WK3- Wound Etiology Part 2

Question 1

Define diabetes mellitus

Answer 1

the body’s inability to produce or use inuslin appropriately

Question 2

What are the different forms of diabetes mellitus ?

Answer 2

Typ1A: immune mediated destruction of beta cells of pancreas, called insulin dependent DM, IDDM

Type1B: idiopathic DM due to heredity

Type2: insulin resistance, people normally overweight, impaired insulin secretion.

Question 3

What is an A1C level and what are the normal, pre-diabetic ranges and diabetic ranges ?

Answer 3

A1C is the average blood glucose over 3 months

HgB A1C levels:
Normal: <5.7%, <100mg/dl glucose

Pre-Diabetes: 5.7-6.4, 100-125 mg/dl

Diabetes: > or equal to 6.5%, 125 mg/dl

Question 4

What are the common and general damage tissue damage theories of DM ?

Answer 4

1. changes RBCs, platelets, capillaries
2. alters blood flow
3. increases microvascular pressure

glycosylated proteins cause trauma, sorbitol accumulation as a result of glucose breakdown damages tissues.

Question 5

What is DM neuropathy and what are its causes ?

Answer 5

neuropathy is degradation of motor, sensory, and or autonomic innervation to distal appendages

theorized to be due to segmental demyelination of nervous cells, or blood being starved from nervous tissue

Question 6

What is diabetic neuropathic osteoarthropathy ?

Answer 6

inflammatory phase characterized by foot edema, erythema, and increased temp

bone and articular destruction ensue, progressing to dislocation and fracture

two theories for cause:
neurovascular theory and neurotraumatic theory

Question 7

What kind of foot deformities can a PT expect to see in those with DM ?

Answer 7

impaired ROM: ankle and great toe

other foot deformities such as pes equinus, hallux valgus

charcot foot: midfoot collapse at tarsal metatarsal junction.

Question 8

What are the general characteristics of neuropathic ulcers ?

Answer 8

typically no pain due to paresthesia

usually on plantar aspect of foot

round, punched out, minimal drainage

dry, cracked skin, callus, foot structural deformities

normal or accentuated pulses to atherosclerosis

normal or increased temp

Question 9

Describe the different grades of the wagner scale

Answer 9

0- no open lesions; may have deformity or cellulitis
1- superficial ulcer
2- deep ulcer to tendon, capsule or bone
3- deep ulcer with abscess, osteolyelitis, or joint sepsis
4- localized gangrene
5- gangrene of entire foot

Question 10

What are the indications for physician referral in patients with neuropathic ulcers ?

Answer 10

ABI less than .8, delayed capillary refill, abnormal doppler studies

Question 11

What is the average healing time for neuropathic ulcers ?

Answer 11

12-14 weeks

Question 12

What are the contraindications to a total contact cast ?

Answer 12

osteomyelitis, gangrene, fluctuating edema, active infection, ABI <.45

Question 13

True or False. Step to gait patterns are ineffective at decreasing plantar pressure

Answer 13

false

Question 14

When should you refer a patient with a neuropathic ulcer ?

Answer 14

ABI <.8
Failure to respond to treatment
Suspect infection
exposed bone or capsule

Question 15

What is the difference between primary and secondary lymphedema ?

Answer 15

primary: congenital malformation or impaired lymphatics
secondary: acquired lymphatic disorder

Question 16

What are the signs and symptoms of lymphedema ?

Answer 16

not painful, fibrosis, heaviness in affected limb, delayed wound healing, lymphorrea, increased risk of infection

Question 17

What are the stages of lymphedema according to the ISL staging system ?

Answer 17

0- subclinical, no edema, but impaired lymph transport
1- early onset, fluid build may subside with elevation; pitting edema present
2- elevation no longer helps, fibrosis present, frequent skin infections ( cellulitis)
3- skin thickening, hyperpigmentation, papillomas

Question 18

What are the three different kinds of burns ?

Answer 18

thermal, chemical, electrical

Question 19

What are the common descriptions of burns ?

Answer 19

superficial
superficial partial
deep superficial
full thickness
subdermal

Question 20

What are the 3 different zones of burns ?

Answer 20

zone of coagulation: central portion, irreparable damage, coagulation ischemia, necrosis
zone of stasis: area of cellular injury and compromised perfusion
zone of hyperemia: outer edges, minimal cellular injury

Question 21

What is the rule of 9s ?

Answer 21

a size of burn estimation tool where body segments are assigned a value of 9%

Question 22

Name five tissues, aside from the integument, that are adversely affected by diabetes.

Answer 22

Diabetes also adversely affects the eyes, kidneys,
blood vessels, immune system, and nerves.

Question 23

You are covering for a physical therapist who is on vacation. The assessment states that Patient Y has
a grade 2 neuropathic foot ulcer. What does this mean?

Answer 23

Patient Y’s ulcer is deep with exposed tendon,
capsule, or bone. A grade 2 ulcer would fit into
Integumentary Preferred Practice Pattern E.

Question 24

Give two reasons why it is important for patients with diabetes to apply moisturizing lotion to their feet.

Answer 24

Patients with diabetes have autonomic neuropathy,
which leads to dry, cracked skin and increased
callus formation. Skin cracks provide a means for
microbes to enter the body. Calluses cause localized
areas of pressure, which can lead to ulceration.
Moisturizing lotion can prevent anhydrous
skin and decrease callus formation.

Question 25

Your patient has a grade 3 neuropathic foot ulcer. You want to unload the ulcer to enhance healing.
State three intervention options.

Answer 25

A grade 3 ulcer is not appropriate for total contact
casting but may be unloaded by having the patient
use a padded ankle-foot orthosis, a walker and partial
weight-bearing gait pattern, or a wheelchair.

Question 26

You are called to the emergency room to examine a patient who spilled hydrochloric acid on his left
hand while conducting an experiment in chemistry class earlier that morning. The wound bed is
blistered and draining. The patient is able to detect light touch and pressure within the burned area.
When digital pressure is applied to the wound bed, the area blanches and capillary refill is rapid.
How would you classify the depth of this burn injury?

Answer 26

The wound appears to be a superficial partialthickness
burn injury. However, because chemical
burns may take 24–72 hours to fully develop, you
should reserve making a definitive diagnosis at
this time.

Question 27

Your 28-year-old patient sustained circumferential full-thickness burns to the right upper and lower
extremities after being trapped in his bedroom when his house caught on fire. Describe how the patient’s
injuries might affect the following areas and the rehabilitation consequences of these dysfunctions.
a. The cardiovascular system
b. The pulmonary system

Answer 27

The patient is at high risk for burn shock due to
the depth and size (27% TBSA) of the burn
wound injury. The clinician should monitor the
patient’s heart rate during therapy to ensure it
stays between 100 and 120 beats per minute to
avoid overstressing the patient’s system. Intravenous
lines should be monitored for signs of
compromise to ensure adequate fluid resuscitation.
Because the patient’s burns are circumferential,
there is a risk of compartment syndrome.
Therefore, the clinician should closely monitor
peripheral pulses. A Doppler ultrasound may be
needed. Any decline in status should be reported
to the physician immediately. The affected limbs
should be elevated to help reduce edema.

b. Because the patient has a history of a closed
space injury, there may be pulmonary involvement
from smoke inhalation. The clinician
should carefully monitor the patient for signs
of respiratory distress, such as dyspnea or stridor.
Any decline in status should be reported to
the physician immediately. To help minimize
any pulmonary damage, the clinician should
encourage aggressive pulmonary hygiene,
including deep breathing.

Question 28

Your patient is a 3-month-old infant who presents with superficial partial-thickness burns of bilateral
lower extremities. The burns extend circumferentially from 5 cm above the ankle distally to the
plantar aspect of his feet. The patient’s parent reports the burns were sustained while bathing.
a. Does the parent’s explanation of the wound etiology warrant further investigation?
b. In addition to the physician, should you report your findings to any other team members? Why?

Answer 28

a. Yes. The burns are suspicious as they may have
resulted from an intentional submersion in hot
water. In cases of accidental scald injuries during
bathing, the infant is more likely to present
with burns to the posterior trunk, buttocks,
and posterior lower extremities.
b. You should report your findings to a social
worker. In addition, you should follow any
state laws and facility policies regarding the
reporting of suspected abuse of a minor.

Question 29

Describe whether you think the following individuals are at low or high risk for developing lymphedema.
Provide your rationale.
a. A competitive female tennis player who had a single axillary lymph node removed from her dominant
arm with no radiation therapy painting an entire room.
b. A sedentary, overweight male who had a complete inguinal lymph node dissection followed by
radiation therapy hiking the Inca trail.

Answer 29

a. This scenario describes a low-risk individual
partaking in a low-force, high-repetition activity.
Taken in context, this individual has a low
risk for developing lymphedema.
b. This scenario describes a high-risk individual
partaking in a high-load, high-frequency task.
Taken in context, this individual has a significant
risk for developing lymphedema.

Question 30

List the anastomoses that can be used to move fluid from a congested left lower extremity in a
patient who had an inguinal node dissection and radiation.

Answer 30

The following anastamoses can be used to move
fluid from the left lower extremity to the uncongested
neighboring quadrants: the anterior inguino–
inguinal pathway, the posterior inguino–inguinal
pathway, and the left inguinal–axillary pathway.

Question 31

Describe LaPlace’s law.

Answer 31

LaPlace’s law is an equation used to determine the
amount of compression exerted by a compression
wrap.
=
(tension) (layers applied) (constant)/
(limb girth) (bandage width)