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Endocrine 1 > Wound Management (PT) > Flashcards

Wound Management (PT) Flashcards

1
Q

neuropathic ulcers

A
  • aka diabetic ulcerations

- incidence: 15-25%

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2
Q

diabetes impact on amputations

A

-DM is responsible for over 600k amputations annually

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3
Q

etiology of diabetes-related tissue damage

A
  • hyperglycemia: changes RBCs, palelets, and capillaries; alters blood flow; increases microvascular pressure
  • glycosylated proteins cause tissue trauma
  • accumulation of sorbitol, d/t breakdown of glucose, results in tissue destruction
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4
Q

risk factors that contribute to NUs and delayed healing

A
  • vascular dz
  • neuropathy
  • mechanical stress
  • abnormal foot fxn and inadequate footwear
  • impaired healing and immune response
  • poor vision
  • ulcer characteristics
  • dz characteristics
  • inadequate care and education
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5
Q

vascular disease

A
  • increased risk for peripheral vascular dz w/ DM
  • accelerated atherosclerosis
  • thickening of basement membrane
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6
Q

what is the major contributing factor to neuropathic ulcers?

A

neuropathy

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7
Q

neuropathy

A
  • MC complication of DM
  • symmetrical and distal
  • affects sensory, motor, and autonomic systems
  • causes: neural ischemia, segmental demyelination
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8
Q

sensory neuropathy

A
  • 50% of pts unaware they have lost protective sensation
  • lack of protective sensation = lack of early detection to irritation or trauma
  • paresthesias
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9
Q

at what point in sensory neuropathy is a person at risk for ulceration?

A

if unable to perceive 10g of pressure

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10
Q

motor neuropathy

A
  • intrinsic muscle weakness/atrophy
  • decreases foot stability
  • leads to deformities
  • increased pressure and shear forces to foot
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11
Q

autonomic neuropathy

A
  • dry, cracked skin d/t decreased ability to sweat
  • increased rate of callus formation
  • arteriovenous shunting leads to decreased perfusion
  • uncontrolled vasodilation lead to osteopenia
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12
Q

mechanical stress

A
  • abnormal or excessive forces predispose to ulceration

- high plantar pressures overload tissue’s ability to repair itself

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13
Q

impact of abnormal foot function and inadequate footwear

A
  • impaired ROM
  • foot deformities
  • prior ulcer/amputation
  • poor footwear
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14
Q

impact of impaired healing and immune response

A
  • decreased ability to build new tissue and fight infection
  • increased frequency of osteomyelitis, soft tissue infections, candida
  • impairs all 3 phases of would healing
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15
Q

poor vision

A
  • DM is leading cause of retinopathy, glaucoma, cataracts
  • increases risk of trauma
  • decreases ability to perform adequate foot care
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16
Q

characteristics of ulcers

A
  • larger and deeper wounds take longer to heal

- woulds present for longer time and take longer to heal

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17
Q

increased risk for diseases

A

-poor glycemic control is associated w/ increased risk of long-term complications

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18
Q

common types of inadequate care and education

A
  • lack of cutting edge knowledge
  • delayed referrals
  • poor adherence to clinical guidelines
  • minor short-term complications but major long-term complications
  • pts don’t understand the link b/w euglycemia and long-term complications
  • absence of pain or short-term effects decreases pt adherence
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19
Q

3 main PT tests and measures for NUs

A
  • circulation
  • sensory integrity
  • gait analysis
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20
Q

tests of circulation

A
  • pulses
  • doppler US
  • ABI
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21
Q

indications for circulation issue

A
  • all open wounds
  • decreased or absent pulses
  • s/s of arterial insufficiency: depends on location
  • hx of PVD
22
Q

when to refer for circulation issue

A
  • arteriography or transcutaneous oxygen measurements if fail to respond
  • refer to vascular specialist if very low ABI
23
Q

main test for sensory integrity

A

semmes-weinstein monofilament

24
Q

semmes-weinstein monofilament

A
  • occlude pts vision
  • begin w/ 5.07 monofilament
  • avoid calloused areas
  • each location tested randomly 3x
25
Q

indications for sensory integrity testing

A
  • all neuropathic ulcers
  • all pts w/ DM
  • all pts w/ plantar foot ulcers
26
Q

monofilament size vs. pressure produced

A
  • 4.17: 1 gm pressure: decreased sensation
  • 5.07: 10 gm pressure: loss of protective sensation
  • 6.10: 75 gm pressure: absent sensation
27
Q

classification system used for NUs

A

Wagner Classification System

28
Q

Wagner Classification System grades

A
  • 0: no open lesions, may have deformity or cellulitis
  • 1: superficial ulcer
  • 2: deep ulcer to tendon, capsule, bone
  • 3: deep ulcer w/ abscess, osteomyelitis, or joint sepsis
  • 4: localized gangrene
  • 5: gangrene of entire foot
29
Q

what is the 5PT method

A
  • pain
  • position
  • presentation
  • periwound
  • pulses
  • temp
30
Q

pain

A
  • lack of pain complaint d/t neuropathy

- possible paresthesias

31
Q

position

A
  • plantar foot
  • plantar aspect of metatarsal heads
  • plantar aspect of midfoot if Charcot deformity
  • may occur under calluses
  • may occur in areas of pressure/friction from inappropriate footwear
32
Q

presentation

A
  • round, punched-out lesions
  • callused rim
  • minimal drainage unless infected
  • eschar or necrotic material uncommon unless infected
33
Q

periwound (and structural changes)

A
  • skin is dry, cracked
  • callus present
  • structural deformities: claw toes, rocker-bottom foot, prior amputation
34
Q

pulses

A
  • normal
  • decreased
  • or may be accentuated w/ vessel calcification
35
Q

temp

A
  • normal

- may be increased in areas of reactive hyperemia or infection

36
Q

good healing prognosis for NUs

A
  • smaller, superficial (Wagner grade 1 or 2)
  • present for < 2 months
  • ulcers decreasing in size w/i 4 weeks of tx
37
Q

poor healing prognosis for NUs

A
  • large size
  • risk of amputation 154x greater w/ infected ulcers
  • if 20-50% decrease in size not noted in first month of tx
38
Q

who all makes up the team approach in a DM patient?

A
  • primary care provider
  • surgeon
  • podiatrist
  • nutritionist/diabetic educator
  • endocrinologist
  • orthotist
  • psychological counselor
  • social worker
39
Q

patient/client related instructions

A
  • dz process/management of DM
  • role of exercise and safety guidelines: benefits, risks, contraindications
  • general guidelines about what to do
  • risk factor reduction
  • daily foot checks
  • poper footwear
  • toenail care
  • demonstrate what decreased protective sensation “feels” like
40
Q

infection precautions

A
  • may not show signs of infection d/t decreased inflammatory response/PVD
  • request culture and sensitivity for wounds that fail to respond to appropriate interventions
  • osteomyelitis must be treated surgically
41
Q

BS monitoring precautions

A
  • hyperglycemia common w/ infections and uncontrolled DM

- hypoglycemia may occur

42
Q

keys to local wound care

A
  • offload the neuropathic ulcer
  • pare (trim) callus flush w/ epithelial surface
  • use petrolatum-based moisturizer daily
  • use toe spacers if enclosing toes in bandage
43
Q

possible adjuncts for local wound care

A
  • negative pressure wound therapy
  • US
  • electrical stimulation
  • growth factors
44
Q

total contact casting

A
  • modified short leg casts used for Wagner grade 1 or 2 ulcers
  • assists wound healing
  • cast is molded to foot and leg, dispersing weight-bearing forces over large area
  • cast rigidity controls edema
  • immobilization of foot protects from trauma and microorganisms
  • assist w/ pt adherence
45
Q

contraindications to total contact casting

A
  • osteomyelitis
  • gangrene
  • fluctuating edema
  • active infection
  • ABI less than .45
46
Q

gait and mobility training

A
  • partial weightbearing gait w/ assistive device
  • alter gait pattern to decrease plantar pressure
  • footwear modifications
47
Q

therapeutic exercise

A
  • ROM exercises: assess/address great toe extension, talocrural dorsiflexion, and subtalar joint motion
  • aerobic exercise: assists w/ glycemic control and weight loss
48
Q

temporary footwear options

A
  • felt or foam inserts
  • padded ankle-foot orthoses
  • walking shoes
49
Q

benefits of temporary footwear

A
  • provides safe ambulation, pressure reduction, room for bandages
  • can use when total contact cast is not an option
50
Q

permanent footwear

A
  • shoes should be about 1/2 inch longer than the longest toe w/ snug heel fit
  • shoe last should match foot shape
  • extra-depth toe box
  • heel height < 1 inch
  • soft, moldable materials
  • soft inserts may decrease pressure
  • fit shoes at middle of day
  • break in shoes gradually
  • pts w/ severe foot deformities or amputations should be referred to orthotist
51
Q

medical interventions

A
  • glycemic control: even 1% decrease in A1c associated w/ improvements in many complications
  • manage neuropathic pain/paresthesias: anticonvulsants, antidepressants, capsaicin
  • management of concomitant arterial insufficiency
  • antibiotic therapy: MC infections of staph or group A strep
  • radiological assessment
52
Q

surgical interventions

A
  • debridement: necrotic tissue, osteomyelitis
  • incision and drainage
  • antimicrobial bead implantation
  • surgery to address abnormal foot function of limited tissue perfusion
  • revascularization surgery
  • amputation: gangrene or wagner grade 4 or 5 ulcers

Endocrine 1 (18 decks)

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