Etiology - University of Missouri



|Part A |

|a.1 |Atherosclerosis, arteriosclerosis, ischemia, |Venous hypertension |Poor sensation impedes perception of trauma, |Prolonged, unrelieved skin pressure |

|Predisposing factors / |incomplete healing from a lesion |Unrelieved high pressure in perforating veins |lesion, shear, |> 32 mm Hg, exceeding capillary pressure, |

|cause | |(which results in back-leakage from deep to | |resulting in hypoxemia, ischemia. |

| |Chronic Occlusion: |superficial veins). |High foot pressure: intrinsic via: Mechanical | |

|(likely Comorbidities) |Thromboangiitis Obliterans (smoking) |Incompetent valves; venous reflux (proximal to |changes / deformities: Hammer Toes, bunions, |PRESSURE & SHEAR |

| |Arteriosclerosis Obliterans |distal) |Charcot, |Friction |

| | |Varicose veins (also called venous dilatation or|1st Met Head common site | |

| |Acute Occlusion: |dilation) | |Incontinence / moisture (maceration) |

| |Thrombus / embolism | |Extrinsic: poorly fitting shoe |Poor nutrition and hydration |

| | |DVT / obstruction | |Poorly fitting orthosis |

| |Vasospasm: Raynauds | |Hyperglycemia causes endothelial damage of small|Abnormal positioning during surgery |

| | |* Impaired calf muscle pump |vessels, impairing circulation, leading to |Muscle atrophy results in less padding and |

| | | |ischemia PVD and neuropathy. |protection |

| | |Extravasation of proteins (RBCs and | |Prolonged corticosteroid use |

| | |macromolecules) begins inflammatory process; |Autonomic neuropathy: decreased stim of |Hypertonicity, Contractures |

| | |capillaries do not diffuse O2 secondary to |sebaceous glands, so dry cracked skin, which | |

| | |fibrin rings |increases infection risk | |

| | | | | |

| | | |Altered response to infection – decreased | |

| | | |leukocyte function | |

|a.2 |Toes, toe tips, interdigital spaces, dorsum of |Between knee and ankle (poor venous circulation |Foot: plantar aspect, met heads, great toe |Bony prominences: |

|Location |foot, areas of friction from footwear, bony |in that location) | |heel, sacrum, ischial tuberosities, elbow, |

| |prominences |esp. proximal to (medial) malleolus. |Deformities (diabetes) predispose to friction, |occiput, scapulae |

| | | |e.g. hammer toe, claw toe | |

|a.3 Appearance |Punched out, sharply defined border, steep sides.|Shallow depth. |Punched out, sharply defined border, steep |Crater-like, cone shaped. |

| |Wound bed: black dry eschar, poor granulation |Border is irregular, shaggy |sides. |Can be deep. |

|Wound bed |Skin: trophic changes, cool, pale, hair absent on|Wound bed: yellow fibrinous slough |Hypertrophic callus (glycosylation of keratin |Often tunneling, undermining |

|Exudate |toes |Warm, Indurated (hardened) skin |protein) | |

|Margins |Painful |Brawny discoloration due to past hemosiderin |Skin: trophic changes, cool, hair absent on |Stages 1-4, & Deep Tissue Injury (DTI) |

|Periwound | |deposit (RBC stain) |toes; dry, cracked skin – fissures, brittle | |

|Pain |Gangrene: black tissue with distinct line of |Bilateral Edema |nails (autonomic neuropathy) |Wound size may increase before it gets smaller. |

| |demarcation |Moderate to heavy exudates |Wound bed: eschar, poor granulation | |

| | |Mild to moderate pain |Insensate = no pain | |

| | |Varicose veins | | |

| | |Periwound eczematous, vesicles, blebs, stasis | | |

| | |dermatitis, periwound tenderness | | |

|a.4 |Ability to restore blood flow to area, ie, |Must manage edema to heal! |Effective diabetic blood sugar mgmt. |Prevention of Pressure, shear, friction |

|Prognosis |collateral circulation via claudication exercise | | | |

| |regimen. |Co-morbid CHF, obesity? |Skin inspection |Increase mobility |

|Probe to bone? 90% | | | | |

|osteomyelitis risk |Stop smoking |Risk of DVT, PE |Control HTN |Nutrition (protein) / Hydration |

| | | | | |

| |Control HTN | | | |

|a.5 |X-ray, CT, MRI to r/o osteomyelitis and need for |Anticoagulant meds if appropriate |Control hyperglycemia |Restore hydration. |

|Medical, |possible amputation | | |Good nutrition: |

|Surgical Mgmt. | |Ligation of incompetent communicating veins |X-ray, CT, MRI to r/o osteomyelitis and need for|adequate protein |

| |Arteriogram: resting leg pain suggests occlusion | |possible amputation |Vit A 25,000 |

|Fever: Antibiotics |at femoral popliteal, or lower arteries. May |Saphenofemoral bypass | |Vit C 500 |

|Diet: high protein |need angioplasty, stents | |Arterial bypass: femoral, popliteal or lower |Zn 50 |

|(albumin level) | |Valvuloplasty | | |

| |Endarterectomy | | |Full or split thickness skin graft or flap |

| | | | | |

| |Meds: Vasodilators | | | |

|Part B |

|b.1 |Claudication time (if present) |Circumferential measurement |Sensation testing w/ Semmes Weinstein |Non-blanching erythema (when you press with your|

|PT Tests & Measures |Rubor of Dependency: > 30 seconds to redden in | |monofilaments, 10gm (5.07) indicates protective|finger and take it away it stays red) indicates |

| |dependent position |Edema reduces somewhat with elevation |sensation. |a Stage 1 injury. |

|(Arterial & venous |Venous filling time: > 10-15 seconds for the | | |Redness, wamth |

|conditions may co-exist)|arterial circulation to refill the superficial |R/O DVT: |Vascular studies | |

| |veins in dependent position (must have intact |Well’s Clinical Decision Rule | |Pressure Inury Risk Assessment Scales: Braden, |

| |venous valves) |Autar DVT risk assessment scale |Wagner Classification |Norton, Gosnell |

| |Capillary refill time >3 sec. Press pads of | |0 intact skin | |

| |toes, or soles of feet. |Venous filling time: nearly immediate |1 superficial ulcer |NPUAP Classification: Stages I – IV |

| |ABI < .8 , < .5 = severe | |2 deep ulcer |Pressure Sore Status Scale, Sussman Tool |

| | | |3 deep, infected ulcer | |

| |Auscultation w/ bruits | |4 partial foot gangrene |Hypertonicity |

| |Arterial Flow Doppler (if pulses not palpable), | |5 full foot gangrene |Contractures |

|b.2 |Claudication exercise regimen |Compression garment: [when ABI > .8 ] |Ambulation Aid when lesion is on plantar |Turning schedule q 2 hours |

|Treatment: | |Semi rigid: Unna’s boot, Circ Aid, |surfaces to decrease WB. | |

|Positioning, |Ambulation Aid when lesion is on plantar surfaces|Elastic: long stretch bandage (“Ace”), short | |Weight shift q 15 min in WC. |

|Modalities, |to decrease WB. |stretch bandage, multi-layer compression (long |Modified footwear to relieve plantar pressure |WC push ups |

|Assistive Devices | |+ short stretch). |zones in wt bearing: |WC cushion modifications |

|Exercise |Bed Rest (if ABI is very low) and PROM during |Wear compression garment during waking hours |plastizote insert to disperse pressure, | |

|Other |early healing stage to avoid excessive muscle |(not at night, when supine) |cut outs for pressure zones, | |

| |activity that would shunt blood away from the | |metatarsal bar/cookie inside shoe, |Proper transfer techniques to avoid shear |

|E-Stim - chronic |skin and extremities. |Elevate when at rest |rocker bottom to decr. toe-off pressures, |forces! |

|Warm up –chronic |Reverse Trendelenburg (LE dependent position), |Ankle pumps, standing calf raises, standing toe |adequate toe box | |

| |HOB elevated 5-7d |curls, resisted ankle PF | |Never position in full sidelying |

| | | | | |

| |Limb protection |Deep Breathing: inhalation creates negative |Total Contact Cast (if not infected) |Air flow mattresses |

| | |intrathoracic pressure, which helps empty out |Posterior walking splint (bivalve) | |

| |Vacuum Assisted Closure |the vena cavae (increasing venous circulation) | |Podus Boot (suspends heel) |

| | | |Vacuum Assisted Closure | |

| |Petroleum jelly for dry skin (avoid alcohol based| | |Vacuum Assisted Closure |

| |lotions) | |Educ: foot inspection, skin and nail care | |

|b.3 |Cardiovascular disease is contraindication for |Avoid dependent hydrotherapy |If WP, cooler temp d/t compromised sensation |PLWS 4 – 15 psi, effective for cleansing |

|Wound |immersion hydro (impaired heat elimination) |Irrigation, PLWS 4 – 15 psi |Irrigation, PLWS 4 – 15 psi (lower end) |tunneling |

|Cleansing |Irrigation, PLWS 4 – 15 psi |Coordinate w/ pain meds | |VAC |

| |Coordinate w/ pain meds | | | |

|b.4 |Sharps (and hydro) contraindicated for dry |Mechanical debridement with gauze |Sharps: total excision accelerates healing, but |Mechanical , Sharps |

|Debridement Methods, |gangrene d/t poor circulation, best to let the |Sharps |caution with lack of protective sensation / pain| |

|Precautions |eschar separate on its own, ie, the eschar is a |Autolytic (semipermeable film is not too heavily|response |Don’t debride heel wound! (serves as bio |

| |“self - bio occlusive dressing” |exudating) | |occlusive dressing) |

| | |Manage exudate |Autolytic; Enzymatic (requires prescription) to | |

| |Anti coag therapy contraindicates sharp |Anti coagulant therapy contraindicates sharp |soften dry hard eschar | |

| |Autolytic (semipermeable film if it is moist | | | |

| |enough) | | | |

| |Enzymatic (requires prescription) to soften dry,| | | |

| |hard eschar | | | |

|b.5 |Goal is to moisten: |Control Exudate: |Maintain moist environment: |Packing ribbon/tape for cavity |

|Dressings typically | |Moderate | |Iodoform ribbon (briefly if infected) |

|required |Hydrogel: Visilon |Hydrocolloid: Duoderm |Hydrogel: Visilon |Hyrdrogel ribbon |

|(function served) | |Heavy | | |

| |Hydrocolloid: Duoderm |Alginates: Algi Derm |Hydrocolloid: Duoderm |Hydrocolloid: Duoderm |

| | |Hydrofiber: Aquacell | | |

| | |Hydrophilic foam: Tielle | | |

| | | | | |

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