Ulcers

Question 1

WHat causes a pressure ulcer?

Answer 1

when skin over a bony prominence is injured by pressure which occludes the capillary blood flow, causing ischemia

typically sacrum, buttocks, heels, shoulders, hips, etc.

Question 2

What is a stage 1 pressure ulcer?

Answer 2

area of non-blanchable erythema

Question 3

What is a stage 2 ulcer?

Answer 3

an ulcer that looks like an unroofed blister with the dermis exposed

Question 4

What is a stage 3 ulcer?

Answer 4

subdermal tissue is exposed, with undermined edges - so the ulcer is probably bigger than it looks

Question 5

what is a stae 4 ulcer?

Answer 5

when bone or tendon is exposed

Question 6

WHen is an ulcer considered unstabeable?

Answer 6

when you can’t see the base due to eschar or exudate

Question 7

What are the three general, overlapping processes of wound healing?

Answer 7

1. inflamation
2. epithelialization

3 remodeling

Question 8

What do the fibroblasts form in wound healing?

Answer 8

they form granulation tissue, which is richly vascular

it provides a supportive base for the advancing epithelial tissue

Question 9

How are pressure wounds different from surgical sounds?

Answer 9

surgical wounds will develop a fibrin clot to protect the advancing epithelial tissue.

a pressure ulcer is not actue, the clot doesn’t form- it’s just a large gap between the edges.

this means healing will take longer and wound dressings are much more important.

Question 10

What does remodeling consist of?

Answer 10

scar formation and contraction

collagen secreted by fibroblasts is the primary ingredient

Question 11

What are some important steps to do before local wound treatment of an ulcer?

Answer 11

1. stage it well
2. check for signs of infection
3. figure out why it happened

Question 12

What are some potential underlying causes for the development of a pressure sore?

Answer 12

fracture

stroke

metabolic problem: hyponatremia, hyperosmolar, uremia

diabetes

medications: sedative, anticholinergic, steroid

Question 13

How can you manage tissue load over an ulcer?

Answer 13

you want to have “zero tolerance” for continued pressure ove rthe wound

you can use pressure relief mattresses or overlays

heal protectors aren’t effective

Question 14

Is bacterial infection a concern in ulcers?

Answer 14

Yes and no

basically all wounds are colonized, so surface cultures are worthless.

Cleansing and debridement are key

You can try a two-week trial of topical antibiotics, but when we’re really worried is when the infection reaches the bone

If it’s clear that they have advancing infection where there’s spreading erythema and fever, then use systemic antibiotics

Question 15

WHat nutritional aspects should be considered in ulcer treatment?

Answer 15

1. protein is key because they need to be in a catabolic state
2. healing requires extra callories - like 30-35 kcal/kg/day

Tube feeding is not helpful unfortunately

Vitamin supplementation not helpful

Question 16

What should local ulcer care entail?

Answer 16

1. debridement
2. cleasning - don’t use antispectics that may be cytotoxic - we want the fibroblasts to hang out!
3. Dressings (just be consistent with what you use)

Question 17

What is autolysis?

Answer 17

debridement that is done by the body basically:

the inflammatory phase of healing is able to handle small amounts of dead tissue and exudate through enzymatic and phagocytotic processes which are together referred to as autolysis.

Question 18

What are the 4 options for debridement?

Answer 18

1. autolytic
2. wet-to-dry
3. enzymatic (collagenases)
4. scalpel

Question 19

WHen there is a lower extremity ulcer and it’s not a pressure ulcer, what is the most likely cause?

What are the two other basic options?

Answer 19

venous insufficiency 80-90% of the time

Arterial Insufficiency

neurotrophic ulcers

Question 20

What are some associated symptoms you’ll see with a venous leg ulcer?

Answer 20

1. location over the medial malleolus
2. stasis dermatitis (hyperpigmentation - brown or purple)
3. Chronic edema that won’t diurese
4. edema is tender to palpation
5. Varicose veins may or may not be present

Question 21

WHat do venous ulcers tend to look like?

Answer 21

shallow and irregulaterly shaped

Question 22

What are the two venous systems in the leg? Where do balbes come in?

Answer 22

the deep system (high pressure) and the superficial system( low pressure)

in a healthy leg, the superficial system is protected from the high pressure system by valves in the deep veins and perforator connections (through which the superficial veins drain into the deep veins)

Question 23

What are three general factors leading to venous ulcers?

Answer 23

1. overload (in CHF or obesity)
2. Obstruction (clot or tumor)
3. Pump malfunction (neurodegeneration, injury or inactivity - sitting too long)

Question 24

Besides cleansing and debridement, what treatment goal is essential in venous ulcers?

Answer 24

control of the edema

you want to restore venous return by way of external compression of about 30-40 mm Hg at the ankle

Ted socks usually not good enough

Unna boot, compression hose, compression pumps

Question 25

WHat do arterial ulcers usually look like? WHere are they typically located?

Answer 25

they are well circumscribe "punched-out" ulcers - often multiple they occur in areas that are not well perfused - like the LATERAL malleolus, tibia, feet, and tips of toes usually surrounded by shiny hairless skin with absent pulses and claudication

Question 26

What other comorbid health problems are there with arterial ulcers?

Answer 26

hypertension smoking diabetes PVD myocardial infarction (this is what usually kills these people - or stroke) AAA claudication

Question 27

If there is a leg arterial ulcer, what artery usually has an arteriosclerotic obstruction?

Answer 27

the superficial femoral artery and/or its branches

Question 28

What is the simplext measure of blood flow into the leb?

Answer 28

The ankle-brachial index (ABI) It's the quotient of the systolic BP at the ankle dividd by the pressure at the brachial artery in the arm 1.0 or higher is normal less than 0.8 = claudication (ulcers can happen under this) less than 0.4 = rest pain

Question 29

People with low ABI and leg ischemia usualy die from what?

Answer 29

myocardial infarction and stroke leg ischemia is a strong indicator of cardiac and cerebral artery disease

Question 30

What is Buerger's DIsease Also known as thrombangiitis obliterans...

Answer 30

It occurs in smokers (often young) who have an unusual sensitivity to the basoactiv eeffects of nicotine, so they have impaired endothelium-dependent relaxation in the peripheral vasculatur (arteries and veins) they get thrombophlevitis and sores on their extremities

Question 31

How can you distinguish Buerger's Disease from arterial ulcers?

Answer 31

1. both venous and arterial involvment will happen in Buergers 2. Buerger's has more diffuse involvement of both upper and lower extremities 3. Do the Allen test

Question 32

How do you do the Allen test?

Answer 32

Occlude radial and ulnar arteries after making a fist to empty blood from the hand. Open hand and release pressure over the ulnar artery. Hand should refill with blood via ulnar artery, evidenced by return of pink color. ## Footnote Positive = persistent pallor.

Question 33

How is treatment for arterial ulcers different than that for venous ulcers?

Answer 33

external compression for arterial ulcers is BAD you also want to deal with smoking cessation, revascularization potential skin graft and potential amputation

Question 34

What happens in a neurotrophic ulcer?

Answer 34

These ulcers results form unrecognized, repetitive trauma due to a lack of sensation in the involved extremities - usually in diabetics or people with neuropathy. they're a sort of hybrid between arterial and pressure ulcers

Question 35

Where do neurotrophic ulcers usually occur?

Answer 35

on the plantar aspect of the foot or toes

Question 36

What happens to the feet in severe neuropathy?

Answer 36

Charcot foot this is the collapse of the ankle and foot structure due to neuropathy - the foot assumes a focker bottom appearance and ther eis usually a deformity at the ankle as well ulcers will often appear over the lateral plantar mid-foot and osteomyelitis is a frequent complication

Question 37

How does one screen for neuropathy?

Answer 37

yse the monofilament touch test on the bottoms of the feet to test for decrease sensitivity

Question 38

WHat are two additional treatment strategies for neurotrophic ulcers?

Answer 38

total contact cast recombinant platelet derived growth factor - becaplermin

Question 39

Why is good glucose control so important in the treatment of neurotrophic ulcers?

Answer 39

hyperglycemis inhibit macrophage and fibroblast function

Question 40

What are the 4 main tipoffs that you may be dealing with a cancerous ulcer?

Answer 40

1. unusual location and looks atypical 2. has nodular component 3. swelling of regional lymph nodes 4. doesn't appear to heal despite good treatment

Question 41

What will basal cell carcinoma uclers look like?

Answer 41

they'll have heaped up or rolled edges. often with perly modularity around the periphery (often with telangiectatic vessles overlying) they are usually on sun-exposed surfaces

Question 42

What will preempt a squamous cell skin cancer ulcer?

Answer 42

an actinic keratosis

Question 43

What is pyoderma gangrenosum? What does it look like?how does it progress?

Answer 43

It starts with a pustular-appearing lesion it grow rapidly with coious exudate and surrounding erythema, so it's often confused with a bacterial infection it gets blue or purplish discoloration around the periphery and a scalloped appearnce of the edges Associated with an inflammatory process like IBS, RA, leukemia, Crohn's, ulcerative colitis, etc. Treat with corticosteroids