Chronic Wounds: Palliative Management for the Frail Population—PART II
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However, the problem with testing sensation with a pin prick, cotton gauze, or tuning fork is that these tests cannot be standardized and, therefore, results will vary among different users. Standardized tests used to measure neuropathy include testing vibration sensation and measuring touch sensation using a monofilament. The limitation of all these tests that measure pain, touch, or vibration sensation is that they depend upon the patient’s ability to communicate his or her response to the test’s measure of sensory acuity. For the frail elderly patient, measurement of neuropathy may be impractical. In these cases, determination of neuropathic origin for a chronic wound will depend heavily on physical assessment and medical history, particularly serial blood glucose levels, hemoglobin, and A1C (glycohemoglobin).
Physical appearance. A typical neuropathic ulcer is found on the plantar surface of the diabetic foot. Patients with sensory loss neuropathy are unaware of any potential pressure they are causing to the bottom surfaces of their feet. The usual initiating factor for breakdown is injury from excessive repetitive pressure on a specific area of the foot.53–55
Among frail elderly adults, neuropathic or diabetic ulcers may be seen on the heels, particularly in those patients who either occasionally use wheelchairs to facilitate efficient movement or are wheelchair bound. These ulcers may also occur when therapeutic footwear or splints are utilized.
Examination of the feet will also reveal variations in shape that may be responsible for exerting excessive pressure on specific areas of the foot. These pressure areas can initiate skin breakdown. Sometimes, the foot shape abnormality is part of the diabetic neuropathy or other disease processes. Abnormalities include clawed toes, rocker bottoms, and abnormal toe nails. Clawed toes occur as a result of imbalance of the muscles in the feet due to diabetic neuropathy. This increases pressure at the tip or apex of the toes. In the presence of neuropathy, these sites become ulcer prone. Rocker-bottom deformity occurs due to Charcot’s joint, which is a complication of diabetic neuropathy. Toe nails can become infected, thickened, and deformed.
Comorbidities. Wounds located on the lower extremities of patients with diabetes diagnosed with some form of neuropathy must be assessed to determine contributing factors. It is imperative that the role of mechanical forces, potential circulatory diseases, and type of neuropathy be distinguished in order to establish the basis of treatment. As reviewed above, controlling the underlying disease processes and/or mechanical forces, when possible, can begin only after a thorough assessment is completed.
Diabetic ulcers must be evaluated to determine if there are any circulatory deficits that may have contributed to the onset of the breakdown. Physical examination of the feet will also yield clues as to the circulatory condition of the lower extremities. Feet that appear purplish in color and feel cold may have impaired circulation. If pulses in the foot can be clearly felt, the risk of foot ulceration due to vascular disease is small. Alternatively, if a person has claudication or rest pain (especially the latter), there is sufficient peripheral vascular disease to consider skin breakdown to be associated with that disease.
When the foot pulses are very weak or not palpable, then it is necessary to carry out noninvasive vascular tests to assess the risk. This is done by measuring the ABI. A simple hand-held Doppler machine is required for this test. The test requires a determination of the brachial artery blood pressure, which is compared to ankle pressure. For example, a patient with a brachial pressure of 120mmHg and an ankle pressure of 132mmHg has an ABI of 1.1 (132/120 = 1.1).
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