Week #7: Neuropathic + Pressure

New Starling’s

Hydrostatic pressure causes filtration, all fluid out into ECM absorbed by lymphatics (100% arteries → 80-90% veins and 10-20% lymphatics)

Most common cause of foot ulcer?

Diabetes

DFU caused by what?

Neuropathy and unchecked pressure

Factors of trineuropathy?

Decreased sensation, loss of intrinsic muscles, decreased sweat/oil production

What migrates which increased pressure on met heads?

Fat pad

What is charcot foot?

• S/s

• Tx

Joint collapse, bone destruction, foot deformity

• Warmth, red/swollen, (dropped arch)

• Casting

Neuropathic ulcer presentation

Pain, 5.07 monofilament, blood flow varies, round/punched out, calloused/dry periwound, underlying tissues exposed, foot deformity, thickened toenails, absent hair

Most common location

3rd metatarsal

Wagner scale

0- intact skin

1- superficial ulcer

2- ulcer into tendon, bone, capsule

3- deep ulcer with osteomyelitis/abscess

4- gangrene of toes/forefoot

5- midfoot/hindfoot gangrene

Dry vs wet gangrene

Dry: mummified

Wet: swelling + odor (active infection), can see some red in there, moist

Which gangrene is a medical emergency?

Wet

Tx of neuropathic ulcer?

Referral, debridement, dressing (reduce bacteria, avoid occlusives, address hydration), off loading, home program, education on skin care/callus/foot inspection

Infection presentation in diabetes?

Decreased local s/s, immunocompromised, careful with occlusive dressings

• Elevated BS, pain in neuropathic foot

Fasting BS range

Average A1C

125+ diabetes, under 100 mg/dL normal

6.5% +, less than 5.7 normal

Force reduction concepts

Redistribute forces, immobilize ankle (shearing from rear→forefoot), offload the foot onto the calf

Gait modifications?

Reduce cadence, reduce stride length

Footwear?

Orthotics, rigid shoe, adhesive felt foam pad, wedge shoes, punch out shoes, removable boots, total contact casting

Gold standard for offloading?

TCC

Pressure injuries can happen in - - and are result of - and -

many different ways, pressure + shear

Pressure → - - → - - → - -

Vascular disruption → edema → tissue breakdown

Friction vs shear

F: Surface rubbing of skin against another object

S: Skin stays while deep tissue moves

Stages of Pressure Ulcers

1- Non-blanchable erythema of intact skin

2- Partial thickness with exposed dermis

3- Full-thickness skin loss

4- Full-thickness skin and tissue loss

Unstageable- Obscured full-thickness skin and tissue loss

Deep Tissue Pressure Injury?

Persistent, non-blanchable deep red/maroon/purple discoloration

Once healed, the stage is - - - -

Same as day diagnosed

Risk factors?

Immobility, insensate, poor nutrition

Main risk assessment tool?

Braden (6-23, low is bad)

Tech diagnostic strategies?

IR thermography, US, Subepidermal moisture readings

Recumbent: HOB less than -, Sidelying -, heels - -

Seated: knees - - hips, buttocks - - -, feet - -

30 degrees, 30, off bed

Level with, back in chair, in contact

_ fabrics and _ _ good for friction reduction

Silk, “glide wear”

_ will help with pressure redistribution, protects against shear, and absorption

Foam

Advanced tech for pressure?

Leaf monitor

_ patients results in increased risk for shear/friction

Diaphoretic

Immersion and envelopment of mattress - -

Can also use - - for temporary offloading

Microclimate managed via what?

Mattress for pulmonary hygiene but not pressure?

Disperses pressure

Alternating Pressure

Moisture/heat can pass through some surfaces

Continuous lateral rotation therapy