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Gerontology Mod12
Integumentary Consideration and Pharmacology Implications
| 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 |
Created by:
jpwittman
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