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Fall 2024: Integumentary Systems > Exam 2: Week 10, Diabetic/Neuropathic Ulcers > Flashcards

Exam 2: Week 10, Diabetic/Neuropathic Ulcers Flashcards

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1
Q

Differentiate between type 1 and type 2 diabetes

A

Type 1: Developed at a young age

Type 2: Developed over time as a teen/adult (Much more common than type 1)

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2
Q

T or F? Individuals with type 2 diabetes are 2-4x more likely to have a heart attack or stroke, 5x more likely to get a foot ulcer/gangrene, and 17x more likely to have kidney disease, and is 8x more likely of going blind (most common cause of blindness)

A

True

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3
Q

Why are diabetic ulcers the hardest wounds to heal?

A

Because diabetes affects small arteries (capillaries) and the patient is sometimes unable to feel it

(Note: Arterial affects larger arteries, diabetic affects smaller arteries)

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4
Q

List some facts about diabetes

A
  • 1/4 of people are unaware that they have the disease
  • 4% higher mortality rate than those withiut diabetes
  • 8% of patients with type II DM have PVD as well
  • 50% will have contralateral ulcer within 18 months
  • 50% will have second amputation within 3-5 years
  • 70% of all amputations are due to DM
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5
Q

List the blood glucose guidelines for patients with diabetes

A

In General:
- 80-120 mg/dL before meals or when waking up
- 100-140 mg/dL at bedtime

(Note: people with DM may have >200 mg/dL after eating a meal)

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6
Q

List the hemoglobin (HgB) levels of a normal patient, a pre-diabetic patient, and a diabetic patient

A

Normal: <5.7%
Prediabetes: 5.7-6.4%
Diabetes: >6.5%

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7
Q

What affects does hyperglycemia have on the body?

A
  • Changes RBCs, platelets, and capillaries
  • Alters blood flows (micro-circulation)
  • Increases microvascular pressure
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8
Q

Describe neuropathic ulcers

A
  • Occurs as a result of nerve damage (neuropathy)
  • Plantar aspect of the foot
  • May occur under calluses
  • May occur in places where pressure and friction are present when wearing inappropriate footwear
  • Pain is usually absent/minimal
  • Little to no drainage
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9
Q

T or F? Forefoot location accounts for the majority of all ulcers and heal faster than midfoot/heel ulcers, while charcot foot is most common near the midfoot

A

True

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10
Q

List the risk factor for vascular disease (PVD & accelerated atherosclerosis)

A

TcPO2/TCOM <30mmHg

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11
Q

List the risk factor for neuropathy

A

<5.07 monofilament

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12
Q

List the risk factor for abnormal foot function and inadequate footwear

A

Charcot, claw toes, hammer toes

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13
Q

List the risk factors for impaired healing and immune respone

A

Thickening of basement membrane (= less O2 delivery)

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14
Q

List some risk factors for neuropathic ulcers

A
  • Inadequate care/education
  • Poor vision
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15
Q

Which is more likely to cause a diabetic ulcer? Ischemia or neuropathy

A

Neuropathy

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16
Q

Describe neuropathy

A
  • Most common complication of diabetes
  • Affects 30-40% of type 2 and even more type 1
  • May be caused by neural ischemia and segmental demyelination
  • Symmetrical, distal
  • Increases risk of plantar ulceration >3.5 times
  • Affects sensory, motor, and autonomic systems
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17
Q

Why is it not uncommon to see an amputee develop an ulcer on the contralateral limb?

A

Because all the pressure is now on one limb rather than two

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18
Q

How can individuals with diabetes limit tissue damage?

A

Monitor/Regulate blood sugars

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19
Q

Where do venous, arterial, and neuropathic/diabetic ulcers form?

A

Venous: Lower limb
Arterial: Foot
Neuropathic/Diabetic: Foot

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20
Q

List the distribution of ulcers in the forefoot

A

Top of Big Toe: 8%
Top of Middle Toe: 8%
Bottom of Big Toe: 20%
Bottom of Mid Foot: 22%
Bottom of Middle Toe: 28%

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21
Q

Describe neuropathy

A
  • Most common complication of diabetes
  • Affects 30-40% of type 2 diabetics, and affects type 1 even more
  • May be caused by neural ischemia (not enough blood to brain), or segmental demyelination
  • Typically symmetrical and distal
  • Increased risk of plantar ulceration (3.5x risk) because the patient is unable to feel sensation
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22
Q

T or F? Diabetic ulcers have “callused” edges whereas arterial ulcers have “punched out” edges

A

True

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23
Q

List the 3 types of neuropathy

A

Sensory Neuropathy:
- Gradual/painless

Motor Neuropathy:
- Leads to muscular atrophy (which increases plantar pressure)
- If patient controls his/her blood sugar, this patient should not get motor neuropathy

Autonomic Neuropathy:
- Sweat, callus, change in blood flow

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24
Q

Describe Sensory Neuropathy

A
  • 50% of patients are unaware they have lost protective sensation
  • Parasthesias (burning pain, tingling, aching)
  • If patient is unable to feel a 5.07 monofilament test, patient is at risk for ulceration
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25
Describe Motor Neuropathy
- Leads to paralysis/weakness of foot intrinsic muscles as a result of poor blood sugar control - Decreased foot stability (especially during "stance phase") - Leads to deformities (hallux valgus, claw toe, high arch) - Muscle atrophy increases pressure and shear forces to the foot
26
Describe Autonomic Neuropathy
- Dry, cracked skin due to increased ability to sweat - Increased risk of callus formation - Arteriovenous shunting leads to decreased perfusion (which decreases ability to heal/repair self) - Uncontrolled vasodilation leads to osteopenia (can lead to charcot foot developing)
27
List the foot deformities
- PF contracture - Varus/valgus - Charcot foot - Toe deformities - Bunion - Calluses
28
What is charcot foot?
"Rocker bottom" foot as a result of neuropathy that impairs the nerves and causes the bones to abnormally form
29
Describe Diabetic Neuropathic Osteo-arthropathy (DNO)
Inflammatory response - Characterized by foot edema, erythema, increases temperature Bone and Articular destruction occurs - Leads to multi-joint dislocations and fracture (charcot foot) Two theories regarding the cause of this - Neurovascular theory: Uncontrolled vasodilation - Neurotramatic theory: Patient is unable to feel sensation (which leads to more damage)
30
T or F? Claw toe deformity is caused by motor neuropathy, muscle atrophy, imbalance of muscles
True
31
List one cause of ischemic necrosis?
- Narrow shoes - 2-3 psi buildup over a long period
32
List one cause of mechanical disruption
- Heat/chemicals or a foreign object - High pressure could change immediate changes
33
List one cause of Inflammatory disruption
- Repetitive moderate pressures (40-60 psi) - Leads to callus/ulcer
34
List one cause of osteomyelitis
- Moderate force when infection is present (walking) - Infection pushed into bone
35
T or F? Poor glycemic control is associated with increased risk of long term complications (Can be improved with glycemic control)
True
36
T or F? Diabetes is the leading cause of retinopathy, glaucoma, cataracts
True
37
Which tests and measures are used for diabetic ulcers?
Sensory Tests - Monofilament testing (gold standard) - Vibration testing (tuning fork) - Pain assessment (0-10) - Proprioceptive assessment - Temperature (hot/cold) Motor Tests - MMT - ROM Autonomic Tests - Skin check - Hair/nail check - Can also use circulation tests (ABI, Rubor, Pulses, Pallor) Footwear Assessment - Tracing the foot Balance Assessment - Single leg or double leg - Eyes open or closed Gait Assessment
38
T or F? Sensory neuropathy is the leading cause of neuropathic ulcers
True
39
T or F? Always start with a 5.07 for monofilament testing
True
40
List the grams produced by each monofilament (4.17, 5.07, 6.10). Explain the interpretation of each (assuming patient is unable to feel)
4.17 - Grams produced: 1g - Interpretation: Decreased sensation 5.07 - Grams produced: 10g - Interpretation: Lots of protective sensation 6.10 - Grams produced: 75 - Interpretation: Absent sensation
41
List the indications for ABI test on patients with neuropathic ulcerations
- Patients with plantar foot ulcerations - Decreased/absent pulses - Signs and symptoms of AI - History of PVD - History of coronary artery disease
42
List the indications for a capillary refill test on patients with neuropathic ulcerations
- Ulcer on toe - Abnormal ABI - Signs and symptoms of AI
43
List the indications for a sensory integrity assessment on patients with neuropathic ulcerations
- All neuropathic ulcerations - Patients with diabetes - Patients with plantar foot ulcerations - Patients with neurological injuries
44
Which scale is used to classify a diabetic ulcer?
Wagner Scale
45
How can you identify a neuropathic ulcer?
Pain: - Absent or significantly decreased Position: - Plantar aspect of the foot (spots with lots of pressure) Wound Presentation: - Round, punched out lesion - Callus rim - Little to no drainage (very dry) - Necrotic base is uncommon Peri Wound: - Dry, cracked skin with callus Pulse: - Normal Temperature: - Normal to increased
46
Differentiate between a "good" and "poor" neuropathic prognosis ulcer prognosis
"Good" Prognosis: - Smaller, superficial ulcer (Wagner grade 1) - Present for <2 months - Ulcer is decreasing in size within the first 4 weeks of treatment "Poor" Prognosis: - Larger size ulcer (Wagner grade 3) - Ulcer does not decrease size by 20-50% within the first month of treatment Note: Average healing time is 12-14 weeks (can vary greatly)
47
T or F? Patients with neuropathic ulcers may not show signs of infection due to decreased inflammatory response/PVD
True
48
T or F? If no improvement of a neuropathic ulcer is present, this patient should be referred to an MD
True
49
T or F? Osteomyelitis is usually treated surgically
True
50
List the signs of hyperglycemia (high blood sugar)
- Fatigue - Thirst - Fruity breath - Increased urination - Blurred vision - Dry mouth - Confusion - Shortness of breath
51
List the signs of hypoglycemia (low blood sugar)
- Confusion - Irritability - Diaphoresis (excessive sweating) - Light headedness
52
List the ways to debride a DM/Neuropathic ulcer with slough and dead tissue
- Autolytic - Monofilament - Enzymatic - Pulse lavage (can also clean biofilms) - Biological Do not use these techniques to debride a callus, use sharp
53
How should you remove a callus/necrotic tissue using sharp debridement?
- Begin in the middle of the ulcer then move out (if the patient does not have PAD) - Make sure that when you are finished, it is level with the epithelial surface - Should be done weekly
54
Is it ok to treat a diabetic/neuropathic patient if he/she has impaired bloodflow?
No
55
When should you utilize modalities on a diabetic/neuropathic wound?
If the wound has not reduced in size by 50% after 4 weeks
56
Which biophysical agents (modalities) can be used on diabetic/neuropathic ulcers?
- NPWT (if the wound is not dry) - Ultrasound (check skin sensation + only use non thermal) - Estim (check sensation) - Laser
57
How should you care for dry feet?
- Can use petroleum to moisturize calluses - Do not apply moisture between the toes
58
T or F? Topical growth factors and collagen can be used if the diabetic ulcer is not infected
True
59
T or F? A patient with a diabetic ulcer should ideally be non weight bearing which means this patient should not use a cane
True (Note: If patient cannot do non weight bearing, have them partially weight bear with the entire foot on the ground.... greater surface area means less pressure on localized ulcer)
60
T or F? Modified short leg casts should only be used for grade 1 and 2 ulcers
True
61
List the contraindications for total contact casts on patients with diabetic/neuropathic ulcers
- Osteomyelitis - Gangrene - Fluctuating edema (edema must be controlled before use) - Infection - ABI <.5
62
Who is indicated for a padded ankle foot orthotic?
Low risk patients
63
T or F? Leather shoes have lots of breathing room and "mold to the foot"
True
64
How would you educate someone with a diabetic ulcer about shoe recommendations?
- Shoe should be 1/2 inch longer than big toe - Heels should not be more than an inch off the ground - Shoe should be made of soft, moldable leather
65
How should you educate a patient who wants to manage their diabetes and reduce the risk of getting an ulcer?
- Encourage exercise - Maintain proper diet - Ensure proper footwear - Express how important it is to off load and non weight bear - Tell them about how smoking and vascular complications can impact wound healing - DO NOT go barefoot and ONLY use white socks without dyes
66
67
T or F? ROM, aerobic exercise, and balance activities should be done by the patient after the ulcer has healed
True
68
What is considered "normal" blood sugar for a diabetic
- 80-120 mg/dL before meals or when waking up - 100-140 mg/dL at bedtime
69
What is the average healing time for a diabetic/neuropathic ulcer
12-14 weeks

Fall 2024: Integumentary Systems (11 decks)

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