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Integumentary > Neuropathic Ulcers > Flashcards

Neuropathic Ulcers Flashcards

1
Q

How many Americans have diabetes?

A

over 24 million

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2
Q

Incidence of neuropathic ulcerations:

A

15-25%

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3
Q

How many amputations is diabetes responsible for a year?

A

600,000

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4
Q

Symptoms of hyperglycemia

A

frequent urination
increased thirst
increased hunger.

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5
Q

Acutecomplications of DM:

A

Diabetic ketoacidosis

Nonketotic hyperosmolar coma

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6
Q

Long term complications of DM:

A 
Heart disease
Stroke
Chronic kidney failure
Foot ulcers
Visual impairment
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7
Q

Type 1 DM:

A

Diagnosed in children or young adults
Results from an immune mediated destruction of pancreatic beta cells
Pancreas is becomes unable to produce insulin

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8
Q

Type 2 DM:

A

Diagnosed at middle age or later
Approximately 80% of diagnosed are overweight
Genetic predisposition to developing type 2
Start as “insulin resistance” where cells in the body do not respond properly to insulin
Excessive weight and inadequate physical activity are contributing factors

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9
Q

Hyperglycemia

A

Changes RBCs, platelets, and capillaries
Alters blood flow
Increases microvascular pressure

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10
Q

What do glycosylated proteins cause?

A

tissue trauma

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11
Q

What is accumulation of sorbitol due to?

A

to breakdown of glucose, results in tissue destruction

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12
Q

Where are diabetic wounds located?

A

Usually on tips of toes, lateral aspect of foot dorsum of foot, metatarsal heads especially 1st and 5th, heels, midfoot and at location of orthopedic deformity

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13
Q

What percentage of diabetic ulcers are neuropathic foot ulcers?

A

60-70%
15-20% of diabetic ulcers are from PVD
15-20% are mixed cause

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14
Q

Wound edges:

A

even, well defined, with and without undermining

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15
Q

What deformity is common in diabetic foot ulcers?

A

Hammer toe/claw toe

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16
Q

Skin changes with DM:

A

Cracking; callous formation

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17
Q

Reasons for delayed wound healing in DM:

A 
Inhibited fibroblast activity
Inhibited endothelial cell activity
Decreased collagen deposition
Delayed re-epithelialization
Decreased re-endothelialization of microarterial anastomoses
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18
Q

Diabetic Risk Factors Contributing Delayed Healing and Neuropathic Ulcers

A 
Vascular disease
Neuropathy
Mechanical stress
Abnormal foot function and inadequate footwear
Impaired healing and immune response
Poor vision
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19
Q

Vascular Disease

A

Risk for PVD greater in patients with diabetes
Accelerated atherosclerosis
Thickening of basement membrane

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20
Q

Neuropathy

A

Most common complication of diabetes
Symmetrical, distal
Affects sensory, motor, and autonomic systems

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21
Q

Causes of neuropathy:

A

Neural ischemia

Segmental demyelination

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22
Q

Sensory neuropathy:

A

the most common type of diabetic neuropathy

causes pain or loss of feeling in the toes, feet, legs, hands, and arms

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23
Q

Autonomic neuropathy

A

causes changes in digestion, bowel and bladder function, sexual response, and perspiration
Can affect the nerves that serve the heart and control blood pressure, as well as nerves in the lungs and eyes

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24
Q

Motor neuropathy

A 
Results in muscle atrophy and weakness
Intrinsic muscle weakness/atrophy
Decreases foot stability
Leads to deformities
Increased pressure and shear forces to foot
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25
Q

Sensory Neuropathy

A

50% of patients unaware they have lost protective sensation
Lack of protective sensation = lack of early detection to irritation or trauma
Paresthesias

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26
Q

At risk for pressure ulceration:

A

If unable to perceive 10g of pressure

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27
Q

Autonomic Neuropathy Ulcers:

A

Dry, cracked skin due to decreased ability to sweat
Increased rate of callus formation
Arteriovenous shunting leads to decreased perfusion
Uncontrolled vasodilation leads to osteopenia

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28
Q

Charcot foot

A

cycle of fracture and healing-

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29
Q

What happens in acute destructive phase of charcot foot?

A

inflammation, sublexation, bone fragments, fractures (deformity can be controlled in this phase)-

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30
Q

What does the acute destructive phase of charcot foot result in?

A 
Increased blood glucose
Peripheral neuropathy
Mechanical stress
Ankle equinus
Autonomic neuropathy causing increased blood flow resulting in osteolysis, osteopenia
Trauma
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31
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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32
Q

Abnormal Foot Function and Inadequate Footwear

A

Impaired ROM
Foot deformities
Prior ulcer/amputation
Poor footwear

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33
Q

Impaired ROM

A

Great toe ext, DF, subtalar joint

Increase vertical pressure and horizontal shear

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34
Q

Foot deformities

A

PF contracture, varus/valgus, Charcot foot

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35
Q

Impaired Healing and Immune Response

A

Decreased ability to build new tissue and fight infection
Decreased ability to fight infection
Increased frequency of osteomyelitis, soft tissue infections, candida
Impairs all 3 phases of wound healing

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36
Q

Poor Vision

A

Diabetes is leading cause of retinopathy, glaucoma, cataracts
Increases risk of trauma
Decreases ability to perform adequate foot care

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37
Q

Ulcer Characteristics

A

Larger and deeper wounds take longer to heal

Wounds present for longer time take longer to heal

38
Q

Disease Characteristics

A

Poor glycemic control associated with increased risk of long-term complications
Complications can be improved/reversed with improved glycemic control

39
Q

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
Patients do not understand link between hyperglycemia and long-term complications
Absence of pain or short-term effects decreases patient adherence

40
Q

PT Tests and Measures

for Neuropathic Ulcers

A

Circulation

Sensory integrity

41
Q

Circulation:

A 
Pulses
Capillary refill
Doppler ultrasound
Ankle-Brachial Index
TCPO2
42
Q

Sensory integrity

A

Sensation to light touch

Sensation to vibration

43
Q

Indications of circulation:

A

All open wounds
Decreased or absent pulses
Signs and symptoms of arterial insufficiency
History of PVD

44
Q

Semmes-Weinstein Monofilaments

A 
Occlude patient’s vision
Begin with 5.07 monofilament
Avoid calloused areas
Each location tested randomly 3x
At least 1 sham application at each point
45
Q

Sensory Integrity indications:

A

All neuropathic ulcers
All patients with diabetes
All patients with plantar foot ulcers

46
Q

Monofilament 4.17

A

Pressure produced: 1 gram

inability to feel: decreased sensation

47
Q

Monofilament 5.07

A

10 grams of pressure

loss of protective sensation

48
Q

Monofilament 6.10

A

75 grams of pressure

absent sensation

49
Q

How many incorrect response with tunning fork indicates peripheral neuropathy?

A

at least 5

50
Q

Grade 0 Wagner:

A

No open lesions
May have deformity or cellulitis
Integumentary Practice Pattern A (at risk)
or B (superficial skin involvement)

51
Q

Grade 1 Wagner:

A

Superficial ulcer

Integumentary Practice Pattern C (partial thickness) or D (full thickness)

52
Q

Grade 2 Wagner:

A

Deep ulcer to tendon, capsule, bone

53
Q

Grade 3 Wagner:

A

Deep ulcer with abcess, osteomyelitis, or joint sepsis

54
Q

Grade 4 Wagner:

A

Localized gangrene

55
Q

Grade 5 Wagner:

A

Gangrene of the entire foot

56
Q

“5PT” Method

A 
Pain
Position
Presentation
Periwound
Pulses
Temperature
57
Q

Pain

A

Lack of pain complaint due to neuropathy

Possible paresthesias

58
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

59
Q

Presentation

A

Round, punched-out lesions
Callused rim
Minimal drainage unless infected
Eschar or necrotic material uncommon unless infected

60
Q

Periwound and Structural Changes

A 
Skin is dry, cracked
Callus present
Structural deformities
Claw toes
Rocker-bottom foot
Prior amputation
61
Q

Pulses

A

Normal

May be accentuated with vessel calcification

62
Q

Temperature

A

Normal

May be increased in areas of reactive hyperemia or infection

63
Q

Good healing

A

smaller, superficial wound (Wagner 1 or 2)
present for less than 2 months
ulcers decreasing in size within 4 weeks of treatment

64
Q

Poor healing:

A

large size
Risk of amputation 154x greater with infected ulcers
If 20–50% decrease in size not noted in first month of treatment

65
Q

Average healing time of DU:

A

Large variability in healing rates

Average healing time 12–14 weeks

66
Q

Patient/Client-Related Instruction

A 
Disease process/management of DM
Role of exercise and safety guidelines
Risk factor reduction
Daily foot checks
Foot care guidelines
67
Q

PT precautions:

A

May not show signs of infection due to decreased inflammatory response/PVD
Request culture and sensitivity for wounds that fail to respond to appropriate interventions
Osteomyelitis must be treated surgically

68
Q

Intervention Goals

A

Tight blood glucose control
Off-loading
Aggressive debridement if arterial supply intact to decrease microbial load and remove senescent cells/biofilm
Removal of callous and irregular wound edges to allow healing from borders

69
Q

Monitor blood sugar

A

Hyperglycemia common with infections and uncontrolled diabetes
Hypoglycemia may occur
Optimal Glucose < 150
>180 inhibits neutrophil activity

70
Q

Off-Loading

A

Avoidance of all mechanical stress on injured extremity, essential for healing
Trauma causes most plantar wounds and ongoing trauma prevents healing

71
Q

Total Contact Casting:

A

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
Assists with patient adherence

72
Q

How does total contact casting heal wounds?

A

by reducing weightbearing pressure and shear force to the plantar aspect of the foot
Minimal padding
Maintains “total contact” with the foot and lower leg.
Closely molded

73
Q

Contraindications to total contact casting?

A 
Osteomyelitis
Gangrene
Fluctuating edema
Active infection
ABI less than 0.45
74
Q

Gait and Mobility Training

A 
PWB gait with assistive device
Alter gait pattern to decrease plantar pressure
Step-to pattern
Slower steps 
Shuffling gait
Footwear modifications
75
Q

Off-loading devices

A

Crutches, wheelchair
Wedge shoes
Total contact casts
Prefabricated cast walker

76
Q

Pressure relief

A

Orthotics
Cushions
Positioning

77
Q

Options for temporary footwear:

A

Felt or foam inserts
Padded ankle-foot orthoses
Walking shoes

78
Q

Benefits of temporary footwear:

A

Provides safe ambulation, pressure reduction, room for bandages
Can use when total contact cast is not an option

79
Q

Wedge Shoe

A

reduces weight bearing pressure on the forefoot which promotes faster healing after surgery, trauma or when forefoot wounds or ulcerations are present.

80
Q

DARCO HeelWedge

A

Off-loads pressure from the heel by shifting weight to the mid and forefoot to promote faster healing after surgery, trauma or when wounds or ulcerations are present on the heel

81
Q

Wound Care Shoe System

A

Deep rocker sole
Four layers of differing density insoles that may be altered for off-loading
Leather upper lined with Plastazote® material
Sections may be removed from the leather upper without disturbing the liner to remove pressure

82
Q

Prefabricated cast walker

A

Custom inflated aircells for individual fit and support
Rocker bottom and rigid sole
Allow forward progression in gait without transferring forces to the forefoot

83
Q

Permanent Footwear dimensions:

A

Shoes should be ~½ inch longer than the longest toe with snug heel fit
Shoe last should match foot shape
Extra-depth toe box
Heel height < 1 inch

84
Q

Permanent Footwear

A 
Soft, moldable materials 
Soft inserts may decrease pressure
Fit shoes at the middle of the day
Break in shoes gradually
Patients with severe foot deformities or amputations should be referred to an orthotist
85
Q

Orthotics

A

Used to correct foot deformities and equalize pressure to prevent ulceration

86
Q

Therapeutic exercise:

A

ROM

Aerobic

87
Q

ROM Exercises

A

Assess/address great toe extension, talocrural dorsiflexion, and subtalar joint motion
Joint mobilizations may be helpful

88
Q

Aerobic Exercise:

A

Assists with glycemic control

Assists with weight loss

89
Q

Medical Interventions

A

Glycemic control
Even 1% decrease in hemoglobin A1c associated with improvements in many complications
Manage neuropathic pain/paresthesias
Anticonvulsants, antidepressants, capsaicin
Management of concomitant arterial insufficiency
Antibiotic therapy
Cultures of neuropathic ulcers average 4–5 different microbes
Most commonly group A Strep and Staph aureus
Radiological assessment
Fracture identification – Charcot foot
Presence of foreign bodies
Bone scan for osteomyelitis

90
Q

Surgical Interventions

A 
Debridement
Necrotic tissue
Osteomyelitis
Incision and drainage
Antimicrobial bead implantation
91
Q

Who would be indicated for surgical interventions:

A 
Surgery to address abnormal foot function or limited tissue perfusion
Joint arthroplasty
Tendon lengthening
Stabilization of Charcot deformities and reduction of abnormal biomechanics
Revascularization surgery
Amputation
Gangrene
Wagner grade 4 or 5 ulcers

Integumentary (18 decks)

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