Question | Answer |
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 |