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Gerontology Mod12

Integumentary Consideration and Pharmacology Implications

What is the most common cause of leg ulcers? Chronic venous insufficiency (CVI) Accounts for 81% of cases
Predisposing factors for venous ulcers (5) Venous HTN Valvular incompetence Impaired calf muscle pump function Obesity Hx of DVT
Ulceration occurs when venous hypertension is __________ > 90 mmHg
What 4 factors result in breakdown in tissue health due to venous stasis. Stale blood pools in LE Waste products are not removed Oxygen is low Toxic effects of accumulating metabolites
What is the location of typical venous ulcers? Medial aspect of the distal 1/3 of LE Posterior medial malleolus Depth is usually shallow
Common appearance of wound bed for venous ulcers (6) Firm edema Beefy red or reddish-brown discoloration Wound shape tends to be large Margins often irregular Calcification in wound base is common Frequently moderate to heavy exudate
Post-Thrombotic Syndrome (PTS) occurs in? Develops in 1/2 of all patients who experience LE DVT
4 symptoms of PTS Chronic leg pain Swelling Redness Ulcers
Classification of Venous Disorders - CEAP (Clinical signs, Etiologic classification, Anatomic distribution, Physiologic dysfunction tool) C0 = no visible or palpable signs C1 = reticular veins (dilated blue and green veins beneath the skin surface) C2 = varicose veins C3 = edema C4 = a) pigmentation and eczema b) atrophy blanche C5 = healed venous ulcer C6 = active ulceration
Goals for PT Treatment of Venous Ulcers (4) Increase venous return Decrease venous stasis and associated edema Provide compression Address wound environment
When should occulsive compression dressings, bandages, wraps, and pneumatic sequential compression devices not be used with venous ulcers? (3) In the presence of clinical signs of infection, cellulitis, or severe arterial disease
What frequency of leg elevation will assist in reducing edema? 30 minutes 3 to 4 times daily and at night
When are elastic wraps contraindicated? (4) Arterial disease Severe infection Weeping dermatitis Friable tissue
What is an unna boot? Special gauze bandage, made of cotton with zinc oxide paste, eases skin irritation and maintains moisture
When should a pneumatic compression cuff be avoided? CHF Severe arterial disease
Compression therapy must reach what pressure to counteract tissue capillary pressure? 30-40 mmHg
Approximately what % of adults over 60 have diabetes? 23%
Diabetic ulcers of LE develop as a consequence of __________. (2) Neuropathy Arterial insufficiency Both
Risk factors for development of Diabetic Ulcers (5) Callus formation Trauma Neuropathy Peripheral vascular disease Hx of ulcer or amputation
What 2 factors can lead to rapid progression of diabetic foot ulcers before they are detected? Abnormal weight bearing Absence of sensory feedback
What are the most common locations of diabetic ulcers? 1st and 2nd MT heads Hallux
Autonomic neuropathy, that accompanies motor and sensation neuropathy, causes what changes that lead to ulceration. Decrease in skin hydration Inability to inhibit ateriovenous shunting mechanism - increases blood flow in diabetic foot Blood is shunted away from capillaries of the skin Atheroscleroisis, common in older adults, adds to arterial insufficiency
Wagner Wound Classification System (Classification of Diabetic Ulcers) Grade 0 = no open lesion may have deformity Grade 1 = superficial ulcer, partial or full thickness Grade 2 = extend to ligament or tendon Grade 3 = deep ulcer with abcess, osteomyelitis, infection Grade 4 = local gangrene Grade 5 = extensive gangrene
University of Texas Treatment-Based Diabetic Foot Classification System (Use) Categories are organized to provide recommendations for prevention and treatment of diabetic ulcerations Found to be a better predictor of clinical outcome
UTTBDF Classification System See Notes Mod12 top of page 7
Tests for distal LE arterial insufficiency using SBP (2 Tests, Ratios) Ankle-Brachial Index (ABI) Toe-Brachial Index (TBI) 1.0-1.2 Normal 0.8-1.0 Mild arterial disease Refer to vascular surgeon if: 0.5-0.8 With mixed venous and arterial disease <0.5 Arterial insufficiency
Where is SBP measured on the LE for ABI? ~2.5 cm proximal to ankle malleolar
How is the ratio for ABI calculated? Highest value of SBP taken in each arm is used Ankle SBP / Brachial SBP
Differential Diagnosis of LE Ulcers Venous vs Diabetic - Wound Depth Venus - shallow, base may be beefy red or covered in thin, yellow fibrin film Diabetic - deep, tunneling, base may be granulation tissue or necrosis
Differential Diagnosis of LE Ulcers Venous vs Diabetic - Margins Venus - Irregular Diabetic - Regular and round from pressure, callus may be present
Differential Diagnosis of LE Ulcers Venous vs Diabetic - Drainage Venus - moderate to heavy Diabetic - low to moderate, heavy drainage may suggest infection
Differential Diagnosis of LE Ulcers Venous vs Diabetic - Surrounding Skin Venus - hemosiderin stained, edematous, inverted champagne bottle shape Diabetic - may be thin and dry
Differential Diagnosis of LE Ulcers Venous vs Diabetic - Location Venus - "gaiter" area, medial aspect of LE, proximal to malleolus Diabetic - 1st & 2nd MT heads, hallux
Decubitus or Pressure Ulcer Destructive process of epithelial tissue-related ischemia, immobility, inactivity, and poor nutrition leading to development of pressure ulce3r
If pressure is greater than what at the skins surface is there a capillary closing pressure and eventual collapse producing subsequent ischemic damage manifesting as an ulcer? > 32 mmHg
What are the most frequent areas for pressure ulcers to occur? Sacrum Greater trochanters Ischial tuberosities Dorsal spine
Pressure Ulcer Score for Healing (PUSH) Reliable tool to track healing of stage II-IV pressure ulcers Used to document only progress of venous ulcers Scored 0-17 with lower scores indicating wound improvement Score of 0 means ulcer has closed
Pressure Sore Status Tool (PSST) aka Bates-Jensen Wound Assessment Tool Method for describing status of pressure ulcers Also measures the progress of venous insufficiency, diabetic, and arterial insufficiency ulcers Scores range from 13-65 with lower scores indicating wound improvement
Sessing Scale Not designed to measure healing instead predicts healing Describe granulation tissue, infection, necrosis, and eschar
Stages of Pressure Ulcers (this scale is pressure ulcer specific) Stage I: Non-blanchable erthema Stage II: Skin blisters or forms an open sore Stage III: Skin develops an open, sunken hole Stage IV: Extends through deep fascia into underlying anatomic structures Unstageable - base of ulcer is covered by dead skin
Length of time to reach wound care goals (Prevention, Deep wounds, Scar maturation) 2 weeks for prevention of wounds 16 weeks to treat a wound extending into fascia, muscle, or bone 2 years for scar maturation
Compression Bandages and Stockings - 16-18 mmHg Antiembolism stockings Used s/p surgery and in non-ambulatory pts with edema
Compression Bandages and Stockings - 25-35 mmHg Low-to-moderate compression Used for edema with or without ulcerations
Compression Bandages and Stockings - 30-40 mmHg Moderate compression Used if lower compression is insufficient to support edema or if ulcers are present for > 6 mo. and are failing to close
Compression Bandages and Stockings - 40-50 mmHg High compression Used for edema secondary to lymphedema
Compression Bandages and Stockings - above 40 mmHg Used for edema secondary to venous insufficiency and ambulatory patients with adequate calf muscle activity
Pharmacokinetics (definition) Describes how the body affects a specific drug after administration through absorption and distribution, and chemical changes of the drug in the body
Pharmacodynamics (definition) Response of the body to the effects of a drug at a given concentration
4 components of Pharmacokinetics 1) Absorption 2) Distribution 3) Metabolism 4) Excretion/Elimination
Absorption (definition) Rate at which a drug leaves the administration site
Absorption in older adults Medications taken orally are generally absorbed through the small intestine, the slowing of the GI tract may delay absorption in older individuals
Bioavailability (definition) Index measure of the amount of drug that reaches systemic circulation Used by manufacturers to determine the optimum drug dosage that produces the desired therapeutic effect
Distribution (definition) Extent of drug dispersion in systemic circulation to the site of action Most rely on the cardiovascular system to passively diffuse to the target site
Effects of aging on water and fat soluble medications Water soluble agents decrease distribution with age due to 10-25% reduction in total body water content Fat soluble drugs are more rapidly and extensively absorbed due to 20-40% increase of fat with age
Metabolism (definition) Biologic transformation of a drug into an inactive molecule, a more soluble compound, or a more potent metabolite
Effects of aging on metabolism of drugs Metabolism occurs primarily in the liver Hepatic blood flow decreases 40% Liver size declines 25-35%
Excretion (definition) Elimination of the drug from the body It is the pharmacokinetic parameter most affected by aging
Drug clearance (definition) Body's ability to eliminate a drug and is used to determine the steady state concentration for a given dose
Effects of aging on the excretion of drugs Kidney is the primary organ responsible for drug elimination Renal function declines by 35-50% with age Average renal clearance declines 50-75% with age
Effects of aging on the kidney 20-25% nephron loss Reduced tubular secretion Decreased renal blood flow 25-50% decline in glomular filtration rate Fibrosis
Aging and thermoregulation Decrease in basal temperature Blunted febrile response
Aging and blood pressure maintenance HTN Orthostasis
Aging and volemic maintenance Prone to dehydration
Aging and respiratory function Blunted sensitivity to increase CO2 levels
Aging and insulin Impaired insulin regulation Insulin resistance
Aging and bone homeostasis Bone absorption > bone formation
Effect of aging on receptors Reduction in number of receptors Reduction in receptor competency Decreased drug receptor affinity
Effect of aging on CNS neurons and receptors Decline in number of dopaminergic and cholinergic neurons and receptors with age Older adults require smaller doses of CNS agents
What percent of hospitalizations are due to drug-related problems? ~28%
Major diseases with underutilization of prescribed medications Osteoporosis and CAD 51% of pts are not taking Ca supplements 24% are on drug therapy 1 year post fx 40% with CAD take ASA 14% with CAD take beta-blockers
Polypharmacy (definition) Use of medication for which no clear indication exists
A third of polypharmacy involves self-mediation with what? Over the counter and herbal drugs
Conditions resulting from polypharmacy Arrhythmias Balance disturbances Cognitive changes GI issues Blood pressure changes (HTN or Hypo) Pseudoparkinsonism Rash Unexpected treatment failure
4 types of drug interaction 1) Drug - Drug 2) Drug - Food 3) Drug - Herbal 4) Drug - Diseases
What percent of patients taking more than 2 drugs have a potential for drug - drug interaction? Over 47% of patients taking more than 2 drugs
Risk of drug - drug interaction for 2, 7, 10 drugs? 2 = 13.2% 7 = 82% 10 = ~100%
Where do drug - food interactions occur? GI CV Cell receptor sites
The enzymes in the GI track that break down statins are blocked by what food/drink? Grapefruit juice
20% of adverse drug reactions are a result of what? Over-the-counter and herbal drugs
What is the typical time frame for adverse drug reactions? Within 4 days of drug initiation
Created by: jpwittman
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