Vascular, Lymphatic, and Integumentary Disorders

Question 1

Name some of the important functions of the arteries

Answer 1

Carry oxygenated blood away from heart

3-layered walls give strength/elasticity

Ability to change diameter in response to BP or ANS (no valves) Lead to capillaries where gas exchange occurs

Question 2

Name some important characteristics of the veins

Answer 2

return de-oxygenated blood to heart

superficial = above the fascia

deep = below the fascia

perforating = in between deep/superficial also 3-layered, but HAS valves lower pressure

Question 3

What are the 2 primary functions of the Lymphatic System? To which part of the cardiovascular system does it connect?

Answer 3

Functions : 1) immune response

2) facilitation of fluid movement between bloodstream and interstitial fluid

**includes lymph vessels, fluid, tissues and organs

Connects/works with Venous System

Question 4

Describe Phase 1 of healing

Answer 4

Phase 1 = Inflammation

initial decrease in circulation to prevent blood loss

necrosis: programmed death/destruction of damaged cells –creation of clean wound

later, increased blood flow to deliver O2

from injury to day 10 of repair

Question 5

Describe Phase 2 of healing

Answer 5

Phase 2 = Proliferation

new tissue growth skin integrity restored, differentiation of epithelial cells may lead to fragile scar tissue formation

Angiogenesis: new blood vessel growth

Day 3-20

Question 6

Describe Phase 3 of healing

Answer 6

Phase 3 = Maturation/Remodeling

continued differentiation of epithelium: scar tissue turns from pink to white

new skin reaches 80% of original tensile strength

replacement of granulation tissue

Day 9- 2 years

Question 7

What’s different about deep wounds in Phase 3 healing?

Answer 7

hair, sweat glands, sebaceous glands and nerves are rarely ever replaced

Question 8

What are the main functions of Oxygen in wound healing? How can we help keep a wound oxygenated?

Answer 8

O₂ supports healing, helps prevent infection

keep area warm, avoid smoking, stay hydrated, control pain and anxiety

Question 9

What can prevent oxygen from getting to a wound? what are the results?

Answer 9

Edema and necrotic tissue prevents oxygenation of healing tissue

this leads to higher likelihood of infection

Question 10

What is debridement? what are the two major types?

Answer 10

Debridement = cleaning necrotic tissue out of the wound

Selective and Non-selective

Question 11

why is it important to keep wounds moist?

Answer 11

dryness inhibits epithelial cell migration, as well as the supply of nutrients and blood flow

also causes scabbing and eschar (dead black tissue)

**in the right conditions, the body’s own enzymes will degrade eschar (autolytic debridement)

Question 12

HOW do we keep wounds moist?

Answer 12

use occlusive dressings, only remove bandages when the exudate begins to leak out, keep wounds at the proper temperature

Question 13

Is nutrition important for wound healing? if so, how do we manage it?

Answer 13

YES! manage through diet, NOT supplements

necessary nutrients include: iron, B12, Folic acid, Vitamin C, Zinc, Vitamin A, Arginine, and protein

Question 14

What are the important bony landmarks prone to bedsores?

Answer 14

Question 15

What are the important characteristics of wounds to be noted, measure, and documented?

Answer 15

Etiology: diabetic, vascular, traumatic, etc

Appearance, Location, Size, Shape, Stage of healing

Depth, edges, tunneling/undermining

Base of the wound: what’s happening inside?

Edema, maceration

Pain level

Question 16

Name the 3 kinds of Wound Closure, and describe them

Answer 16

Primary Intention: edges surgically closed

at risk for **dehiscence: **when wound opens again because of maceration or infestation

Secondary Intention: the wound is left to heal on its own

Tertiary Intention: allowed to heal by secondary intention, but closed by primary

Question 17

What are the signs of Infection?

Answer 17

Increased drainage

change in color/odor

lingering swelling

redness, warmth

pain and/or tenderness

tissue culture is positive

fever, nausea, fatigue, loss of appetite

Question 18

Define Arterial Insufficiency and name the main cause

Answer 18

Arterial Insufficiency: lack of adequate blood flow to a region(s) of the body (typically the legs)

main cause = Peripheral Vascular Disease: disrupted arterial blood flow to/ venous return from the extremities

may be related to smoking, cardiac disease, Diabetes Mellitus, Hypertension, renal disease, elevated cholesterol & triglycerides

**obesity and sedentary lifetyle are secondary contributors

Question 19

Name and define 5 more causes of arterial insufficienty

Answer 19

Arteriosclerosis: thickening, hardening, and loss of elasticiy in arterial walls

Atherosclerosis: plaque formation

Ateriosclerosis Obliterans: peripheral manifestation of arteriosclerosis -throphic changes and resting pain observed, most likely to lead to ulceration

Thromboangitis Obliterans: inflammation leads to arterial occlusion and tissue ischema

Raynaud’s Disease: vasomotor disease of small arteries and arterioles -leads to pallor and cyanosis of fingers and feet, unknown etiology, agravated by cold and emotional distress

Question 20

What is Intermittent Claudication? Which arterial insufficiency displays it?

Answer 20

Intermittent Claudication: pain that occurs when exercising muscles don’t recieve the blood perfusion needed

occurs in Arteriosclerosis Obliterans

Question 21

What are the symptoms of arterial insufficiency we’ll see in the clinic?

Answer 21

10-25% of Lower Extremity Ulcers

more likely to lead to limb loss

most frequently on lateral malleoli and the dorsum of feet and toes

most patients have diabetes

trophic changes: abnormal nail growth, decreased foot/leg hair, dry skin, skin is cool to touch

wounds are painful, base is usually necrotic/pale

skin around the wound may be black

decreased pulses, pallor when elevated, rubor when dependent (below the heart)

Question 22

How do we treat arterial insufficieny?

Answer 22

1 preventative measure: QUIT SMOKING

restore chemical and gaseous homeostatis

provide wound care

if the wound is not healing, or gangrene is present, may have to amputate

Question 23

Define Venous Insufficiency and name some of the predisposing factors

Answer 23

Venous Insufficiency: Inadequate drainage of venous blood from body parts, resulting in edema and/or skin abnormalities -deemed chronic when it persists for long periods of time

**incidence is much higher than arterial insufficiency: most common cause of leg ulcers

Predisposing Factors: age, lack of exercise, obesity, pregnancy, long hours standing/sitting, heredity

*predictors of ulceration due to Chronic Venous Insufficiency also include history of Deep Vein Thrombosis, # of pregnancies, family history

Question 24

What symptoms of Venous Insufficiency will we see in the clinic?

Answer 24

Swelling in one or both legs

complaints of itching, fatigue, aching, and/or heaviness of the involved limb

Skin changes: fibrosis (thickening of dermis)

Increased temp in skin of lower legs

Wounds: usually just proximal to medial malleoli, not significantly painful, wet tissue bed, large amount of exudate

May see signs of lymphedema

Question 25

How do we treat Venous Insufficiency?

Answer 25

Compression Therapy: specialized bandages/garments, intermittent compression unity

Gait training

Exercise

Manual lymphatic drainage

Question 26

What is Lymphedema? What’s the difference between Primary and Secondary?

Answer 26

Lymphedema: abnormal accumulation of lymph fluid in the tissues of one or more body parts/regions due to mechanical disruption of the lymphatic system

Primary: congenital or hereditary condition

hypoplasia: fewer lymphatic vessels than normal

Secondary: injury to one or more components of the lymphatic system

more common than primary; most common causes = surgery, radiation, or Chronic Venous Insufficiency

Question 27

What symptoms of Lymphedema will we see in the clinic?

Answer 27

swelling distal/adjacent to area of impairment that is not alleviated by elevation

pitting edema in early stages (when you press your finger into the swelling and the indent remains)

non-pitting edema in late stages

fatigue, heaviness, pressure, tightness in affected limb

dermal abnormalities like cysts

increased susceptibility to infection

loss of ROM and mobolity

Impaired wound healing

Question 28

How do we treat Lymphedema?

Answer 28

Manual Lymphatic Drainage

Compression Therapy: elevation, bandaging, compression garments, intermittent pneumatic compression, positioning, and pressure redistribution devices (for skin protection)

Question 29

What is a Pressure Ulcer? In what population are they most common?

Answer 29

Pressure Ulcer: wound caused by unrelieved pressure to dermis and underlying vascular tissues -tissue cannot repair/recover without care

**superficial dermis can tolerate ischemia cause by pressure for 2-8 hours before breaking down: deepr muscle, connective and adipose tissue tolerance is less than 2 hours

most common in immobilized individuals

Question 30

What are the symptoms of pressure ulcers?

Answer 30

**First sign is blanchable erythema (area of red/irritated skin that turns white and stays white when you press on it)

Progresses to a superficial abrasion, blister, or shallow crater in the skin

Full Thickness = deeper crater, minimal bleeding, warm tissues, eschar, and tunneling

6 Primary bony areas: sacrum, coccyx, greater trochanters, ischial tuberosity, calcaneus, and the lateral malleoli

Question 31

How do we treat pressure ulcers?

Answer 31

Facilitate homeostasis: wound care

reduction of pressure to the area

use of turning/positioning schedules

education of pt, caregivers, and family

Other factors: nutrition, sensation, co-morbitidies, mobility status

Question 32

What is Neuropathy? How does it affect diabetic patients?

Answer 32

Neuropathy: disease on nerves- peripheral, cranial, or autonomic that exists in many disease processed

**results in altered or lack of sensation

Diabetic Neuropathy: majority will occur in lower extremities -foot insensitivity and ulceration possible

Question 33

What are the symptoms of Neuropathy?

Answer 33

Ulceration on weight-bearing surfaces or over bony prominences

sensory neuropathy: no sense of pain or pressure, increased risk of skin breakdown due to mechanical, repetitive stresses placed on skin

motor neuropathy: loss of intrinsic muscle control- leads to hammer/claw toe deformities and foot-drop

Autonomic neuropathy: decreased/absent sweat/oil production = dry inelastic skin, increased risk of skin breakdown, and heavy callus formation

Dysvascular symptoms: usually arterial, ischemia, impaired healing time, imparied O2 transport, antibiotics & nutrients needed for healing

Question 34

How do we treat neuropathy?

Answer 34

patient/caregiver education

wound care

maintaining appropriate blood glucose levels (for Diabetic pt)

Possible AD for foot wounds

Orthotics

Exericise

Modalities

Question 35

Name and describe 5 methods of Selective Debridement

Answer 35

Sharp: removal of necrotic tissue with sterile instruments (Gold Standard)

Chemical/ Enzymatic: topical agent applied to dissolve necrotic tissue (includes autolytic)

Biosurgery: maggot debridement therapy (most recently used to help with MRSA)

**Medical Grade Honey: **high osmotic potential, low pH, assists in autolytic debridement (medihoney)

Autolytic Debridement: endogenous enzymed on wound bed digest devitalized tissue and promote granulation tissue formation

Question 36

Name and describe 4 methods of Non-Selective Debridement

Answer 36

Wet-to-Dry dressings: wet dressing applied, dries, and debrides the wound when removed

frequently VERY uncomfortable, can cause bleeding and trauma

Surgical Debridement: for large wounds, tunneling wounds, necrotic and/or infected to the bone

Pulsatile Lavage: water + suction debrides and cleans

Whirlpool

Question 37

What Modalities can we use to help aid the healing process?

Answer 37

Whirlpool: cleaning and debridement

Pulsatile Lavage: wound irrigation + suction (more debridement)

Ultrasound: stimulates cell activity to accelerat healing

E-stim: eliminate bacteria, promote granualtion, decrease inflammation, reduce edema, reduce wound pain, augment blood flow

Diathermy

UV Radiation

Hyperbaric Oxygent Therapy

Cold Laser Therapy: similar to ultrasound, but works at the cellular level –no pt sensation

Question 38

What are some important things to remember when treating pt for Lymphedema?

Answer 38

Compression is important, but be careful not to apply too much pressure: this will occlude the superficial lymph capillaries

complete decongestive theory: Phase1 -skin care, MLD, lymphedema bandaging, exercise, compression garments

Phase 2 -(self management phase) skin care, compression garment during the day, exercise, lymphedema bandaging at night, MLD as needed

**should be done by certified CDT therapist

Question 39

Name the different dressings used in wound care, and describe them

Answer 39

Gauze

Impregnated gauze: prevents gauze from sticking

Transparent Film: doesn’t allow bacteria or moisture to get it

Foam: highly absorbant (for wounds with excessive exudate)

Hydrogels: increase moisture in dry wounds

Hydrocolloids: most moisture retentive, most occulsive

Alginates: absorb 20-30 times their own weight, easy to apply/remove

Hydrofibers: selective absorbent capacity, combines foam and gel dressing benefits