlusive dressing that is used as a primary dressing, is minimally absorptive, provides minimal protection, does not enhance a moist environment, and may create a greasy wound bed.
One of its more appropriate uses is as a primary dressing over new sutures to prevent them from catching or sticking in a gauze secondary dressing
Impregnated gauze/Petroleum gauze
62
_______ Dressings: Semi permeable; keep wound bed at optimal environment; barrier to germs, limit scab formation. Promotes autolytic debridement.
Occlusive dressings
63
Occlusive dressings:
Op site, _____: transparent, non-absorbent
____: very absorbent, hydrogel sheet, nonadherent
____: hydrocolloid, self adherent, minimal absorption
___-___: absorbent, foam adds cushion
Calcium _____: made from seaweed, very absorbent
```
Tegaderm
Vigilon
Duoderm
Epi-lock
Calcium alginate
```
64
Which 2 occlusive dressings are good for infection and absorption?
Alginates and hydrofibers
65
[occlusive dressings]
Semi-permeable films: most are adherent, allows some _______ but no _____.
Semi-permeable foams: insulation, good _____ for fibroblasts and epithelial cells, good _____
Evaporation, NO absorption
Absorption
66
Between hydrogels and hydrocolloids, which is good for hydrating dry wounds?
Hydrogels
*hydrocolloids- very occlusive, good absorption
67
Materials used for bandaging and dressing:
____: Light, cool, allows air to circulate, it does not stretch or conform well to body parts.
____: It is sterile and does not adhere to the wound. It does not come in a variety of sizes.
____ ____: Sterile and will not adhere to wound if changed frequently. It will adhere to wound if left in place for a long period of time.
_____: Gauze-like material, but has elasticity, it will cling to itself, and contours well to body parts and may adhere to wound.
Gauze
Adaptic
Telfa pad
Kling
68
Materials used for bandaging & dressing continued:
- ______: Comes in a large roll container and may be cut to the desired length. Used between cast and patient. Secures dressings and keeps them clean.
- Ace bandages
- Compressogrip
Stockinette
69
```
Cavity Management (wounds):
_____: to delay wound closure
_____: to allow wound to fill in from inside out
```
*depends on moisture of the wound
Packing
Filling
70
4 types of debridement:
1) Sharp
2) Mechanical
3) Chemical
4) Autolytic
71
_____ debridement: Uses chemical ointment that has enzymes to break down necrosis. Only for necrotic wounds
_____ debridement: Uses the body’s own enzymes to break down necrotic tissue; optimized by occlusive dressings
Chemical/enzymatic
Autolytic
72
_____ debridement: scissors, forceps, scalpel, very selective, effective in speeding healing process
Sharps
73
Selective vs. Non-Selective Debridement
_______ : Removes only nonviable tissues
_____: Removes viable and nonviable tissues
Selective
Non-Selective
74
______: A condition in which the epithelial edge of a wound rolls under itself, the cells contact each other, causing contact inhibition and re-epithelialization ceases
Epiboly
75
_____: Result of excessive moisture on epithelial surfaces. The tissue will appear swollen and bleached out. An example is the result of staying in a pool too long or in the bath
Maceration
76
______: The drying out of a wound. May occur due to a non-occlusive dressing allowing fluid to evaporate or excessive dressing changes with loss of fluid
Dessication
77
______: Growth of granulation tissue in excess of the surface of the wound. Allows the wound to develop a mound exceeding the height of the surrounding skin and producing a scar
Hypergranulation
78
2 types of wound over-repair:
- ______ scars: don’t extend injury site
- _______: extend past injury site and can regrow after excision
Hypertrophic scars
Keloids
79
Which type of skin graft takes better, full thickness graft or cultured epithelial autografts (CEA)?
Full thickness graft
80
Skin graft vs. Flap
| Which can be thicker?
Flap
* blood supply and tissue still connected
Skin graft-Tissue and Blood supply completely removed, revascularization is vital, can’t be too thick
81
Flap types:
-
-
-
Local
Distant
Free
*Stretching and strengthening avoided for 2 to 3 weeks if it tenses area, avoid shesring
82
Elastic wraps are applied in a ____-____ pattern to LEs.
| ______ wraps are used on the UEs and trunk.
Figure-eight
Spiral
83
The application of pressure with pressure garments helps to prevent _______ scarring and assists the ______ fibers to lay down in an orderly fashion.
Hypertrophic
Collagen
84
Indications for use of pressure garments (compression):
| 7
1) Edema
2) Varicose veins
3) Radical mastectomy
4) Anti-embolism therapy
5) Lymphedema
6) Burns
7) PVD
85
Contraindications of pressure garments (compression):
| 5
1) Unhealed burns
2) Active phlebitis
3) Infection
4) Inflammation
5) When increased venous pressure is not desired
86
Three factors besides pressure commonly contribute to pressure ulcer formation. These include: _____, ____, and ______.
Shear, friction, moisture (maceration)
87
Stages of Pressure Ulcers (4):
Which stage?
Full thickness skin loss with extensive distruction, tissue necrosis or damage to muscle, bone, or supporting structures, tendon, joint capsule, etc.
Stage IV
88
Stages of Pressure Ulcers (4):
Which stage?
Full thickness skin loss involving damage on a crisis of subcutaneous tissues which may extend down to, but not through underlying fascia. The ulcer presents as a deep crater with or without undermining.
Stage III
89
Stages of Pressure Ulcers (4):
Which stage?
Partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
Stage II
90
Stages of Pressure Ulcers (4):
Which stage?
Non-blanchable erythema of intact skin
Stage I
91
Def: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood filled blister.
Deep tissue pressure injury (DTPI)
92
Ulcers of the lower leg:
_____ ulcer- The veins of the leg are ill-equipped for the task of moving blood back to the heart against gravity. These are usually located over the medial malleolus and have irregular borders, are usually shallow, and the fascia and deep structures are just generally not exposed. Pain RELIEVED with elevation.
Venous
93
Ulcers of the lower leg:
_____ ulcers: They are known as Ischemic ulcers or infarcts and are caused by arterial insufficiency. These ulcers frequently involve the pretibial area or dorsum of the toes or feet. Tend to be more painful and leg elevation AGGRAVATES the pain because gravity assists ______ flow. These ulcers are usually deep and tendons are visible.
*Arterial ulcers
Arterial flow
94
Ulcers of the lower leg:
______ ulcers- most are based on a combination of ischemia and neuropathy. The typical neuropathic foot ulcer occurs on the plantar surface of the foot, such as the heel, toes, and metatarsal heads. They are usually deep and infected and the ischemic limb is cool, skin appears shiny. The ulcer itself is painless but patients may complain of burning and paresthesia in extremities. In neuropathic ulcers touch, pressure, and proprioception are lost.
Diabetic Ulcers
95
Gait deviation: Abduction or lateral trunk bending toward prosthesis (TF)
Intrinsic and Extrinsic causes-
Intrinsic: Weak hip ABductors, painful residual limb, lack of proper gait training
Extrinsic: Prosthesis too long, abducted socket
96
Gait dev: Pistoning
Intrinsic and Extrinsic causes-
Intrinsic: Normal volume loss
Extrinsic: Socket too loose (add socks)
97
Gait dev: Vaulting
Intrinsic and Extrinsic causes-
Intrinsic: Weak hip flexors or knee flexors ; Improper training
Extrinsic: Prosthesis too long or locked/stiff prosthetic knee
Poor suspension, medial wall too high
98
Gait dev: Circumduction
Causes-
Intrinsic: Weak hip flexors or knee flexors, Lacks confidence/ability to flex knee, Abduction contracture, lack of proper gait training
Extrinsic: Prosthesis too long or locked knee, Inadequate suspension, medial wall too high
99
Gait dev: Foot slap
Causes-
Extrinsic: Heel bumper too soft
100
Gait dev: Excessive knee flexion in early stance
Causes:
Intrinsic: Flexion contracture, weak quads
Extrinsic: Heel cushion too firm, anterior socket placement
101
3 Types of LE prostheses:
Exoskeletal (conventional)
Endoskeletal (Modular)
Cosmetic (Non-functional
102
______ knees: stable, promotes normal gait (must load toe to unlock)
Polycentric knees
103
__________ knee units: “C-leg”, has stumble recovery and stance stability; variable cadence
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