Week 2 Flashcards
1
Q
What are the things to observe during the visual inspection of the vascular status of a patient?
A
• Skin
• Vein distention, varicose veins
• Edema – compared to contralateral side, bilateral
- Soft, hard, pitting, etc.
2
Q
What are we looking for when observing the skin during the visual inspection of the vascular status of a patient?
A
- Discoloration, hyperpigmentation (hemosiderin staining)
- Dry/cracked, old scar, hair loss, thick yellow nails
- Dermatitis, lipodermatosclerosis, atrophie blanche
3
Q
What are the things to observe performing palpation to determine the vascular status of a patient?
A
• Temperature
• Pulses - macrovascular exam
- BUE & BLE
- Compare intensity (spot to spot)
- Warm room, in supine
Posterior tib
Dorsalis Pedis- absent up to15% of time
• Edema – soft, pitting, fibrous, etc.
4
Q
When testing for capillary refill in the microvascular exam, where do we press?
A
Press end of toe/proximal to wound
5
Q
What is normal capillary refill time?
A
< 3 seconds
6
Q
What are the positions for the rubor of dependency test?
A
- Supine, LE elevated 30-600
* LE in dependency
7
Q
What do you you observe in the LE elevated rubor of dependency test?
A
Observe for pallor/blanching
8
Q
What is are the possible results of the LE elevated rubor of dependency test?
A
- Normal- little to no color change
- Mild to moderate insufficiency 45-60 & 30 seconds respectively
- Severe 25 seconds or less
9
Q
What do you you observe in the LE in dependency rubor of dependency test?
A
• Observe color
10
Q
What is are the possible results of the LE in dependency rubor of dependency test?
A
• <15 seconds, return of pink color (normal)
• ≥30 & dark red/rubor (Reactive hyperemia)
- (+) for severe ischemic disease
11
Q
What is the position that venous filling time is tested?
A
Supine, LE elevated 30-600
12
Q
What is the procedure for the venous filling time test?
A
• Observe the veins drain out on top of foot (60 sec)
• Return to dependent position
- Normal venous filling 5-15 seconds
- >20 seconds indicates arterial disease
13
Q
What is the ankle brachial index (ABI)?
A
Ratio of ankle systolic to brachial systolic pressure
14
Q
What is the procedure for performing the ABI?
A
- BP cuff proximal to ankle, inflated
- Doppler: Dorsalis pedis & Post tib pulses, use higher pressure
- Obtain L & R brachial pressures, use higher pressure
- Ankle/brachial systolic pressures = ratio
15
Q
What are the contraindications for performing the ABI?
A
Ulcer near the ankle
16
Q
What are the considerations to keep in mind when performing the ABI?
A
Calcified, noncompressible vessels will skew results
- Diabetes, renal insufficiency, edema, obesity, poor cardiac output, etc
17
Q
What does an ABI of >1.2 mean?
A
Unreliable (vessel calcification)
18
Q
What does an ABI of 1.0-1.2 mean?
A
Normal
19
Q
What does an ABI of 0.8-1.0 mean?
A
Mild PAD, compression for edema with caution/monitoring
20
Q
What does an ABI of 0.5-0.8 mean?
A
Moderate PAD, intermittent claudication <0.8 (refer to vascular specialist)
21
Q
What does an ABI of 0.6-0.8 mean?
A
Cautious modified compression (contraindicated <0.6), night pain
- Refer to vascular specialist
22
Q
What does an ABI of <0.5 mean?
A
Severe ischemia, rest pain (“critical limb ischemia”)
- Compression & debridement absolutely contraindicated
23
Q
What does an ABI of <0.2 mean?
A
Tissue death
24
Q
What is the procedure for performing a claudication onset time test?
A
- Walk on treadmill, 1 mph, level grade
- Record time to pain onset
25
What is the claudication onset time test used for?
- Developing a supervised progressive walking program
| - Tracking improved ambulatory endurance
26
What is arterial insufficiency?
Decreased arterial blood flow
27
What is the main cause of arterial insufficiency?
- Arteriosclerosis: thickening or hardening of arterial walls
- Atherosclerosis: degenerative process where the lumen are gradually encroached upon secondary to fatty plaques in the arterial walls
28
What is one of the 1st sign/symptom of arterial insufficiency?
Intermittent Claudication
29
What are the characteristics of Intermittent Claudication?
* Activity specific discomfort
* Discomfort goes away within 1-5 minutes of stopping activity
* Repeatable and predictable
30
What is the difference between intermittent claudication and spinal stenosis?
• AI – s/s relief with cessation of activity, predictable, repeatable
w/same level of activity
• Spinal stenosis – s/s relief w/change of position
31
As arterial insufficiency progresses, patient may begin to experience ischemic rest pain. What is ischemic rest pain?
Burning pain with elevation or at night
32
How is ischemic rest pain relieved?
Dependency
33
What typically happens after ischemic rest pain?
Ischemic Ulcer or Gangrene
34
What typically causes ulcers?
Trauma
35
What are the potential risk factors of arterial insufficiency?
• Hyperlipidemia, hypertriglyceridemia (CAD, heart disease, etc.)
• Smoking
• DM
- DM associated neuropathy may prevent pain normally associated w/AI (can mask early
signs)
• HTN
• Trauma: Shoes, bite/scratch, accidental injury (bump, MVA), burn (cold feet)
• Advance Age
• PAD: Occlusive, inflammatory, vasomotor
• Obesity
36
How long after the cessation of smoking do we see improvements?
Circulation improvements in 4 weeks, decrease CAD risk by ½ in 1 year
37
What are the general exam findings in arterial insufficiency?
* Skin: dry, withered, shiny, thin, taut
* Comparatively cool: recommend 5 mins without socks/shoes before checking temp
* Loss of hair
* Limb/surrounding area pale/dusky: pallor w/elevation, rubor w/dependency
* Decreased sensation
* Muscle atrophy & weakness (MMT, girth): claw toes w/mm atrophy of foot intrinsics
* Nails: yellow, hard, brittle, thick (fungus)
* Edema: Not usually (dependent possible, CHF, VI)
38
What are the clinical vascular exam for arterial insufficiency?
• Palpation
- Skin temp, pulses (femoral, popliteal, dorsal pedis, posterior tib)
- Can use Doppler to assist w/pulse assessment
• Capillary refill
• Rubor of Dependency (loss of vasomotor control)
• Claudication time
• Ankle-Brachial Index (ABI)
• Venous filling time
39
What is the pain pattern of arterial insufficiency?
• Increases w/elevation & exertion (walking)
• Numbness, tingling, cold, ache w/exertion (mms steal blood)
• Worse at night
• Go to sleep, then up w/pain
- How do they relieve?
• Can walk but require rest breaks
- Fatigue, pain
• Increasing pain is an indication for vascular consult
- Pain meds, edu, lifestyle changes, revascularization, etc.
- Uncontrolled pain, poor QOL – amputation?
• Pain can be masked by neuropathy in patients w/DM
40
What are the characteristics of the location of a wound from arterial insufficiency?
```
Commonly below ankle
• Foot, heel, met heads, tips of
toes, “bunion” areas
• Possible superior to lateral
malleolus or anterior lower leg
```
41
What are the characteristics of the drainage of a wound from arterial insufficiency?
* Minimal to none
| * Usually dry and hard
42
What are the characteristics of the tissue of a wound from arterial insufficiency?
* Black/brown eschar
* Pale granulation tissue
* Mixed
43
What is the presentation of a wound from arterial insufficiency?
* Start shallow then deepen
* “punched out” appearance
* Usually round
44
What are the characteristics of dry gangrene?
* Mummification
* No drainage, hard
* Little/no odor
* Clear demarcation
* Protect, off-load
* Monitor for conversion to wet gangrene
* Auto-amp?
45
What are the characteristics of wet gangrene?
* Drainage
* Odor
* Fluctuance/edema
* Erythema
* Less clear demarcation
* Urgent referral to a vascular surgeon
46
What are the things to do if a therapist thinks their patient has arterial insufficiency?
* MD referral
* Pt education
* Safe, graded exercise (if cleared)
47
What are the components of the MD referral if a therapist thinks their patient has arterial insufficiency?
* Vascular testing for final confirmation, severity, sx repair if needed
* Cardiac workup, meds
48
What are the components of the pt education if a therapist thinks their patient has arterial insufficiency?
Disease, progression, self-care
• Skin care & protection (shoe checks, warming, etc.)
- Hot water bottles, “gentle warming” – heat groin, low back
• Behavior modification (smoking, diet, exercise, meds, etc.)
• Sleep (bed position)
• Wound mgmt (protection, off-loading, wound care, etc.)
49
What are some actions to take before a patient with arterial insufficiency develops a wound?
• Address modifiable risk factors
• Positioning – avoid excessive hip/knee flex
- Periodic dangle LE
• Gentle flexibility exercise – especially ankle
• Aerobic exercise – graded walking program
- Benefits – collateral vessel formation, weight loss, etc.
• Screening & Monitoring : high % w/CAD
- Excessive exercise diverts blood flow to mms = pain
50
According to Kisner and Kolby, what are the prescriptive exercise for arterial insufficiency?
• Walking or biking until onset of pain-rest-repeat
- Monitor vitals
• Better utilization of oxygen - that is present
- Increased ability for work
- Can encourage collateralization
- Ischemia triggers collateralization
51
According to Goodman, what are the prescriptive exercise for arterial insufficiency?
Progressive conditioning program
• Walk until pain – rest – walk again
• Progress to max tolerable pain before rest
• Progress to 30-45 min w/o pain in 6-8 wks
- Patients typically won’t do on their own – pain
52
According to McCullough & Kloth, what is a supervised exercise program for arterial insufficiency?
3 x wk, short bouts of treadmill walking x 40-60 minutes each session
53
What are the benefits of the supervised exercise program for arterial insufficiency proposed by McCullough & Kloth?
Improved oxygen metabolism, collateralization, improved blood viscosity, improved walking economy
54
What are the interventions to do when working with an arterial insufficiency patient with a wound?
• Treat, wait for auto-amp, surgical intervention?
• Conservative approach
• Gangrene: monitor for conversion
- Protection: dry, padded, NWB on affected limb
• Moisturize surrounding skin
• Monitor for infection (may not show s/s)
• ROM for joint mobility and muscle flexibility
• Exercise/walking program as appropriate
• Foot Care Guidelines
55
Where are the potential referrals for patients with arterial insufficiency?
```
• Dietitian
- Reduced caffeine, smoking, proper nutrition & hydration
• Diabetic Educator
• Podiatry
• Prosthetics (if having an amputation)
```
56
What are the precautions and contraindications of wound care following arterial insufficiency?
• Moist dressings – never on dry gangrene/eschar, careful at other times, depends on surgical candidacy
• Unhealable AI ulcer: treat all AI wounds this way until proven healable – keep dry
• Healable AI ulcer: must have objective evidence of vascular status (ABI >0.5) – consult w/vascular MD
- Expect slower progression
• Avoid adhesives – no tape to injure fragile skin
• PT role –identify, refer, protect, monitor, educate
- Wound care, exercise
- Treatment after re-vascularization/amp, team effort
57
Why should caution be taken when looking to debride a wound as a result of arterial insufficiency?
Lack of good blood flow, decreased healing
58
What type of debridement in typically contraindicated for a wound following arterial insufficiency?
Sharp debridement
59
What is the ABI cutoff for debridement of a wound following arterial insufficiency?
• ≤ 0.8 ABI – no debridement of “stable” eschar
- Goal is maintenance
- Same for heel pressure wounds
60
What are the guidelines for ABI and compression when treating arterial insufficiency?
• ABI ≥ 0.8 = compression 35-40 mmHg
- MD “OK” below 0.8 (follow facility guidelines)
- May see claudication start when <0.8
• ABI <0.8 but > 0.6 = cautious light compression 17-25 mmHg
• ABI < 0.5 = no compression, rest pain (contraindicated)
61
What are the contraindications for compression?
Pain and no sensation
62
What do we do after the patient has received a re-vascularization procedure or amputation?
• Ensure vascular status & monitor
• Go after it - moist wound environment, debridement
• Amp: stump wrapping/shaping/prosthetics
- ROM, positioning, STR, mobility, balance, offloading,
- Work w/podiatrist for shoes, etc.
• Edema control
63
What are the ways to prevent arterial insufficiency wounds?
• Recognize risk factors & encourage lifestyle changes before it progresses
- Takes less O2 to maintain intact skin then to heal the loss of skin
• Smoking cessation
• Control DM (A1c <7%), HTN (<130/80), etc.
• Take prescribed meds (Antiplatelet, vasodilators, pain, etc.)
• Healthy diet & hydration
• Ex (30min x 3/wk), control stress
• Soft appropriate/protective shoes
• Avoid cold temperatures
• Off-loading & positioning prn
• Bed sheets/blankets, soft “heel lift” boots for bed
64
Where is the typical locations for venous insufficiency wounds?
* Above the malleoli in the distal 3rd of the lower leg (medial & lateral)
* If outside this area, may not have VI etiology (unless mixed etiology)
65
What is the presentation for the surrounding skin of a venous insufficiency wound?
• Hyperpigmentation - hemosiderin staining
• Lipodermatosclerosis
- Scarring of skin/fat (fibrin deposition)
- Results in hard, thickened, immobile skin
- Can cause “champagne-bottle leg” (scarring can restrict fluid flow)
• Hypertrophic changes – thick/scaly epidermis
- Breaks in the skin = openings for bacteria = risk of cellulitis
• Irritation from chronic exposure to large amounts of drainage, dressings & constant compression
• Varicose veins – common due to overloaded, backed-up system
66
What are the characteristics of a wound due to venous insufficiency?
• Uneven edges (can be diffuse or rolled), shallow
• Highly exudative (especially at initiation of tx), primarily serous
- If little/no drainage - consider AI component
• Pain – usually not too bad, if severe consider AI or vasculitis
67
What are the characteristics of the periwound due to venous insufficiency?
* Maceration common (initially or w/inadequate dressings or change schedule)
* Diffuse edges
* Irritation
68
What are the considerations for decision making for a compression for venous insufficiency?
```
• Comfort, cosmesis, tolerance
- Some compression is better than none
• Frequency of dressing change
- Okay to compress over most wound dressings
• Change at home or only in clinic
• Condition of skin
• Vascular status
- Varying amounts of compression
• Ambulation
- Calf muscle pump working
• Pt status – CHF?
• Cost
• What has/has not worked before?
• Decisions are not final
- Change as wound status/drainage changes
- 1st choice may not “work”
• For wound healing or long-term maintenance/prevention?
```
69
What are the methods of compression for treating venous insufficiency?
* Tubigrip
* Long Stretch
* Short Stretch
* In-elastic
* Multilayer
* Stockings
* Garments
70
What are the characteristics of a tube- like (tubigrip) compression used for treating venous insufficiency?
• Least compression, inexpensive, easy to apply/remove/reapply,
reusable, comfortable
• Generally considered light compression (can double it), stretches
out w/repeated use
• Conservative trial to determine compression tolerance
• Utilized with UE & LE issues or with at risk of mild edema –
sprains, wounds
• Variation in compression
- Different sizes
- Can pair different sizes
- Depends on limb contour
- Typically 10-12 MmHg
71
What are the characteristics of a long stretch compression used for treating venous insufficiency?
‘Stretches a long way’
• Wants to return to its resting state (ACE wrap)
• Delivers constant compression – can feel “tight” at rest
- Increased compression during calf muscle contraction
- Good for ambulatory pts, but also for low/non-ambulatory pts if tolerated
• Applied with figure of 8 or spiral technique – requires skill, difficult self-application
- Consistent tension & layering
- Can telescope (injury/restricted blood flow)
• Caution with use in patients with AI
• Reusable, but stretch out quickly
• Issues w/inconsistent tension
- Self-application at home
72
What are the characteristics of a short stretch compression used for treating venous insufficiency?
• Stretches a short distance
• Applied with consistent tension/spiral layering – sometimes >50% overlap
• Can telescope – frequently rewrapped x 1-2 daily
• Can be used for most patients with AI unless compression contraindicated
- Utilize ABI values to help determine safe levels
- Good for mixed VI/AI ulcers
• Delivers high compression during muscle contraction
• low compression during rest
73
What are the characteristics of a In-Elastic compression used for treating venous insufficiency?
```
Inelastic – Unna Boot
• Applied w/only enough tension to hold in place
- No specific technique
- 2-3 layers over entire LE (or UE)
- Requires secondary wrap
- Usually long stretch or coban
• Kerlix may be added for padding
- Considered a multi-layer wrap
• Longer wear time – up to 1 week
- Telescopes as edema reduces
- Can cause more frequent changing during first week due to initial significant
changes in limb size
• Can rub – especially along bend at anterior ankle
```
74
What are the characteristics of a Multi-layer compression used for treating venous insufficiency?
2-4 layers
• More layers = higher levels of compression 30-40 MmHg
- “On” during work or rest
- If long stretch layer – can feel tight at rest
• Specific layering techniques & sequence
- Allows for some adjustment
- Profore, Profore Lite, 3-M, etc.
• More expensive, more time for application
- Adds padding for fragile skin/bony prominences
- Adds bulk – shoes, heat, etc.
• Less telescoping for some
• Long wear time – up to 1 week
• Requires skilled application
• Appropriate for ambulators & non-ambulators
• Disposable, single use
75
What are the characteristics of a stockings compression used for treating venous insufficiency?
• Not just for VI, can be for support/vein health
• Replace ~ 6 mths, buy 2 pair, hand wash, air dry
• Custom vs OTC – different colors & materials, can double layer
• Can be worn during wound closure after edema resolved
• Not 100% effective at prevention/maintenance - even when worn
• Prescribe lowest effective level for maintenance – comfort,
application, heat, etc.
76
What is the indication for 15-20mmHg of stocking at the ankle?
Early sxs w/o ulcer, lite prophylaxis for high risk pts, “tired legs”
77
What is the indication for 20-30mmHg of stocking at the ankle?
Mild VI sxs w/o ulcer, prophylaxis for high risk pts, post healing, VI w/ulcer &
inability to tolerate higher forms of compression (ABI 0.8-0.9), lymphedema
78
What is the indication for 30-40mmHg of stocking at the ankle?
Moderate VI w/wo ulcer, post-ulceration, pronounced varicose veins, moderate lymphedema, post traumatic edema, burn scar management
79
What is the indication for 40-50mmHg of stocking at the ankle?
Severe VI, VI ulcer & no AI, severe lymphedema
80
What is the indication for 60+mmHg of stocking at the ankle?
Severe lymphedema, elephantiasis, severe post thrombotic disease
81
What are the characteristics of garment compression "farrow wrap" used for treating venous insufficiency?
* Foot piece & series of Velcro bands (function similar to short stretch bandages)
* Easier don/doff vs compression stockings
82
What are the characteristics of garment compression "Circ-Aid" used for treating venous insufficiency?
Custom, non-elastic, Velcro bands, for VI & lymphedema
83
What does LaPlace’s Law do?
Gives us an equation to calculate the amount of compression needed
84
What is the LaPlace’s Law equation?
Tension x # of layers x 4630 divided by
| limb girth x bandage width
85
What are the adjustments to the overall amount of graduated or graded compression that can be utilized?
• Increase/decrease tension
• Change number of layers
• Will change automatically based on girth
- Ankle typically smaller than calf – so normally achieve graded compression with simple change in leg circumference
- Pad oddly shaped lower legs for “normal” conical shape
• Bandage width – smaller = higher compression
• Caution – if using smaller rolls at foot/ankle – may need fewer layers or less tension
• Figure 8 wrap 2x the compression of a spiral wrap
86
What are the exercise recommendations for patients with venous insufficiency ulcers?
• Gastroc stretches to optimize ankle ROM (facilitate calf muscle pump)
- Assess ankle ROM/flexibility - may also require ankle mobs, etc.
• Ankle pumps, circumduction, ABCs
- Rocker board ex
• Heel-toe raises in sitting & standing
• Step overs – step over 3-4 inch obstacle using heel strike in front, toe push-off in back
• Exaggerated heel-toe sequence during walking
• Walking
• Biking
• Aquatics (if no wound)
87
What are the patient education guidelines for patients with venous insufficiency?
• Compression
- Chronic situation (unless corrected by surgery), understand etiology & intervention
• Extended standing or sitting, crossing legs
- Ankle pumps, knee bends, etc. when necessary
• Elevation – true elevation is not ‘neutral’ – above heart level
- Elevation alone is not adequate, must have compression when dependent
• Care & replacement of compression stockings
• Healthy lifestyle – weight, smoking, diet, sleep, etc.
88
What are the goals for physical therapy in regards to venous insufficiency?
• Prevention - Recognize early sxs
- Referrals – vascular screening, sx repair, plan for chronic compression use
• Tx - Set the stage for body to heal
- Relieve pressure & congestion – resolve/manage edema
- Care for open wounds – manage drainage, protection, etc.
- Compression – determine level/method
• Help patient adjust to life-long issue
- Edu re: condition, expectation for other wounds w/o intervention
- Long term compression needs
89
What are the general techniques for compression in the treatment of venous insufficiency?
Spiral & Figure of 8
• 50% overlap, 50% tension
• Base of toes to just over gastroc (2 fingers at posterior knee)
• Smooth, minimize wrinkles
Want graduated/graded compression
• Example: ankle ~30-40mmHg, proximal calf ~18mmHg
• Ankle circumference w/multilayer systems due to higher levels of compression
• Leg shape & padding - normal, pencil, inverted champagne-bottle
90
What are the risk factors for a neuropathic wound?
```
• Diabetes Mellitus
• Impaired Healing
• Vascular disease
• Tri-neuropathy
- Sensory, Motor, Autonomic
• Mechanical stress
• Impaired ROM
• Foot deformities
• Pervious ulcer or amputation
```
91
What are the characteristics of a neuropathic ulcer?
• Round, punched out, may be deep/probe to bone
- Tracts/tunnels
• Peri-wound callus (surrounding skin dry/cracked)
• Often on plantar aspect of foot (met hds, gr. toe)
• Min to mod drainage, eschar uncommon
• Red-pale granulation
• Typically “pain” free (abnormal sensation/burning, etc.)
• Wound itself is not painful
92
What are the characteristics of the exam of a neuropathic wound?
• Thoroughly explore wound bed
- Depth/tunnels/tracts, named structures
- Probe to bone?
• Callus
93
What does a 0 on the classifications of a neuropathic wound exam according to the wagner grading scale mean?
No open lesions, may have deformity or cellulitis
94
What does a 1 on the classifications of a neuropathic wound exam according to the wagner grading scale mean?
Superficial Ulcer
95
What does a 2 on the classifications of a neuropathic wound exam according to the wagner grading scale mean?
Deep Ulcer to tendon, capsule, or bone
96
What does a 3 on the classifications of a neuropathic wound exam according to the wagner grading scale mean?
Deep Ulcer with abscess, osteomyelitis, or joint sepsis
97
What does a 4 on the classifications of a neuropathic wound exam according to the wagner grading scale mean?
Localized gangrene
98
What does a 5 on the classifications of a neuropathic wound exam according to the wagner grading scale mean?
Gangrene of entire foot
99
People with diabetes have hyperglycemia, which impairs all phase of healing like...?
* Bacteria proliferate rapidly in high glucose environment
* Impaired production & migration of Neutrophils
* Impaired chemotaxis, migration, & mobility of Macrophages
* Impaired function of Fibroblasts
* Deficient blocking of “normal” enzymes that degrade tissue
* Endothelial cell dysfunction
* Impaired epithelial cell migration
* Further complicated by underlying decreased blood flow
100
Impaired healing leads to...?
Slower healing & Decreased
Ability to Fight Infection
• Higher risk of local/systemic infection
• Impaired ability to fight infection once present (skin, wound,
UTI, lung, etc.)
• Blunted s/s
• Difficult to determine, frequently mismanaged
- Limited understanding of diagnostic/tx options
- Insufficient resources, patient behavior/choices
- Clinician education/ training/awareness
101
What are the characteristics of the sensory, motor, and autonomic presentation associated with tri-neuropathy (Diabetic Neuropathy)?
```
• Usually symmetrical
• Affects distal nerves first – feet (hands)
• Severity increases with
- Age
- Disease duration (~10 yrs)
- Glucose control
```
102
What are the characteristics of the sensory presentation of a tri-neuropathy (Diabetic Neuropathy)?
```
• Poor awareness of trauma
to the feet
• Occurs gradually
• Paresthesias: burning,
tingling, aching
- Painful and debilitating
- False sense of protective
sensation
```
103
What are the characteristics of the motor presentation of a tri-neuropathy (Diabetic Neuropathy)?
• Paralysis of foot intrinsics
- Increased plantar forces
• Hallux Valgus
• Claw toe
104
What are the characteristics of the autonomic presentation of a tri-neuropathy (Diabetic Neuropathy)?
• Altered sweating (dry, less elastic, cracked skin)
• Callus formation (increased pressure)
• Blood flow
- AV shunting (less perfusion at skin)
- Vasodilation (increase blood to bone, leaches calcium, predisposes bones of foot to fx secondary to osteopenia)
105
What are the clinical exams used for tri-neuropathy (Diabetic Neuropathy)?
```
• Lab values (Fasting glucose, A1C, albumin, pre-albumin)
• Inspection of skin & nails
- Dry, scaly skin, callus; nails - hypertrophic, fungus
- Warmth
• Foot deformity
- Joint subluxation, dislocation, etc.
• Vascular
- Noninvasive vascular screen (including ABI)
• Motor/ROM
- STR of ankle/foot mms
- Flexibility
- DF ROM - at least 10 degs
- Gr toe ROM, metatarsal mobility, etc. (stiff foot)
- General gait analysis & balance
- Heel strike, wt shift/mvmt through ft to gr. toe
• Sensory testing
- Monofilament, vibration, etc
• LE reflexes
• Leg length discrepancy
- Unequal wt bearing (Hinkes, 2015)
• Check other ft
- Between toes
- Both shoes
```
106
What are the characteristics of charcot foot?
• Fx & dislocation = foot deformity & abnormal pressure/shear forces
• Suspect if: inflammation, edema, warm, bounding pulse, may have open
wound (or may come after)
- Temp 4-150 higher w/o ulcer – may indicate Charcot foot (Sibbald, Mufti, Armstrong, 2015)
• Dx: x-ray, MRI (physical exam)
• Tx: casting for 6-12 mths - TCC, boots (CROW)
107
What are the common interventions for neuropathic ulcers?
• Aggressive debridement & callus saucerization
- Depends on vascular status
- No debridement for stable heel ulcers
** EWMA Position Document – “heel difficult to heal”***
• Moist wound environment
• Offloading – key
• Monitor closely for infection
• Patient edu – key
- Glucose control - key
• Silver (antimicrobial) dressings common
- May be discontinued with sustained progression
• Growth factors
• Skin substitutes (MD application)
- Apligraf, etc.
108
What are the common do nots for neuropathic ulcers?
* Use whirlpool
| * Patients should not soak feet
109
What are the characteristics of offloading as an intervention for neuropathic ulcers?
```
Reduce pressure, promote slow ambulation, facilitate “normal” gait as possible
• Total Contact Cast (TCC)
• Charcot Restraint Orthotic Walker (CROW)
• Boots
• Half shoes & AFOs
• Assistive Devices
- FWW, SPC, crutches ok for some
- WC as last resort
```
110
What are the characteristics of Total Contact Cast (TCC) as an intervention for neuropathic ulcers?
```
• Gold standard
• For forefoot ulceration & Charcot
foot
• Requires special training
• Forced offloading
• Changed 1-2 weeks
• Decreases activity level, stride
length, cadence
• Hot, heavy, difficult self-care
```
111
What are the characteristics for proper shoe fit (Without Ulceration) as an intervention for neuropathic ulcers?
• Shape of shoe conforms to shape of foot
• 3/8 – ½ in. space between longest toe & end of shoe
• Deep toe box allows toe spread & toe clearance
- Pointy toe boots, dress shoes, etc. (not good)
• Adjustable laces or straps for snug fit over instep
• Fit snuggly around heel – always wear socks!
• Closed toe, no high heels
112
What are the exercise guidelines as an intervention for neuropathic ulcers?
• Avoid if glucose >250 with ketosis or >300 w/o
• Stress = increased insulin requirements
• Hydrate before: ~ 17 oz
• Eat 2 hrs before ex or ex 1 hr after food intake
• Snacks: quick vs slower absorption
- Eat quick absorbing (fruit) every 30 minutes, eat slow absorbing (bread, crackers, pasta) after exercise
• Type 2 – no more than 2 days between bouts of ex for best
control
113
Who are those involved in the treatment team for a neuropathic ulcer?
* PCP
* Diabetic educator
* Podiatrist
* PT
* Orthotist
* Orthopedic surgeon
* Vascular surgeon
114
What are the general exercise guidelines as an intervention for neuropathic ulcers?
• Plan carefully with food & meds
• Best to ex regularly & at same time
- Around injection/food intake schedule
- May need to adjust insulin/food when starting a new ex program
• No ex if glucose <70
• Avoid heavy ex late at night & do not ex alone
- Delayed hypoglycemic event during sleep
• Do not use injection site over mm that will be ex heavily that
day (Ex = faster absorption of insulin)
• Avoid high intensity/impact & “head down” ex
- Low impact & resistance activities best – (can mix high & low intensity depending on overall status, CVD, etc.)
- Walking, stationary bike, swimming, rowing, UE ex
• Prediabetes - lose 5-10% of body weight & at least 150 minutes mod ex per week
• Focus on overall health & importance of regular ex
- Gait, balance, fall prevention
115
What are the characteristics of heat physical agents in regards to the treatment of a neuropathic ulcer?
Careful with heat application
• Faster insulin absorption from injection site
- hypoglycemia
• More likely to burn (blood flow, sensation)
• Ex - abnormal cardiac responses, vitals, glucose levels, etc.
116
What are the characteristics of cold physical agents in regards to the treatment of a neuropathic ulcer?
Careful with cold application
• Slower absorption from injection site -hyperglycemia
• Cold tissue injury (blood flow, sensation)
117
What patients are at greatest risk for pressure injuries?
* SCI
* Hospitalized patients
* Long term care patients
118
What are the pathophysiology causes of pressure injuries?
• Pressure > intracapillary blood pressure = dec blood flow to soft tissue and obstructed lymphatic channels
• Local tissue ischemia
• Inc metabolic waste and acidosis = inc cell death
• Capillary permeability and local edema inc further limiting
circulation and inc tissue necrosis
• Dec fibrinolysis leading to fibrin deposits leading to microthrombi thus further occluding vessels and necrosis
119
What are the extrinsic causes of pressure injuries?
* Amount of pressure
* Duration of pressure
* Friction
* Shear
* Moisture
* Temperature
120
What are the intrinsic causes of pressure injuries?
```
• Muscle atrophy
- Impaired Mobility
• Medications
• Malnutrition
• Medical conditions
- Impaired Sensation
- Previous pressure ulcer
• Advanced Age
```
121
What are the common locations of pressure injuries in supine?
- Posterior heel
- Sacrum/coccyx
- Spinous process
- Medial humeral epicondyle
- Scapula
- Occiput
122
What are the common locations of pressure injuries in prone?
- Anterior tibia
- Anterior knee
- Iliac crest
123
What are the common locations of pressure injuries in side-lying?
- Malleolus
- Medial and lateral femoral condyles
- Greater trochanter
- Lateral humeral epicondyle
- Ear
124
What are the common locations of pressure injuries in sitting?
- Sacrum/coccyx
- Ischial tuberosity
- Greater trochanter
125
What does a pressure injury classification normal mean?
Healthy skin light or dark pigmented
126
What does a pressure injury classification stage 1- pressure injury- lightly pigmented mean?
Non-blanchable erythema
• Localized
• Typically over bony prominence
• Difficult to detect with dark pigmented skin
127
What does a pressure injury classification stage 2 pressure injury mean?
Partial thickness skin loss with exposed dermis
• Red or pink wound without slough or granulation tissue
• Usually moist
• Stage II is not:
- Skin tears
- Dermatitis
- Maceration
128
What does a pressure injury classification stage 3 pressure injury mean?
```
Full thickness skin loss
• Adipose is visible
• Slough may be present
• Undermining, tracts, and epibole
possible
```
129
What does a pressure injury classification stage 4 pressure injury mean?
Full Thickness Skin and Tissue Loss
• Exposed bone, tendon, or muscle
• May have slough and eschar
• Undermining and tracts common
130
What does a pressure injury classification unstageable pressure injury mean?
* Obscured full thickness skin and tissue loss
* Base covered by slough/eschar
* True depth can’t be determined
131
What does a pressure injury classification deep tissue pressure injury (DTPI) pressure injury mean?
* Localized area of discolored intact or non-intact skin
* Purple or maroon
* Damage of underlying soft tissue
* Difficult to detect in dark skin tones
132
What are the characteristics of pressure injury prevention strategy: education?
```
• Patients, caregivers, healthcare workers
• Daily skin checks
- Mirrors
• Transfer techniques
• Position changes
• Incontinence management
- Mild soap, pat dry, moisture barriers
- No diapers, talc based powders
```
133
What are the characteristics of pressure injury prevention strategy: Positioning- In bed?
* Avoid side positioning- 30 degree lateral instead
* Pillows or foam pads b/w bony prominences
* HOB lowest degree of elevation (prevent shear)
* Clean and wrinkle free bed linens
* Pillows/wedges to prop heels and head
* Support surfaces- more to come
* How often?: IT DEPENDS
134
What are the characteristics of pressure injury prevention strategy: Positioning- In chair?
```
• Sitting in intervals
• Change position of chair
• Reposition frequently
- Wheelchair pushups
- Weight shifts
• Support surfaces
```
135
What are the characteristics of pressure injury prevention strategy: mobility?
* Encourage
* Lengthen lines and tubes as able
* Avoid polypharmacy
* Adequate pain control
136
What are the characteristics of pressure injury prevention strategy: nutrition?
Assessed by RD
137
What are the characteristics of pressure injury prevention strategy: incontinence?
* Moisture barriers
* Speedy gentle hygiene
* Incontinence pads
* Voiding/defecating schedule
* Neuromuscular re-education
* Call light in reach
138
What are the characteristics of pressure injury treatment strategy: dressing selection?
```
Consider:
• Moisture balance
- Amount of exudate
• Bacterial bio-burden
• Tissue condition in wound bed
• Peri-wound skin
• Size, depth, and location
• Tunneling, undermining
• Goals
```
139
What are the specific tools used for pressure injury evaluation?
Bates-Jensen Wound Assessment Tool (BWAT)
• 15 items describing wound and peri-wound
• Correlates with severity of wound
• The higher the number the more severe
Pressure Ulcer Scale for Healing (PUSH)
• Developed by NPUAP to monitor healing of ulcers
140
What are the characteristics of pressure injury treatment strategy: cleanse?
```
Cleanse – the wound
• Normal saline
• Tap water
• Anti-septics
• Confirmed or suspected infection, high level of debris or bacteria
• Short-term use only
Cleanse- the periwound
```
141
What are the characteristics of pressure injury treatment strategy: debridement?
* If needed, appropriate, and consistent with goals
* For LE, ensure adequate vascular supply for healing prior to debridement
* Do not debride dry stable eschar in ischemic limbs
