Chronic Wounds: Palliative Management for the Frail Population—PART II
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The affected limb will have a waxy appearance, no hair, and the patient, if able to communicate, will report claudication pain.
Comorbidities. Patients that present with arterial ulcers will often have additional chronic illnesses that complicate the potential for healing. They include diabetes, hypertension, and a family history of arterial disease. Arterial ulcers can also present with varying degrees of neuropathy. Spinal cord injuries that resulted in either paraplegia or quadriplegia with associated disturbances to arterial blood flow predispose patients to arterial ulcers of the lower extremities.
Diabetic/neuropathic ulcers. Definition. Diabetic neuropathy refers to various types of nerve damage, a common sequelae of diabetes. Nerve damage is the etiologic basis for diabetic ulcers. Neuropathy leads to loss of protective sensation, setting the stage for skin breakdown. How the nerves are injured is not entirely clear, but research suggests that high blood glucose changes the metabolism of nerve cells and causes reduced blood flow to the nerve. In a study of diabetic patients with foot ulcers, 60 to 70 percent were related to neuropathy, 15 to 20 percent were related to peripheral vascular disease (PVD), and 15 to 20 percent related to PVD combined with neuropathy.48 Peripheral neuropathy is a major contributing factor in more than 90 percent of foot ulcers and, ultimately, amputation.49,50
There are different types of nerves and, therefore, different types of possible diabetic neuropathy. These can be grouped as sensory (ability to detect heat, cold, and pain sensation), motor (ability to contract muscles to control movement), and autonomic (ability to regulate heart rate and
The most common type of diabetic neuropathy affects the sensory nerves in the legs and is usually known as peripheral neuropathy. The motor and autonomic nerves can also be involved, which will adversely impact the patient’s mobility and control over normal bodily functions. Patients with neuropathy were found to have seven-fold increased risk of ulceration when compared with diabetic patients without this complication.51
Neuropathy can result in two sets of seemingly contradictory problems. The first is the loss of ability to feel pain and other sensations, which leads to neuropathic ulceration. The second problem is symptoms of pain, burning, a sensation of pins and needles, or numbness. These sensations cause varying degrees of discomfort and pain. Most patients with neuropathy have only one of these problems, while others can be affected by both.
While there are changes in microvascular function in the diabetic foot, neuropathic ulcers are the result of alterations in nerve cell transmissions that cause a loss or complete absence of sensitivity to pressure and pain. This observation is strengthened by the similarity found between foot ulcers in diabetic patients and those patients with Hansen’s disease where there is no vascular compromise, only sensory loss.52 The fact that foot ulceration does not occur among diabetic patients during enforced bed rest demonstrates the major role played by direct mechanical load in the development of neuropathic foot ulceration.52
Assessment. The first step in assessing a suspected diabetic/neuropathic ulcer is to confirm the presence of one or more types of neuropathy. There are many different methods of diagnosing and grading diabetic neuropathy. The most important aspect of grading diabetic neuropathy is the assessment of potential and degree of loss of sensation in the feet. Diabetic neuropathic ulcers are primarily a consequence of loss of protective sensation (LOPS), which is a significant change caused by neuropathy.49 Tests are conducted that determine if the patient can feel the pain of a pin prick, the touch of cotton gauze, or the vibration of a tuning fork.
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