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Integumentary > Week 2 > Flashcards

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.

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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
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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.
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4
Q

When testing for capillary refill in the microvascular exam, where do we press?

A

Press end of toe/proximal to wound

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5
Q

What is normal capillary refill time?

A

< 3 seconds

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6
Q

What are the positions for the rubor of dependency test?

A
  • Supine, LE elevated 30-600

* LE in dependency

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7
Q

What do you you observe in the LE elevated rubor of dependency test?

A

Observe for pallor/blanching

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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
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9
Q

What do you you observe in the LE in dependency rubor of dependency test?

A

• Observe color

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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

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11
Q

What is the position that venous filling time is tested?

A

Supine, LE elevated 30-600

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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

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13
Q

What is the ankle brachial index (ABI)?

A

Ratio of ankle systolic to brachial systolic pressure

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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
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15
Q

What are the contraindications for performing the ABI?

A

Ulcer near the ankle

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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

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17
Q

What does an ABI of >1.2 mean?

A

Unreliable (vessel calcification)

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18
Q

What does an ABI of 1.0-1.2 mean?

A

Normal

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19
Q

What does an ABI of 0.8-1.0 mean?

A

Mild PAD, compression for edema with caution/monitoring

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20
Q

What does an ABI of 0.5-0.8 mean?

A

Moderate PAD, intermittent claudication <0.8 (refer to vascular specialist)

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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

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22
Q

What does an ABI of <0.5 mean?

A

Severe ischemia, rest pain (“critical limb ischemia”)

- Compression & debridement absolutely contraindicated

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23
Q

What does an ABI of <0.2 mean?

A

Tissue death

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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

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25
Q

What is the claudication onset time test used for?

A
  • Developing a supervised progressive walking program

- Tracking improved ambulatory endurance

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26
Q

What is arterial insufficiency?

A

Decreased arterial blood flow

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27
Q

What is the main cause of arterial insufficiency?

A
  • 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
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28
Q

What is one of the 1st sign/symptom of arterial insufficiency?

A

Intermittent Claudication

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29
Q

What are the characteristics of Intermittent Claudication?

A
  • Activity specific discomfort
  • Discomfort goes away within 1-5 minutes of stopping activity
  • Repeatable and predictable
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30
Q

What is the difference between intermittent claudication and spinal stenosis?

A

• AI – s/s relief with cessation of activity, predictable, repeatable
w/same level of activity
• Spinal stenosis – s/s relief w/change of position

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31
Q

As arterial insufficiency progresses, patient may begin to experience ischemic rest pain. What is ischemic rest pain?

A

Burning pain with elevation or at night

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32
Q

How is ischemic rest pain relieved?

A

Dependency

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33
Q

What typically happens after ischemic rest pain?

A

Ischemic Ulcer or Gangrene

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34
Q

What typically causes ulcers?

A

Trauma

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35
Q

What are the potential risk factors of arterial insufficiency?

A

• 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

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36
Q

How long after the cessation of smoking do we see improvements?

A

Circulation improvements in 4 weeks, decrease CAD risk by ½ in 1 year

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37
Q

What are the general exam findings in arterial insufficiency?

A
  • 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)
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38
Q

What are the clinical vascular exam for arterial insufficiency?

A

• 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

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39
Q

What is the pain pattern of arterial insufficiency?

A

• 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

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40
Q

What are the characteristics of the location of a wound from arterial insufficiency?

A 
Commonly below ankle
• Foot, heel, met heads, tips of
toes, “bunion” areas
• Possible superior to lateral
malleolus or anterior lower leg
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41
Q

What are the characteristics of the drainage of a wound from arterial insufficiency?

A
  • Minimal to none

* Usually dry and hard

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42
Q

What are the characteristics of the tissue of a wound from arterial insufficiency?

A
  • Black/brown eschar
  • Pale granulation tissue
  • Mixed
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43
Q

What is the presentation of a wound from arterial insufficiency?

A
  • Start shallow then deepen
  • “punched out” appearance
  • Usually round
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44
Q

What are the characteristics of dry gangrene?

A
  • Mummification
  • No drainage, hard
  • Little/no odor
  • Clear demarcation
  • Protect, off-load
  • Monitor for conversion to wet gangrene
  • Auto-amp?
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45
Q

What are the characteristics of wet gangrene?

A
  • Drainage
  • Odor
  • Fluctuance/edema
  • Erythema
  • Less clear demarcation
  • Urgent referral to a vascular surgeon
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46
Q

What are the things to do if a therapist thinks their patient has arterial insufficiency?

A
  • MD referral
  • Pt education
  • Safe, graded exercise (if cleared)
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47
Q

What are the components of the MD referral if a therapist thinks their patient has arterial insufficiency?

A
  • Vascular testing for final confirmation, severity, sx repair if needed
  • Cardiac workup, meds
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48
Q

What are the components of the pt education if a therapist thinks their patient has arterial insufficiency?

A

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.)

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49
Q

What are some actions to take before a patient with arterial insufficiency develops a wound?

A

• 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

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50
Q

According to Kisner and Kolby, what are the prescriptive exercise for arterial insufficiency?

A

• 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

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51
Q

According to Goodman, what are the prescriptive exercise for arterial insufficiency?

A

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

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52
Q

According to McCullough & Kloth, what is a supervised exercise program for arterial insufficiency?

A

3 x wk, short bouts of treadmill walking x 40-60 minutes each session

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53
Q

What are the benefits of the supervised exercise program for arterial insufficiency proposed by McCullough & Kloth?

A

Improved oxygen metabolism, collateralization, improved blood viscosity, improved walking economy

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54
Q

What are the interventions to do when working with an arterial insufficiency patient with a wound?

A

• 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

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55
Q

Where are the potential referrals for patients with arterial insufficiency?

A 
• Dietitian
  - Reduced caffeine, smoking, proper nutrition &amp; hydration
• Diabetic Educator
• Podiatry
• Prosthetics (if having an amputation)
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56
Q

What are the precautions and contraindications of wound care following arterial insufficiency?

A

• 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

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57
Q

Why should caution be taken when looking to debride a wound as a result of arterial insufficiency?

A

Lack of good blood flow, decreased healing

58
Q

What type of debridement in typically contraindicated for a wound following arterial insufficiency?

A

Sharp debridement

59
Q

What is the ABI cutoff for debridement of a wound following arterial insufficiency?

A

• ≤ 0.8 ABI – no debridement of “stable” eschar

  • Goal is maintenance
  • Same for heel pressure wounds
60
Q

What are the guidelines for ABI and compression when treating arterial insufficiency?

A

• 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
Q

What are the contraindications for compression?

A

Pain and no sensation

62
Q

What do we do after the patient has received a re-vascularization procedure or amputation?

A

• 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
Q

What are the ways to prevent arterial insufficiency wounds?

A

• 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
Q

Where is the typical locations for venous insufficiency wounds?

A
  • 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
Q

What is the presentation for the surrounding skin of a venous insufficiency wound?

A

• 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
Q

What are the characteristics of a wound due to venous insufficiency?

A

• 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
Q

What are the characteristics of the periwound due to venous insufficiency?

A
  • Maceration common (initially or w/inadequate dressings or change schedule)
  • Diffuse edges
  • Irritation
68
Q

What are the considerations for decision making for a compression for venous insufficiency?

A 
• 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
Q

What are the methods of compression for treating venous insufficiency?

A
  • Tubigrip
  • Long Stretch
  • Short Stretch
  • In-elastic
  • Multilayer
  • Stockings
  • Garments
70
Q

What are the characteristics of a tube- like (tubigrip) compression used for treating venous insufficiency?

A

• 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
Q

What are the characteristics of a long stretch compression used for treating venous insufficiency?

A

‘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
Q

What are the characteristics of a short stretch compression used for treating venous insufficiency?

A

• 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
Q

What are the characteristics of a In-Elastic compression used for treating venous insufficiency?

A 
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
Q

What are the characteristics of a Multi-layer compression used for treating venous insufficiency?

A

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
Q

What are the characteristics of a stockings compression used for treating venous insufficiency?

A

• 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
Q

What is the indication for 15-20mmHg of stocking at the ankle?

A

Early sxs w/o ulcer, lite prophylaxis for high risk pts, “tired legs”

77
Q

What is the indication for 20-30mmHg of stocking at the ankle?

A

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
Q

What is the indication for 30-40mmHg of stocking at the ankle?

A

Moderate VI w/wo ulcer, post-ulceration, pronounced varicose veins, moderate lymphedema, post traumatic edema, burn scar management

79
Q

What is the indication for 40-50mmHg of stocking at the ankle?

A

Severe VI, VI ulcer & no AI, severe lymphedema

80
Q

What is the indication for 60+mmHg of stocking at the ankle?

A

Severe lymphedema, elephantiasis, severe post thrombotic disease

81
Q

What are the characteristics of garment compression “farrow wrap” used for treating venous insufficiency?

A
  • Foot piece & series of Velcro bands (function similar to short stretch bandages)
  • Easier don/doff vs compression stockings
82
Q

What are the characteristics of garment compression “Circ-Aid” used for treating venous insufficiency?

A

Custom, non-elastic, Velcro bands, for VI & lymphedema

83
Q

What does LaPlace’s Law do?

A

Gives us an equation to calculate the amount of compression needed

84
Q

What is the LaPlace’s Law equation?

A

Tension x # of layers x 4630 divided by

limb girth x bandage width

85
Q

What are the adjustments to the overall amount of graduated or graded compression that can be utilized?

A

• 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
Q

What are the exercise recommendations for patients with venous insufficiency ulcers?

A

• 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
Q

What are the patient education guidelines for patients with venous insufficiency?

A

• 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
Q

What are the goals for physical therapy in regards to venous insufficiency?

A

• 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
Q

What are the general techniques for compression in the treatment of venous insufficiency?

A

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
Q

What are the risk factors for a neuropathic wound?

A 
• Diabetes Mellitus
• Impaired Healing
• Vascular disease
• Tri-neuropathy
   - Sensory, Motor, Autonomic
• Mechanical stress
• Impaired ROM
• Foot deformities
• Pervious ulcer or amputation
91
Q

What are the characteristics of a neuropathic ulcer?

A

• 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
Q

What are the characteristics of the exam of a neuropathic wound?

A

• Thoroughly explore wound bed
- Depth/tunnels/tracts, named structures
- Probe to bone?
• Callus

93
Q

What does a 0 on the classifications of a neuropathic wound exam according to the wagner grading scale mean?

A

No open lesions, may have deformity or cellulitis

94
Q

What does a 1 on the classifications of a neuropathic wound exam according to the wagner grading scale mean?

A

Superficial Ulcer

95
Q

What does a 2 on the classifications of a neuropathic wound exam according to the wagner grading scale mean?

A

Deep Ulcer to tendon, capsule, or bone

96
Q

What does a 3 on the classifications of a neuropathic wound exam according to the wagner grading scale mean?

A

Deep Ulcer with abscess, osteomyelitis, or joint sepsis

97
Q

What does a 4 on the classifications of a neuropathic wound exam according to the wagner grading scale mean?

A

Localized gangrene

98
Q

What does a 5 on the classifications of a neuropathic wound exam according to the wagner grading scale mean?

A

Gangrene of entire foot

99
Q

People with diabetes have hyperglycemia, which impairs all phase of healing like…?

A
  • 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
Q

Impaired healing leads to…?

A

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
Q

What are the characteristics of the sensory, motor, and autonomic presentation associated with tri-neuropathy (Diabetic Neuropathy)?

A 
• Usually symmetrical
• Affects distal nerves first – feet (hands)
• Severity increases with
  - Age
  - Disease duration (~10 yrs)
  - Glucose control
102
Q

What are the characteristics of the sensory presentation of a tri-neuropathy (Diabetic Neuropathy)?

A 
• Poor awareness of trauma
to the feet
• Occurs gradually
• Paresthesias: burning,
tingling, aching
  - Painful and debilitating
  - False sense of protective
sensation
103
Q

What are the characteristics of the motor presentation of a tri-neuropathy (Diabetic Neuropathy)?

A

• Paralysis of foot intrinsics
- Increased plantar forces
• Hallux Valgus
• Claw toe

104
Q

What are the characteristics of the autonomic presentation of a tri-neuropathy (Diabetic Neuropathy)?

A

• 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
Q

What are the clinical exams used for tri-neuropathy (Diabetic Neuropathy)?

A 
• Lab values (Fasting glucose, A1C, albumin, pre-albumin)
• Inspection of skin &amp; 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 &amp; 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
Q

What are the characteristics of charcot foot?

A

• 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
Q

What are the common interventions for neuropathic ulcers?

A

• 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
Q

What are the common do nots for neuropathic ulcers?

A
  • Use whirlpool

* Patients should not soak feet

109
Q

What are the characteristics of offloading as an intervention for neuropathic ulcers?

A 
Reduce pressure, promote slow ambulation, facilitate “normal” gait as possible
• Total Contact Cast (TCC)
• Charcot Restraint Orthotic Walker (CROW)
• Boots
• Half shoes &amp; AFOs
• Assistive Devices
  - FWW, SPC, crutches ok for some
  - WC as last resort
110
Q

What are the characteristics of Total Contact Cast (TCC) as an intervention for neuropathic ulcers?

A 
• Gold standard
• For forefoot ulceration &amp; Charcot
foot
• Requires special training
• Forced offloading
• Changed 1-2 weeks
• Decreases activity level, stride
length, cadence
• Hot, heavy, difficult self-care
111
Q

What are the characteristics for proper shoe fit (Without Ulceration) as an intervention for neuropathic ulcers?

A

• 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
Q

What are the exercise guidelines as an intervention for neuropathic ulcers?

A

• 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
Q

Who are those involved in the treatment team for a neuropathic ulcer?

A
  • PCP
  • Diabetic educator
  • Podiatrist
  • PT
  • Orthotist
  • Orthopedic surgeon
  • Vascular surgeon
114
Q

What are the general exercise guidelines as an intervention for neuropathic ulcers?

A

• 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
Q

What are the characteristics of heat physical agents in regards to the treatment of a neuropathic ulcer?

A

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
Q

What are the characteristics of cold physical agents in regards to the treatment of a neuropathic ulcer?

A

Careful with cold application
• Slower absorption from injection site -hyperglycemia
• Cold tissue injury (blood flow, sensation)

117
Q

What patients are at greatest risk for pressure injuries?

A
  • SCI
  • Hospitalized patients
  • Long term care patients
118
Q

What are the pathophysiology causes of pressure injuries?

A

• 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
Q

What are the extrinsic causes of pressure injuries?

A
  • Amount of pressure
  • Duration of pressure
  • Friction
  • Shear
  • Moisture
  • Temperature
120
Q

What are the intrinsic causes of pressure injuries?

A 
• Muscle atrophy
  - Impaired Mobility
• Medications
• Malnutrition
• Medical conditions
  - Impaired Sensation
  - Previous pressure ulcer
• Advanced Age
121
Q

What are the common locations of pressure injuries in supine?

A
  • Posterior heel
  • Sacrum/coccyx
  • Spinous process
  • Medial humeral epicondyle
  • Scapula
  • Occiput
122
Q

What are the common locations of pressure injuries in prone?

A
  • Anterior tibia
  • Anterior knee
  • Iliac crest
123
Q

What are the common locations of pressure injuries in side-lying?

A
  • Malleolus
  • Medial and lateral femoral condyles
  • Greater trochanter
  • Lateral humeral epicondyle
  • Ear
124
Q

What are the common locations of pressure injuries in sitting?

A
  • Sacrum/coccyx
  • Ischial tuberosity
  • Greater trochanter
125
Q

What does a pressure injury classification normal mean?

A

Healthy skin light or dark pigmented

126
Q

What does a pressure injury classification stage 1- pressure injury- lightly pigmented mean?

A

Non-blanchable erythema
• Localized
• Typically over bony prominence
• Difficult to detect with dark pigmented skin

127
Q

What does a pressure injury classification stage 2 pressure injury mean?

A

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
Q

What does a pressure injury classification stage 3 pressure injury mean?

A 
Full thickness skin loss
• Adipose is visible
• Slough may be present
• Undermining, tracts, and epibole
possible
129
Q

What does a pressure injury classification stage 4 pressure injury mean?

A

Full Thickness Skin and Tissue Loss
• Exposed bone, tendon, or muscle
• May have slough and eschar
• Undermining and tracts common

130
Q

What does a pressure injury classification unstageable pressure injury mean?

A
  • Obscured full thickness skin and tissue loss
  • Base covered by slough/eschar
  • True depth can’t be determined
131
Q

What does a pressure injury classification deep tissue pressure injury (DTPI) pressure injury mean?

A
  • 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
Q

What are the characteristics of pressure injury prevention strategy: education?

A 
• 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
Q

What are the characteristics of pressure injury prevention strategy: Positioning- In bed?

A
  • 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
Q

What are the characteristics of pressure injury prevention strategy: Positioning- In chair?

A 
• Sitting in intervals
• Change position of chair
• Reposition frequently
  - Wheelchair pushups
  - Weight shifts
• Support surfaces
135
Q

What are the characteristics of pressure injury prevention strategy: mobility?

A
  • Encourage
  • Lengthen lines and tubes as able
  • Avoid polypharmacy
  • Adequate pain control
136
Q

What are the characteristics of pressure injury prevention strategy: nutrition?

A

Assessed by RD

137
Q

What are the characteristics of pressure injury prevention strategy: incontinence?

A
  • Moisture barriers
  • Speedy gentle hygiene
  • Incontinence pads
  • Voiding/defecating schedule
  • Neuromuscular re-education
  • Call light in reach
138
Q

What are the characteristics of pressure injury treatment strategy: dressing selection?

A 
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
Q

What are the specific tools used for pressure injury evaluation?

A

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
Q

What are the characteristics of pressure injury treatment strategy: cleanse?

A 
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
Q

What are the characteristics of pressure injury treatment strategy: debridement?

A
  • 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

Integumentary (3 decks)

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