Unit 4 - Effects of Chronic Diseases on the Lower Limb Flashcards
1
Q
Diabetes
A
A metabolic disorder characterized by the inability to manufacture or properly use insulin.
The body’s ability to convert sugars, starches, and other foods into energy is impaired.
2
Q
Long-term effects of hyperglycemia?
A
The long-term effects of hyperglycemia are damage to the eyes heart kidneys feet nerves large and small blood vessels FL
3
Q
DM Type 1
More commonly diagnosed in? Percentage of people diagnosed? Cause? Leading to? Treatment?
A
children and adolescents
10% of people diagnosed with diabetes have Type 1 diabetes.
Pancreatic beta cell destruction causes the pancreas to stop producing insulin.
Without enough insulin, glucose isn’t metabolized properly, so it builds up in the bloodstream.
diet and exercise. clients are dependent on insulin.
4
Q
DM Type 2
Commonly diagnosed in?
Cause?
Treatment?
A
adults
The pancreas does not produce enough insulin
or
the body does not use the insulin effectively (insulin resistant).
diet and exercise. oral medication and/or insulin.
5
Q
Gestational diabetes
A
Onset of temporary glucose intolerance in pregnancy.
This puts both mother and baby’s health at risk.
6
Q
Other causes of diabetes?
GGG DED
A
genetic defects of pancreatic beta cell function
genetic disorders known to cause diabetes
genetic defects in insulin action
drug-induced (corticosteroid-induced)
endocrine disorders known to cause diabetes
disease of the endocrine pancreas
7
Q
In 2016, how many Canadians aged 12 and older reported being diagnosed with diabetes?
Percentage? # of people?
A
7%
Roughly 2.1 million people
8
Q
Male VS Female percentage? (Diabetes)
A
Males 7.6%
Females 6.4%
9
Q
Fat prevalence in 2016? (Diabetes)
A
Obese 13.2%
Overweight 6.6%
Normal weight 3.6%
10
Q
The percentage of Canadians aged 12 and older who had been diagnosed with diabetes was lowest amongst?
…speaking in QUINTILES then percentage
A
households that fell within the highest income quintile
4.9%
11
Q
Which quintiles were most likely to report being diagnosed with diabetes?
A
Households among the
lowest and second lowest
income quintiles
12
Q
Between 2004 and 2008, how many diabetes-mellitus-related deaths were recorded in Canada?
They accounted for ??.?% of all deaths that occurred in the period.
A
120,050
10.6%
13
Q
In Manitoba, what is the expected increase in diabetes prevalent cases between 2016 and 2026?
A
37%
14
Q
Diabetes complications are associated with?
A
Premature death.
Diabetes reduces lifespan by 5–15 years.
15
Q
How many deaths in Canadian adults was attributable to diabetes in 2008-2009?
A
One of ten
16
Q
Foot ulceration affects an estimated ??%–??% of Manitobans with diabetes in their lifetime.
A
15%–25%
17
Q
In 2011–2012, how many amputations were performed on people reporting a diabetic foot wound?
A
One-third of amputations in 2011–2012
18
Q
MB – High Risk populations for type 2 diabetes
A SHIT Loo
A
Asian
South Asian
Hispanic
Indigenous
The Africans
Low income
overweight
older
19
Q
Diabetes rates in First Nations in comparison to the general population?
A
Diabetes rates are 3–5 times higher in First Nations than in the general population
20
Q
Diabetes rates are 3–5 times higher in First Nations than in the general population.
This situation is compounded by?
A
Barriers to care for Indigenous people
21
Q
Metabolic syndrome
A
a cluster of conditions that occur together, increasing risk of
heart disease
stroke
type 2 diabetes
22
Q
DM-II
Risk factors associated with metabolic syndrome
Hi, HAVA POD
A
History of IGT (impaired glucose tolerance)
or
IFG (impaired fasting glucose)*
Hypertension
Abdominal obesity*
Vascular disease*
Acanthosis nigricans*
Polycystic ovary syndrome
Overweight
Dyslipidemia
23
Q
DM-II
More risk factors
A
1st-degree relative c diabetes
Older than 40
Smoking
Schizophrenia
GDM (gestational diabetes mellitus)
Hx of GDM
Delivery of a macrosomic infant ( > 4500g/9lb)
24
Q
Of all the risk factors, what risk factor is most important?
A
Weight
25
What %age of diabetes sufferers are classified as overweight?
More than 80%
26
Screening for Type 2 diabetes in individuals WITHOUT risk factors is recommended beginning at?
age 40
27
Screening for Type 2 diabetes in individuals WITHOUT risk factors is recommended beginning at age 40.
How often? What test?
Every three years the client should have fasting blood glucose levels tested.
28
How often should individuals with risk factors should be screened? Beginning when?
Testing for clients at risk involves?
annually or more
beginning earlier than 40
a 75-gram oral glucose tolerance test
29
Signs and Symptoms of diabetes
PIPP’S TUBE
```
Polyuria
Infections - frequent/recurring
Polydipsia
Polyphagia
Slow to heal - cuts/bruises
```
Tingling on numbness in hands or feet
Unexplained weight loss/gain
Blurred vision
Extreme fatigue or lack of energy
30
What is important to note about people who have Type 2 diabetes?
It is important to note that people who have Type 2 diabetes may not display symptoms.
31
The long term effects of hyperglycemia involve?
As well as?
macrovascular and microvascular changes
neuropathy
32
Diabetes (Type 1 and 2) can result in serious long-term complications affecting
eyesight (retinopathy)
kidney function (nephropathy)
circulation and sensation in the feet
33
Because diabetes is a systemic disease affecting many different parts of the body, ideal management requires?
a team approach
34
Because diabetes is a systemic disease affecting many different parts of the body, ideal management requires a team approach?
As foot care nurses in the community, you may be the person the client turns to for answers.
What is and important first step?
Diabetes education
35
People with diabetes must become knowledgeable about their condition in order to make?
healthy lifestyles choices
36
In order to prevent foot damage, precautions must be taken with respect to...
PEGS
proper footwear (both socks and shoes)
exercises
gait modifications
skin care
37
What is the most effective form of Tx?
Prevention!
38
The foot care nurse, as an integral part of the team, has documented success in the prevention of ?
Amputations?
39
The key to amputation prevention in diabetic clients is?
Early recognition and regular foot screening
40
How often should the physician inspect the person with diabetes feet?
The nurse?
@ least annually
the nurse provides regular foot care and assessment Q.4 – 8.Weeks
41
What does Hyperglycemia lead to? (3)
Further to impaired WBC function, vascular changes can cause? (2)
Poor circulation leads to? (1)
Increased blood viscosity
Inhibition of WBC performance
A hospitable environment for pathogens to flourish
Ischemia and tissue necrosis
Prevention of proper wound healing
42
What explains why a simple breach of skin integrity can lead to a complicated foot ulcer, which in turn can lead to amputation?
Hyperglycemia causing/creating:
1) Inhibition of WBC performance
2) A hospitable environment for pathogens to flourish
3) Ischemia -- poor circulation prevents proper wound healing
43
Occlusive lesions in vessels of the lower limbs will cause?
This leads to
claudication -- pain caused by too little blood flow
leg pain at rest
night cramps
44
What may relieve leg pains @ rest?
legs in dependent position (dangling)
45
In the case of a total occlusion
the pain will not be eased by dependency
46
What is important for both the foot care nurse and the client to recognize?
that a painful, cool, white limb is an emergency
47
Acute Limb Ischemia
Occurs when???
6 Ps
Occurs when there is a sudden lack of blood flow to a limb.
Pain -- Rest pain that worsens on passive movement of the limb and is most severe in the distal aspects of the ischemic limb.
Pallor -- Skin over the ischemic limb initially appears pale and then becomes mottled and purple-blue.
Paralysis -- Initial muscle weakness progresses to profound irreversible paralysis
Pulselessness -- Absent peripheral pulses distal to the site of occlusion
Paresthesia -- An abnormal dermal sensation (e.g., a tingling, pricking, chilling, burning, or numb sensation on the skin) with no apparent physical cause
Poikilothermia -- The ischemic limb is typically cold to touch but may be warm in hot environments (i.e., it takes on the ambient temperature).
48
Claudication
pain caused by too little blood flow
49
What causes claudication?
Occlusive lesions in vessels of the lower limbs
50
Neuropathy
damage to the nervous system
51
Neuropathy refers to damage to the nervous system.
It is a...?
Especially in...?
serious and frequent complication of diabetes
clients who have had diabetes for 10 years or more
52
It is not uncommon for a diabetic client to present with...?
Clients with diabetic neuropathy are frequently unaware that...?
corn and/or callus formation that is “pain free”
they have the condition(s), and may even deny the evidence
53
Symptoms of neuropathy include:
| NL PUPIES
Newfoundland pupies
numbness
loss of feeling/balance
“pins & needles” / tingling or burning
unable to feel feet when walking
pain that is usually worse at night
inability to detect temperature
edema
structural changes in the foot (specifically Charcot’s Foot / Joint)
54
Charcot’s Foot/Joint
| from the interwebs, not 'text' book
Diabetes also damages blood vessels, decreasing the blood flow to the feet. Poor circulation weakens bone, and can cause disintegration of the bones and joints in the foot and ankle. As a result, people with diabetes are at a high risk for breaking bones in the feet.
When a diabetic fractures a bone in the foot, he or she may not realize it because of nerve damage. Continuing to walk on the injured foot results in more severe fractures and joint dislocations. Sharp edges of broken bone within the foot can point downward toward the ground, increasing the risk of chronic foot sores from the abnormal pressure.
The combination of bone disintegration and trauma can warp and deform the shape of the foot. This condition is called Charcot arthropathy, and is one of the most serious foot problems that diabetics face.
55
Screening with a 10 gram monofilament is a validated method to assess for...
This can help determine...
protective sensation (neuropathy) in the feet
the risk of foot ulceration
56
Monofilament testing is simple, inexpensive, non-invasive and a useful test that should be used when and for what
At regular intervals -- ongoing monitoring
To Ax the sensory perception in the feet
57
Monofilament testing results should be?
And?
documented for ongoing monitoring
referrals should be made as appropriate
58
Sensory neuropathy
nerve damage that affects the body’s ability to sense pain
59
Sensory neuropathy is manifested by?
sensations of burning feet or numbness
60
Sensory neuropathy is manifested by sensations of burning feet or numbness.
This can lead to? (3)
Injury
Impaired proprioception*, often causing changes in gait pattern
*Proprioception (position sense) the ability to feel whether or not the foot is firmly planted on the ground
61
Autonomic neuropathy
nerve damage that affects the body’s ability to regulate body temperature
Autonomic neuropathy occurs when the nerves that control involuntary bodily functions are damaged.
62
Autonomic neuropathy is manifested by?
Which leads to?
What is a common cause of fissures?
decrease in production of sweat, reducing or eliminating perspiration
leading to dry, cracked atrophic skin
anhidrosis - the inability to sweat normally
63
Dehydration of the epidermis results in?
Impaired skin integrity d/t loss of keratin, flexibility and elasticity
64
Motor neuropathy
nerve damage that affects the intrinsic muscles ability to receive and send messages to flex and extend the foot
65
Motor neuropathy is manifested by?
an imbalance with the larger extrinsic muscles
or
dislocation or collapse of the foot
66
nerve damage that affects the body’s ability to sense pain
Sensory neuropathy
67
nerve damage that affects the body’s ability to regulate body temperature
Autonomic neuropathy
68
nerve damage that affects the intrinsic muscles ability to receive and send messages to flex and extend the foot
Motor neuropathy
69
What are three components to peripheral neuropathy?
Sensory
Autonomic
Motor
70
COMPONENTS of peripheral neuropathy
& how they may increase risk of ulcer development
SENSORY NEUROPATHY
-- Pathophysiology
Myelin sheath disrupted by hyperglycemia
Disruption leads to segmental demyelinization process
accompanied by
slowing of motor nerve conduction
and
impairment of sensory perception
71
COMPONENTS of peripheral neuropathy
& how they may increase risk of ulcer development
SENSORY NEUROPATHY
-- Assessment
10-gram (5.07) monofilament
to determine the presence of protective sensation
gait analysis
72
COMPONENTS of peripheral neuropathy
& how they may increase risk of ulcer development
SENSORY NEUROPATHY
-- Outcome
loss of protective sensation
sensory ataxia
leading to
falls
73
Rate of falls in person with sensory neuropathy secondary to diabetes?
15-fold increase compared to those without diabetes
74
COMPONENTS of peripheral neuropathy
& how they may increase risk of ulcer development
AUTONOMIC NEUROPATHY
-- Pathophysiology
SLAP BG
```
sympathetic denervation
(denervation = loss of nerve supply)
```
loss of vasomotor control
(vascular bed becomes widely dilated)
```
arteriovenous shunting
(autonomic neuropathy can result in an increased rate of blood flow. the faster rate of blood flow, exacerbated by poor glucose control, results in new channels opening up between the arterial and venous systems in the lower leg and foot. this is called arteriovenous shunting. Shunt = the act of pushing something)
```
peripheral blood flow
(increased)
bone blood flow hyperemia
(hyperemia = increase in blood flow to a tissue due to a change in general conditions. increased blood flow causes bone resorption and weakening.)
glycosylation of collagen
75
arteriovenous shunting
Autonomic neuropathy can result in an increased rate of blood flow. The faster rate of blood flow, exacerbated by poor glucose control, results in new channels opening up between the arterial and venous systems in the lower leg and foot. This is called arteriovenous shunting.
This phenomenon is thought to be aggravated by the rigidity of the smaller arteries in the foot caused by arteriosclerosis and the widely dilated vascular bed caused by autonomic disorder.
Clinically these changes are seen as the presence of distended veins over the dorsum of the foot and lower leg, and an easily palpable, bounding pulse in the foot. Although these signs could be interpreted as indicators of a good blood supply to the foot, it has been suggested that the fast rate of flow actually fails to fill the smaller vessels of the foot resulting in a reduced distal blood supply. Although the foot is warm to the touch with a strong pulse, the autonomic pathology and co-existence of micro and macrovascular disease means the picture of healthy skin and a good pulse is often confused by the presence of localised ischaemia or ulceration.
76
COMPONENTS of peripheral neuropathy
& how they may increase risk of ulcer development
AUTONOMIC NEUROPATHY
-- Assessment
I'M LTD
inspect between the toes especially between the fourth and fifth toes for fissures
maceration
loss of hair growth
thickened toenails
dry scaly skin caused by lack of hydration
77
COMPONENTS of peripheral neuropathy
& how they may increase risk of ulcer development
AUTONOMIC NEUROPATHY
-- Outcomes
FAP COW
fissures
anhydrosis
peripheral edema
callus
onychomycosis (fungal nails)
waxy skin = altered joint mobility
78
COMPONENTS of peripheral neuropathy
& how they may increase risk of ulcer development
MOTOR NEUROPATHY
-- Pathophysiology
Subluxation of metatarsophalangeal joints
(a subluxation is a partial dislocation, where the bones are out of position, but not completely separated).
Atrophy of intrinsic muscles of the foot
(toe plantar flexors)
Non-enzymatic glycosylation
(non-enzymatic glycosylation is the covalent attachment of a sugar to a protein or lipid. Glycosylation refers to the covalent bonding of blood glucose to the red blood cells. Normally, only a small percentage of blood glucose, usually between 4.5%- 6%, is covalently linked to the red blood cells in hemoglobin of the non diabetes population.)
79
COMPONENTS of peripheral neuropathy
& how they may increase risk of ulcer development
MOTOR NEUROPATHY
-- Assessment
RAID
range of motion
absent deep tendon reflexes
increased peak pressure
diminished vibratory sense
80
COMPONENTS of peripheral neuropathy
& how they may increase risk of ulcer development
MOTOR NEUROPATHY
-- Outcomes
Cchamp pa
Charcot arthropathy
claw toes
Hyperextension of the MTP, a flexion deformity at both the proximal interphalangeal joint (PIP) and the distal interphalangeal joint (DIP)
With claw toe, the joint at the base of the toe is bend up. The middle joint is bent down.
hammer toes
Flexion deformity of the proximal interphalangeal joint (PIP) along with a hyperextension of the distal interphalangeal joint (DIP). The MTP joint is neutral or extended.
With hammertoe, the middle joint is bent
ankle equinus
Equinus is a condition in which the upward bending motion of the ankle joint is limited. Someone with equinus lacks the flexibility to bring the top of the foot toward the front of the leg.
muscle weakness
```
Pes Cavus (high arch)
An increase in the height of the medial longitudinal arch. The subtalar joint (Articulation b/w the talus and calcaneus) is hyperflexed. There is an alteration in the position of the talus and the navicular.
```
```
Pes Planus (flat foot)
Flattening of the medial longitudinal arch usually involving the talus, navicular and associated tendons and ligaments
achilles tendon contracture
```
81
Charcot’s Foot (Charcot’s Arthropathy)
What two things cause this?
Loss of protective sensation = ability to sense pain and position of the joint is impaired.
Muscles lose their ability to support the foot correctly.
82
Charcot’s Foot (Charcot’s Arthropathy)
Loss of protective sensation = ability to sense pain and position of the joint is impaired.
Muscles lose their ability to support the foot correctly.
As a result of this, what happens? (2)
minor trauma (eg sprains; stress fractures) to the foot goes undetected
This leads to
slackness of the ligaments
joints being dislocated
bone and cartilage being damaged
and deformity to the foot.
83
What can the Charcot process lead to?
collapse of the medial longitudinal arch (Pes Planus)
dramatic changes in the shape of the foot
The foot becomes unstable and spontaneous fractures and/or dislocations occur.
Finally, the bone structure of the foot collapses.
84
With the Charcot process, The foot becomes unstable and spontaneous fractures and/or dislocations occur.
What does this cause?
redness and swelling
85
With the Charcot process, The foot becomes unstable and spontaneous fractures and/or dislocations occur.
This causes redness and swelling that is often mistaken for?
osteomyelitis or cellulitis
86
Charcot process.
Finally, the bone structure of the foot collapses.
How is this treated?
What happens if it is not treated?
The foot is casted.
If the foot is not casted, the foot heals in a flat-footed or “rocker-bottom” position. (because of the breakdown of bone, it heals into a deformed foot)
87
Charcot process.
Because of the abnormal shape of the foot, a person with Charcot joint encounters what 3 problems?
UTI
ulcerations on the plantar surface of the feet
trouble fitting shoes
increased callus formation
88
Diabetic foot ulcers are a devastating complication of diabetes, and are related to the effects of ...? (3)
the disease itself
macrovascular and microvascular changes
neuropathy
89
In a diabetic with peripheral neuropathy, foot ulcers may occur as a result of...? (3)
CDs
changes in pressure points on the foot
diminished sensation
structural deformities
90
Ulcers can originate from?
But frequently develop where?
cuts and abrasions
at areas of undue pressure
or
under corns or calluses
91
As a corn or callus develops in the insensate foot in response to pressure, friction or shear, the hyperkeratosis continues to develop unabated because why?
the person is unable to feel sensations of pain and tenderness that would normally accompany a developing ulcer or abscess
92
Fully 85% of lower extremity amputations are preceded by?
non-healing ulceration
93
What percent of lower extremity amputations are preceded by non-healing ulceration?
85%
94
Peripheral vascular disease (PVD) refers to?
diseases of the blood vessels of the extremities
95
Simply put, PVD interferes with?
blood flow through veins or arteries
96
PVD can be referred to as?
Which is also know as? (2)
peripheral artery disease (PAD)
“hardening of the arteries”
or
atherosclerosis of the legs
97
The vast majority of clients with peripheral vascular disease also have?
diabetes
98
Other risk factors that can lead to PVD include:
SHHHH ADO
sedentary lifestyle
heredity
hypertension
history of smoking
history of DVT
dyslipidemia
athero/arteriosclerosis
obesity
99
People with PAD often have?
fatty buildup in the arteries of the heart and brain
100
People with PAD often have fatty buildup in the arteries of the heart and brain, giving them a higher risk of?
heart attack or stroke
101
Most people with PAD can be treated with?
Lifestyle changes, medication or both
102
Most people with PAD can be treated with lifestyle changes, medication or both. Lifestyle changes to lower ones risk include? (5)
smoking cessation
glycemic control
BP control
physically activity
low-saturated fat, low-cholesterol diet
103
Signs and symptoms (presentation) of PVD will vary depending on? (2)
If the insufficiency affects venous or arterial flow.
The degree of occlusion or insufficiency.
104
Nearly 75 percent of people with PAD do not experience?
Women VS Men?
symptoms
Women are less likely to have symptoms than men.
105
Venous insufficiency
inadequate venous return from the legs, with a resultant build up of blood and pressure in the legs
106
inadequate venous return from the legs, with a resultant build up of blood and pressure in the legs
Venous insufficiency
107
Venous insufficiency may result from?
extensive valvular incompetence associated with varicose veins
108
The signs and symptoms of venous insufficiency depend on?
whether the condition is
chronic or acute
localized or general
109
ACUTE venous insufficiency is caused by?
thrombophlebitis
Thrombophlebitis (throm-boe-fluh-BY-tis) is an inflammatory process that causes a blood clot to form and block one or more veins, usually in your legs. The affected vein might be near the surface of your skin (superficial thrombophlebitis) or deep within a muscle (deep vein thrombosis, or DVT).
110
S/S of ACUTE venous insufficiency caused by thrombophlebitis (3)
WET
warmth/redness
edema
tenderness or pain over the area of involvement
111
Treatment for acute venous insufficiency caused by thrombophlebitis?
immediate referral to physician
112
CHRONIC venous insufficiency is caused by?
heredity
occupation hazard -prolonged standing
venous thrombosis
A venous thrombus is a blood clot (thrombus) that forms within a vein. Thrombosis is a term for a blood clot occurring inside a blood vessel. A common type of venous thrombosis is a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg.
CHF
113
S/S of CHRONIC venous insufficiency
CHEFS
c/o aching and tired legs and feet
```
hemosiderin staining (erythocyte pigmentation)
Hemosiderin staining. Hemosiderin — a protein compound that stores iron in your tissues — can accumulate under your skin. As a result, you may notice yellow, brown, or black staining or a bruiselike appearance. Stains most often appear on the lower leg, sometimes covering the space between your knee and ankle.
```
edema
feeling of heaviness, fatigue
stasis ulceration
114
Treatment of CHRONIC venous insufficiency (2-ish)
Leg elevation
Refer to physician for treatment and management, may include:
- diuretic
- compression therapy
115
Arterial insufficiency can affect either?
the small or large vessels
116
In the case of the large arteries, the disease may be either?
acute or chronic
117
Constant pain in a resting extremity may be due to?
acute arterial occlusion
118
Constant pain in a resting extremity may be due to acute arterial occlusion and is?
a medical emergency
119
CHRONIC arterial insufficiency of the lower extremity causes two classic symptoms...
intermittent claudication
night rest pain
120
What may develop from chronic arterial insufficiency?
Ulcers
121
ACUTE arterial insufficiency S/S
sudden pain
coldness
pallor below the site of the occlusion
122
Acute arterial insufficiency Tx
immediate referral to physician or ER – possible vascular bypass
123
CHRONIC arterial insufficiency S/S
```
Hair (1)
Skin (3)
Nails (2)
Palpate
Complaint
```
Decreased hair growth
Tight, shiny skin
Color – pale after 1-2 minutes of elevation, normal to dusky red when lowered
Non-healing ulcers
Thickened toenails
Slow nail growth
Weak or absent pedal pulses
Intermittent claudication
124
CHRONIC arterial insufficiency Tx
encourage smoking cessation
Referral to Family Dr. to assess:
- possible anti-platelet medication
- possible ABI
- possible referral to vascular surgeon
The ankle-brachial index test compares the blood pressure measured at your ankle with the blood pressure measured at your arm. A low ankle-brachial index number can indicate narrowing or blockage of the arteries in your legs.
You may have ankle-brachial index testing before and immediately after walking on a treadmill. An exercise ankle-brachial index test can assess the severity of the narrowed arteries during walking.
125
CHRONIC arterial insufficiency...If circulation cannot be improved:
PRAP
Protective footwear
Regular preventative foot care
All wounds monitored and MD notified if any worsening of same
Palliative care of any wounds
126
Venous Insufficiency
VS
Arterial Insufficiency
Skin
brownish red skin discolouration (hemosiderin staining)
weeping
ulcers that are slow to heal
```
decreased skin tugor
shiny, cool skin
cyanosis or dependant rubor
ulcers that do not heal
ischemic or necrotic areas
```
Ischemia is a restriction in blood supply to tissues, causing a shortage of oxygen that is needed for cellular metabolism (to keep tissue alive). Ischemia is generally caused by problems with blood vessels, with resultant damage to or dysfunction of tissue.
Dependent rubor or erythema is stigmata of peripheral arterial disease involving the erythematous discoloration of the limb in dependent position due to the effect of gravity. (mistaken as cellulitis)
Dependent rubor is a fiery to dusky-red coloration visible when the leg is in a dependent position but not when it’s elevated above the heart. The underlying cause is peripheral arterial disease (PAD), so the extremity is cool to the touch.
127
Venous Insufficiency
VS
Arterial Insufficiency
Objective
edema of limbs
weak or absent pedal pulses
128
Venous Insufficiency
VS
Arterial Insufficiency
Subjective
tired, aching legs
mild to moderate pain
```
muscle cramping (intermittent claudication)
moderate to severe pain
```
129
The rule of thumb re. ulcers?
ulcers that occur BELOW the ankle are ARTERIAL
while
ulcers that occur ABOVE the ankle are VENOUS
130
intermittent claudication
a condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries
When muscles are being used during exercise or walking, they need more blood flow. If there’s a blockage due to plaque buildup, the muscles won’t get enough blood during exercise to meet their needs. This causes the pain, which is called “intermittent claudication”.
131
Pain secondary to intermittent claudication usually occurs where?
distal to the arterial narrowing or obstruction
132
Which vessels are most commonly affected by the atherosclerotic process?
Atherosclerosis is a disease in which plaque builds up inside your arteries. Arteries are blood vessels that carry oxygen-rich blood to your heart and other parts of your body. Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood. Over time, plaque hardens and narrows your arteries.
femoral and popliteal
133
Since the superficial femoral and popliteal arteries are the vessels most commonly affected by the atherosclerotic process...?
the pain of intermittent claudication is most often localized to the calf
134
The femoral and popliteal vessels are most commonly affected by the atherosclerotic process.
What are the two next most frequent sites of involvement?
the distal aorta and its bifurcation into the two iliac arteries
135
Narrowing of the distal aorta and its bifurcation into the two iliac arteries may produce pain where?
in the buttocks or the thighs as well as the legs
136
intermittent claudication
As the disease progresses the client may complain of?
leg pain even at rest
137
As ischemia worsens the incidence of rest pain increases.
The pain is usually felt where?
When?
What usually relieves the pain?
Possibly causing?
in the foot or the toes,
often the great toe
Soon after elevating the leg, occurring classically on going to bed.
Hanging the foot out of the bed or sleeping in a chair.
Dependent edema
138
As nouns the difference between occlusion and ischemia
Occlusion is the process of occluding, or something that occludes (obstructs)
while
Ischemia is (pathology. cardiology) local disturbance in blood circulation due to mechanical obstruction of the blood supply (vasoconstriction, thrombosis or embolism)
Thrombosis occurs when a thrombus, or blood clot, develops in a blood vessel and reduces the flow of blood through the vessel.
Embolism occurs when a piece of a blood clot, foreign object, or other bodily substance becomes stuck in a blood vessel and largely obstructs the flow of blood.
139
Acute arterial occlusion is said to present with the
4 Ps
Pain
Pulseless
Paresthetic (numb)
Pallor
140
Acute Limb Ischemia
Occurs when???
6 Ps
Occurs when there is a sudden lack of blood flow to a limb.
Pain -- Rest pain that worsens on passive movement of the limb and is most severe in the distal aspects of the ischemic limb.
Pulselessness -- Absent peripheral pulses distal to the site of occlusion
Paresthesia -- An abnormal dermal sensation (e.g., a tingling, pricking, chilling, burning, or numb sensation on the skin) with no apparent physical cause
Pallor -- Skin over the ischemic limb initially appears pale and then becomes mottled and purple-blue.
Poikilothermia -- The ischemic limb is typically cold to touch but may be warm in hot environments (i.e., it takes on the ambient temperature).
Paralysis -- Initial muscle weakness progresses to profound irreversible paralysis
141
Ischemia Ax
Objective (2)
Subjective (1)
Pedal pulses weak or absent
Delayed capillary refill time
Pain with activity that is relieved with rest
142
Clients with arthritis, musculoskeletal or venous insufficiencies also have pain with activity, which is also relieved with rest.
However, it is usually easy to distinguish between the pains of each condition.
How?
The client with PAD will specify the amount or intensity of the activity that causes the discomfort. The discomfort will also be completely resolved with a short period of rest.
In contrast, exercise in arthritis, musculoskeletal and venous insufficiency will cause pain, but the pain will last for several hours or even days after the client begins to rest.
143
Peripheral vascular disease (PVD) is a problem with poor blood flow. It affects blood vessels outside of the heart and brain and gets worse over time. ... Other blood vessel problems like deep vein thrombosis (DVT), varicose veins, and chronic venous insufficiency are linked to PVD.
What is venous peripheral insufficiency?
Chronic venous insufficiency occurs when your leg veins don't allow blood to flow back up to your heart. ... But when these valves don't work well, blood can also flow backwards. This can cause blood to collect (pool) in your legs.
Yah, so!
144
The goal of treatment for clients with intermittent claudication -- chronic arterial insufficiency -- of the lower extremities is twofold.
eliminate ischemic symptoms and prevent progression to vascular occlusion to the affected limb(s)
prevent cardiovascular complications
(stroke, myocardial infarction, and/or death)
145
arterial insufficiency complications
THUMP
```
thrombus formation
hypoxia leading to necrosis
ulceration
mein Gott!...amputation
pain
```
146
venous insufficiency complications
chronic edema of lower limbs
chronic ulceration
varicose veins
stasis dermatitis
pain
147
Simply put, arthritis is...
...a group of inflammatory (pain/swelling) conditions that affects the joints.
There are over 100 types or classifications of arthritis.
148
The economic burden of arthritis is 16.4 billion dollars, making it?
the 2nd most costly chronic illness in Canada
149
4 classifications of arthritis to know
Osteoarthritis
Rheumatoid Arthritis
Gout
Psoriatic Arthritis
150
What is the most common type of arthritis?
Describe.
Osteoarthritis (OA)
A degenerative joint disease, characterized by the deterioration of the articular cartilage that covers the ends of bones in the joints.
151
OA is a degenerative joint disease, characterized by the deterioration of the articular cartilage that covers the ends of bones in the joints.
What does this cartilage normally do?
reduces friction
| absorbs shock during movement
152
In a healthy person, cartilage production and breakdown stay in balance, but in a person with OA?
this balance is lost, and cartilage breaks down faster than it’s regenerated
153
As OA progresses what happens? (3!)
cartilage becomes stiff and loses its elasticity
eventually it wears away completely, leading to painful bone-on-bone contact
spurs grow from the bone edges and bony cysts develop
154
As OA progresses, spurs grow from the bone edges and bony cysts develop.
This leads to?
joint deformity
pain
disability
155
What is the most common cause of OA
aging
156
What is the most common cause of OA aging.
What are other causes?
```
trauma
genetics
obesity
overuse of joints
joint abnormalities
scoliosis
```
157
When do the chances of developing OA greatly increase?
After 60
158
OA presentation
Clients will frequently c/o stiff and painful joints.
What is most commonly affected in the feet?
This may contribute to? (2)
The first metatarsophalangeal joint (MTPJ)
hallux valgus
or
hallux rigidus
159
Rheumatoid arthritis (RA)
Definition
It is considered?
a systemic autoimmune disease that attacks the joint lining, or synovial tissue of the joint
Considered the most painful form of arthritis
160
A degenerative joint disease, characterized by the deterioration of the articular cartilage that covers the ends of bones in the joints.
Osteoarthritis (OA)
161
a systemic autoimmune disease that attacks the joint lining, or synovial tissue of the joint
Rheumatoid arthritis (RA)
162
What is considered to be the most debilitating form of arthritis?
RA affects more that 2 million people.
Male VS Female
RA
two-thirds affected are women
163
The synovial membrane contains synovial fluid that transports nutrients to the cartilage and keeps its surface well lubricated so the joints can work smoothly.
In rheumatoid arthritis, an autoimmune defect causes...?
healthy cells to be attacked, releasing enzymes that attack surrounding tissues, causing
synovium inflammation
leading to
swelling and pain
164
RA Sx
JAM
joint pain and stiffness
anemia
muscle aches
165
Sx of RA are very general,
(joint pain and stiffness
anemia
muscle aches)
but just the same...?
if they occur repeatedly, they should not be overlooked
166
RA can lead to severe structural deformities of the foot.
What happens to
METATARSAL HEADS
What does this cause? (1)
What happens to
METATARSOPHALANGEAL JOINTS
What does this cause? (3)
What happens to
PROXIMAL/DISTAL INTERPHALANGEAL JOINTS
What does this cause? (1)
metatarsal heads
> SUBLUX @ PLANTAR SURFACE
> causes the underlying fat pad to shift away from the ball of the foot
```
metatarsophalangeal joints
>HYPEREXTEND
> Hallux valgus
> Claw toe
> subluxations of lesser MTP joints result in hammer toe
```
proximal and distal interphalangeal joints
> overlapping toes (toes drift laterally)
167
RA can lead to severe structural deformities of the foot.
Structural deformities can lead to?
Which leads to?
pressure areas
corns and calluses will develop in these areas as a natural protective measure
Rheumatoid nodules appear in approximately one-quarter of all people with RA. Nodules are firm, pea sized masses made up of scar tissue and are not usually painful.
168
What also appear on the foot in approx. one-quarter of all people with RA?
Describe.
Rheumatoid nodules
pea-sized masses made up of scar tissue
not usually painful.
169
RA Complications
MTH are less protected
Toes are easily traumatized by footwear
Impaired skin integrity (espec. elderly)
Impaired ROM/mobility
Impaired functional capacity (confined to home, need help with ADLs)
170
Gout
Definition
It is considered?
a metabolic disorder in which uric acid builds up in the blood and is deposited (crystallizes) in the joints, causing inflammation, swelling and pain
Considered the most painful form of arthritis.
171
a metabolic disorder in which uric acid builds up in the blood and is deposited (crystallizes) in the joints
Gout
172
Gout
Male VS Female
Onset
Origin
Men are eight to nine times more likely to experience gout than women.
It can occur at any age, but the peak age of onset occurs in the fifth decade.
85% of all persons with gout have a genetic or familial tendency to develop the disease.
173
Gout occurs for two reasons.
the liver either produces more uric acid than the body can excrete in the urine
diet of rich foods (red meat, creamy sauces, red wine) which puts more uric acid into the bloodstream than the kidneys can filter
In both cases, hyperuricemia results.
174
Gout is a metabolic disorder in which uric acid builds up in the blood and is deposited (crystallizes) in the joints.
Usually where?
In 70% of cases, the uric acid crystals will settle in the first metatarsal phalangeal joint.
175
Gout Sx
extremely rapid inflammatory process, occurring over a few hours
extreme pain
erythema and swelling of involved joint
176
How long can a gout attack last?
Between attacks of gout?
What happens if the disease is untreated?
several days or weeks
between attacks of gout, the client may be asymptomatic
attacks can occur with gradually increasing frequency if the disease is untreated
177
Psoriatic arthritis
Definition.
Cause.
Relationship to psoriasis?
inflammatory process that causes swelling and pain in and around the joints
ALSO
affects tissues surrounding the joints including tendons and ligaments
Believed to be genetic
Develops in up to 30% of people with psoriasis
178
inflammatory process that causes swelling and pain in and around the joints
ALSO
affects tissues surrounding the joints including tendons and ligaments
Psoriatic arthritis
179
Psoriatic arthritis and digits
Describe.
may cause a swelling of the whole digit called “sausage” finger or toe
180
Psoriatic arthritis and the foot
Frequently causes?
Leads to extensive changes in which two joints?
What is a distinguishing feature?
Frequently causes forefoot difficulties
metatarsophalangeal
interphalangeal
Bony ankylosis of the hallux interphalangeal joint is a distinguishing feature.
Bony ankylosis - union of the bones of a joint by loss of articular cartilage, resulting in complete immobility
181
Psoriatic arthritis Tx
rest
exercise
anti-inflammatory analgesics
182
Muscular Dystrophy (including ALS):
What does the disease cause?
What does this lead to?
causes degeneration & weakness of the muscles
leads to impaired ambulation and foot deformities
183
Multiple Sclerosis:
Describe the disease.
What does this lead to?
autoimmune disease affects the nervous system
impaired mobility
muscle contractures
neuropathic pain
184
Renal Failure:
edema in lower extremities
muscle cramping
nail changes
185
Heart Failure:
What does it cause?
What does this lead to?
edema in lower extremities
venous stasis ulcers
weeping of excess fluid
stasis dermatitis
186
Cerebral Palsy:
Causes?
Leads to?
motor impairment
uncontrolled movements
impaired gait
hip subluxation
187
Raynaud’s Disease:
Describe.
Pathophysiology
Male VS Female?
More common in people who?
A condition that causes some areas of the body — fingers, toes, tip of nose and ears — to feel numb/cool in response to cold temperatures or stress.
More a nuisance than a disability.
arteries that supply blood to your skin narrow, limiting blood circulation to affected areas
Women are more likely to have Raynaud's disease.
live in colder climates
188
Metatarsalgia is a general term, not a specific diagnosis. The term is used to denote a painful foot condition of the metatarsal pad.
Describe.
What causes it?
With this condition, it is common to experience?
one or more of the metatarsal heads (ball of the foot) become painful and/or inflamed
usually due to excessive pressure over a long period of time
(improper fitting footwear, most frequently by women’s dress shoes...women suffer forefoot problems 4x more often than men)
189
Metatarsalgia is a general term, not a specific diagnosis. The term is used to denote a painful foot condition of the metatarsal pad.
Leads to what kind of pain?
Forefoot pain can be associated with?
acute, recurrent, or chronic pain
```
toe deformities (claw, hammer, mallet)
calluses or corns
```
190
Morton’s Neuroma
Describe.
Most often involves?
“pinched nerved” -- a swelling of the nerve tissue
most often involves the nerve that supplies the sensation to the third and fourth toes
191
Morton’s Neuroma Sx
pain in the forefoot
burning, tingling or numbness
across the metatarsal heads
burning, tingling or numbness, SWELLING
between the toes
192
Morton’s Neuroma
Pain is often assoc. with?
Commonly found in?
What relieves the pain?
walking or standing for long periods of time
people who wear tight-fitting shoes (more often women)
Stopping the walk, removing the footwear and rubbing the affected area often relieve the pain.
193
Morton’s Toe
Describe.
a common forefoot condition where the second toe is longer than the hallux
194
Morton's toe can lead to excessive pressure on the second metatarsal head resulting in?
metatarsalgia
callus formation under the second metatarsal head due to this excessive pressure
mallet toe in second longer toe if footwear is not fitted to accommodate its length
195
Heel Pain
The calcaneus is the largest bone in the foot and absorbs the greatest amount of shock and pressure.
Causes? (4)
Treatment?
faulty biomechanics that places too much stress on the heel bone and/or the soft tissue that attach to it
injury/trauma
poor footwear
being a fat fuck
Treatment can only occur after a diagnosis of the cause of the pain.
196
Heel Spurs
Describe.
Cause?
a bony growth on the plantar surface of the heel bone
Strain on the muscles and ligaments of the foot, by stretching or repeated tearing of the plantar fascia.
Calcium deposits form where the plantar fascia pulls away from the heel area.
197
Plantar Fasciitis
What is the plantar fascia?
What are the two functions of the plantar fascia?
What is commonly assoc. with the plantar fascia?
The inflammation may be aggravated by footwear that lack arch support.
The plantar fascia is the flat band of tissue (ligament) that extends from the calcaneous to the metatarsal bones (connects rearfoot to forefoot)
maintain and support the longitudinal arch of the foot
provide push off power when beginning to rise on the toes
heel pain and heel spurs
198
Plantar Fasciitis
Describe.
This leads to? (3)
plantar fascia is strained (stretched) over time, causing the fibers of the fascia to tear
inflammation
pain
possibility the growth of a bone spur
199
Plantar fasciitis can be caused by: (5)
AEIOU
a sudden increase in physical activity
excessive weight (obesity or pregnancy)
improper fitting footwear (lack of arch support)
over-pronation (flat feet) which result in the arch collapsing with weight bearing
unusually high arch
200
Plantar fasciitis presentation
pain along the arch as well as heel pain
Getting up in the morning can be very painful. After walking for several minutes (stretching the plantar fascia), the pain usually subsides. The pain will return after sitting for prolonged periods of time. The pain may increase over time.
201
Haglund’s Deformity (pump bump)
Define.
Cause.
Male VS Female?
a bony enlargement (deformity) at the back of the heel bone, in the area where the achilles tendon attaches to the calcaneous
generally the result of buritis caused by pressure against the shoe and can be aggravated by footwear
More common in women than men.
