Ulcers Flashcards
WHat causes a pressure ulcer?
when skin over a bony prominence is injured by pressure which occludes the capillary blood flow, causing ischemia
typically sacrum, buttocks, heels, shoulders, hips, etc.
What is a stage 1 pressure ulcer?
area of non-blanchable erythema
What is a stage 2 ulcer?
an ulcer that looks like an unroofed blister with the dermis exposed
What is a stage 3 ulcer?
subdermal tissue is exposed, with undermined edges - so the ulcer is probably bigger than it looks
what is a stae 4 ulcer?
when bone or tendon is exposed
WHen is an ulcer considered unstabeable?
when you can’t see the base due to eschar or exudate
What are the three general, overlapping processes of wound healing?
- inflamation
- epithelialization
3 remodeling
What do the fibroblasts form in wound healing?
they form granulation tissue, which is richly vascular
it provides a supportive base for the advancing epithelial tissue
How are pressure wounds different from surgical sounds?
surgical wounds will develop a fibrin clot to protect the advancing epithelial tissue.
a pressure ulcer is not actue, the clot doesn’t form- it’s just a large gap between the edges.
this means healing will take longer and wound dressings are much more important.
What does remodeling consist of?
scar formation and contraction
collagen secreted by fibroblasts is the primary ingredient
What are some important steps to do before local wound treatment of an ulcer?
- stage it well
- check for signs of infection
- figure out why it happened
What are some potential underlying causes for the development of a pressure sore?
fracture
stroke
metabolic problem: hyponatremia, hyperosmolar, uremia
diabetes
medications: sedative, anticholinergic, steroid
How can you manage tissue load over an ulcer?
you want to have “zero tolerance” for continued pressure ove rthe wound
you can use pressure relief mattresses or overlays
heal protectors aren’t effective
Is bacterial infection a concern in ulcers?
Yes and no
basically all wounds are colonized, so surface cultures are worthless.
Cleansing and debridement are key
You can try a two-week trial of topical antibiotics, but when we’re really worried is when the infection reaches the bone
If it’s clear that they have advancing infection where there’s spreading erythema and fever, then use systemic antibiotics
WHat nutritional aspects should be considered in ulcer treatment?
- protein is key because they need to be in a catabolic state
- healing requires extra callories - like 30-35 kcal/kg/day
Tube feeding is not helpful unfortunately
Vitamin supplementation not helpful
What should local ulcer care entail?
- debridement
- cleasning - don’t use antispectics that may be cytotoxic - we want the fibroblasts to hang out!
- Dressings (just be consistent with what you use)
What is autolysis?
debridement that is done by the body basically:
the inflammatory phase of healing is able to handle small amounts of dead tissue and exudate through enzymatic and phagocytotic processes which are together referred to as autolysis.
What are the 4 options for debridement?
- autolytic
- wet-to-dry
- enzymatic (collagenases)
- scalpel
WHen there is a lower extremity ulcer and it’s not a pressure ulcer, what is the most likely cause?
What are the two other basic options?
venous insufficiency 80-90% of the time
Arterial Insufficiency
neurotrophic ulcers
What are some associated symptoms you’ll see with a venous leg ulcer?
- location over the medial malleolus
- stasis dermatitis (hyperpigmentation - brown or purple)
- Chronic edema that won’t diurese
- edema is tender to palpation
- Varicose veins may or may not be present
WHat do venous ulcers tend to look like?
shallow and irregulaterly shaped
What are the two venous systems in the leg? Where do balbes come in?
the deep system (high pressure) and the superficial system( low pressure)
in a healthy leg, the superficial system is protected from the high pressure system by valves in the deep veins and perforator connections (through which the superficial veins drain into the deep veins)
What are three general factors leading to venous ulcers?
- overload (in CHF or obesity)
- Obstruction (clot or tumor)
- Pump malfunction (neurodegeneration, injury or inactivity - sitting too long)
Besides cleansing and debridement, what treatment goal is essential in venous ulcers?
control of the edema
you want to restore venous return by way of external compression of about 30-40 mm Hg at the ankle
Ted socks usually not good enough
Unna boot, compression hose, compression pumps
WHat do arterial ulcers usually look like? WHere are they typically located?
they are well circumscribe “punched-out” ulcers - often multiple
they occur in areas that are not well perfused - like the LATERAL malleolus, tibia, feet, and tips of toes
usually surrounded by shiny hairless skin with absent pulses and claudication
What other comorbid health problems are there with arterial ulcers?
hypertension
smoking
diabetes
PVD
myocardial infarction (this is what usually kills these people - or stroke)
AAA
claudication
If there is a leg arterial ulcer, what artery usually has an arteriosclerotic obstruction?
the superficial femoral artery and/or its branches
What is the simplext measure of blood flow into the leb?
The ankle-brachial index (ABI)
It’s the quotient of the systolic BP at the ankle dividd by the pressure at the brachial artery in the arm
1.0 or higher is normal
less than 0.8 = claudication (ulcers can happen under this)
less than 0.4 = rest pain
People with low ABI and leg ischemia usualy die from what?
myocardial infarction and stroke
leg ischemia is a strong indicator of cardiac and cerebral artery disease
What is Buerger’s DIsease
Also known as thrombangiitis obliterans…
It occurs in smokers (often young) who have an unusual sensitivity to the basoactiv eeffects of nicotine, so they have impaired endothelium-dependent relaxation in the peripheral vasculatur (arteries and veins)
they get thrombophlevitis and sores on their extremities
How can you distinguish Buerger’s Disease from arterial ulcers?
- both venous and arterial involvment will happen in Buergers
- Buerger’s has more diffuse involvement of both upper and lower extremities
- Do the Allen test
How do you do the Allen test?
Occlude radial and ulnar arteries after making a fist to empty blood from the hand.
Open hand and release pressure over the ulnar artery.
Hand should refill with blood via ulnar artery, evidenced by return of pink color.
Positive = persistent pallor.
How is treatment for arterial ulcers different than that for venous ulcers?
external compression for arterial ulcers is BAD
you also want to deal with smoking cessation, revascularization
potential skin graft and potential amputation
What happens in a neurotrophic ulcer?
These ulcers results form unrecognized, repetitive trauma due to a lack of sensation in the involved extremities - usually in diabetics or people with neuropathy.
they’re a sort of hybrid between arterial and pressure ulcers
Where do neurotrophic ulcers usually occur?
on the plantar aspect of the foot or toes
What happens to the feet in severe neuropathy?
Charcot foot
this is the collapse of the ankle and foot structure due to neuropathy - the foot assumes a focker bottom appearance and ther eis usually a deformity at the ankle as well
ulcers will often appear over the lateral plantar mid-foot and osteomyelitis is a frequent complication
How does one screen for neuropathy?
yse the monofilament touch test on the bottoms of the feet to test for decrease sensitivity
WHat are two additional treatment strategies for neurotrophic ulcers?
total contact cast
recombinant platelet derived growth factor - becaplermin
Why is good glucose control so important in the treatment of neurotrophic ulcers?
hyperglycemis inhibit macrophage and fibroblast function
What are the 4 main tipoffs that you may be dealing with a cancerous ulcer?
- unusual location and looks atypical
- has nodular component
- swelling of regional lymph nodes
- doesn’t appear to heal despite good treatment
What will basal cell carcinoma uclers look like?
they’ll have heaped up or rolled edges. often with perly modularity around the periphery (often with telangiectatic vessles overlying)
they are usually on sun-exposed surfaces
What will preempt a squamous cell skin cancer ulcer?
an actinic keratosis
What is pyoderma gangrenosum?
What does it look like?how does it progress?
It starts with a pustular-appearing lesion
it grow rapidly with coious exudate and surrounding erythema, so it’s often confused with a bacterial infection
it gets blue or purplish discoloration around the periphery and a scalloped appearnce of the edges
Associated with an inflammatory process like IBS, RA, leukemia, Crohn’s, ulcerative colitis, etc.
Treat with corticosteroids
