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Wound Care > Exam 2: Chapter 5 & 6 > Flashcards

Exam 2: Chapter 5 & 6 Flashcards

1
Q

What are all of the basic wound characteristics to look for when assessing a wound (Let us not see miss deght)

A

location, shape, size, depth, edges, undermining/tunneling, necrotic tissue, exude, edema, surrounding skin tissue, induration, granulation, epithelialization, maceration, and hemorrhagic tissue

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2
Q

Important aspects of the location characteristics of a wound

A

Be very specific when taking notes.

Body diagrams are helpful and we can even draw the wound on a body diagram

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3
Q

Important aspects of the shape characteristics of a wound

A

The shape of the wound will change with healing. The shape also determines the size of a wound

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4
Q

Important aspects of size characteristics of a wound

A

Determine size by using LxW method (most common) or undermining technique. Using the same reference point improves the reliability since it difficult to determine where to measure the wound

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5
Q

Important aspects of the depth characteristics of a wound

A

Depth is hard to measure and is not very accurate, but measuring multiple parts of a wound is more accurate. It is hard to measure because all tissue heals at different rates

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6
Q

Important aspects of the edges characteristics of a wound

A

Note if its indistinct and diffuse, attached or not attached, rolled under and thickened, or hyperkeratosis

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7
Q

True or False:

Not attached wound edges give the appearance of depth because it is truly showing there is depth to the wound

A

False, it gives the appearance of depth but does not have depth

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8
Q

Why are rolled under and thickened wound edges bad news

A

If they continue to thicken or go through fibrosis then the edges are hard and healing is hard to progress

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9
Q

What is hyperkeratosis and what wound characteristic does it fall under?

A

It falls under wound edge characteristics and it is a callus tissue that can form around wound edges that make healing difficult to take place

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10
Q

Important aspects of undermining/tunneling characteristics of a wound

A

It represents the loss of tissue underneath the intact surface which means we aren’t seeing the extent of the damage

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11
Q

Important aspects of necrotic tissue characteristics of a wound

A

The amount that is present, the color, consistency, and adherence to wound bed

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12
Q

Which is less severe, slough or eschar?

A

slough

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13
Q

What can be defined as dead devitalized tissue

A

necrosis

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14
Q

What are the color characteristics of necrotic tissue and what are the two types of necrotic tissue

A

The color can be yellow, brown or black. The two types of necrotic tissue are slough and eschar.

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15
Q

What type of tissue is slough and eschar considered to be?

A

necrotic tissue

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16
Q

What are the two methods to measure necrotic tissue

A
  1. Clinical judgement using transparency/tracing

2. Liner measurements of length and width

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17
Q

Important aspects of exudate characteristics of a wound

A

Can be difficult to asses using moist wound healing dressings. Judging the amount is done by observing the wound itself or wound dressing

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18
Q

Important aspects of surrounding skin characteristics of a wound

A

Can be the first sign of further tissue damage, erythema may be present (halo of erythema) and check for blanchability

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19
Q

Important aspects of edema characteristics of a wound

A

edema slows healing, check if it is pitting or nonpitting, check the periwound tissue within 4cm of wound edge

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20
Q

What does induration mean

A

hardness

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21
Q

Important aspects of surrounding induration characteristics of a wound

A

indication of further pressure-induced tissue trauma, abnormal firmness with margins should be assessed within 4 cm of wound edge

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22
Q

When we check for maceration of a wound what should we look for

A

whiteness around a wound indicating there is too much moisture

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23
Q

When we check for hemorrhagic tissue, what should we look for

A

blue/red color that indication trauma from the wound

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24
Q

Important aspects of granulation characteristics of a wound

A

It is a marker of wound healing and signals proliferation phase of wound healing and eventual closure

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25
Q

What type of wound thickness does granulation only occur in

A

full thickness wounds

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26
Q

Important aspects of epithelialization characteristics of a wound

A

Process of epidermal resurfacing and appear as pink or red

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27
Q

What are the different types of tools to monitor wound healing

A
  1. Sussman wound healing tool (SWHT)
  2. Pressure Ulcer Scale for Healing (PUSH)
  3. Bates-Johnson Wound Assessment Tool (BWAT)
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28
Q

Which wonld healing tool describes changes in tissue status and size over time using the acute wound healing model

A

SWHT sussman wound healing tool

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29
Q

Is the SWHT qualitative or quantitative

A

qualitative

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30
Q

Which wound healing tool develops a biologically accurate and easy to use instrument to replace reverse staging

A

PUSH pressure ulcer scale for healing

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31
Q

Is the PUSH healing tool quantitative or qualitative

A

quantitative

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32
Q

Which wound healing tool evaluates 13 wound characteristics rating them with a numerical score from best to worst

A

BWAT Bates-Johnson wound assessment tool

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33
Q

What type of wounds is the BWAT recommended for use as a method of assessment and monitoring?

A

Pressure ulcers and other chronic wounds

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34
Q

True or False:

In regards to the BWAT scoring a lower number results in a more severe wound status

A

False, the higher the number the more severe a wound is

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35
Q

What three things should a physical examination include

A
  1. Inspection
  2. Palpation
  3. Special Diagnostic physical exam maneuvers`
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36
Q

One of the key aspects of physical examination is the inspection. What are some examples of what to look for during inspection

A

Look at the size of the limb and check for swelling and type of edema if present. Also check for color, texture, capillary refill on nailbeds, and hair on feet/toes for circulation.

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37
Q

One of the key aspects of physical examination is palpation. What are some examples of places to palpate

A

Skin, popliteal fossa, pulses, varicose veins, scars, and rashers

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38
Q

During palpation, what is the most important thing to palpate

A

area of pulses

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39
Q

What location and arteries for checking pulse were mention in Dr. Matheny’s Vascular Evaluation PowerPoint

A

Femoral artery, popliteal artery, dorsalis pedis, and posterior tibial artery

40
Q

Which arteries/pulses that were discussed in the Vascular Evaluation PowerPoint are the most distal?

A

Dorsalis Pedis and Posterior Tibial Arteries. Although the dorsalis pedis artery is technically a little more distal than posterior tibial artery

41
Q

During the history and physical examination, ____________ can distinguish the cause of the wound. As a PT, I need to be able to differentiate between ____ and ____ involvement. Make sure to consider claudication.

A

Symptomatology, venous and arterial

42
Q

In the comparison of arterial and venous insufficiencies, describe what an arterial wound looks like

A

Distal ulceration especially on toes, heels, and in between web spaces. May develop gangrene and severe joint loss

43
Q

In the comparison of arterial and venous insufficiencies, describe what an venous wound looks like

A

Shallow ulcers in the gaiter distribution of the foot and ankle, usually on the medial surface above the malleolus

44
Q

What does the term “gaiter” mean

A

The are of the leg from the knee to the ankle

45
Q

When it comes to vascular testing, there is an invasive method and a noninvasive method. Which method uses ultrasound?

A

noninvasive

46
Q

What is the most common noninvasive vascular testing technique?`

A

ultrasound

47
Q

When it comes to vascular testing, there is an invasive method and a noninvasive method. Which method uses contrast injection and data acquisition using radiographs

A

Invasive

48
Q

What are the most common invasive vascular testing techniques

A

contrast injection and data acquisition using radiographs

49
Q

What is the most common technique to measure ABI and what does it measure?

A

The technique is a noninvasive instrument called the continuous wave doppler and it determines the velocity and direction of blood flow

50
Q

True or False:

The continuous wave doppler gives a phasic flow patter representing four phases

A

False, it does have a phasic flow but there are only three phases

51
Q

What are the three phases of the continuous wave doppler

A
  1. forward flow during systole
  2. Reverse Flow in diastole
  3. Returns to forward
52
Q

What does an ABI compare?

A

Ankle pressure to the arm pressure

53
Q

Discuss how the ABI is taken

A

First assess the highest arm pressure and then place the BP cuff just above the ankle and obtain the systolic number with the Doppler. Observe the posterior tibial artery and dorsalis pedis artery. Ankle pressure is then divided by arm pressure

54
Q

If someone has an ABI of less than 0.5, what are the implications?

A

Refer to a vascular specialist because they have a severe arterial disease. Compression should not be used to treat

55
Q

If someone has an ABI from 0.5-0.8, what are the implications

A

Refer to a vascular specialist because of a moderate arterial disease. Intermittent claudicant present so don’t use compression to treat

56
Q

Is someone has an ABI from 0.8/9-1.00, what are the implications?

A

Mild peripheral arterial occlusive disease, can be treated with compression with caution

57
Q

ABI higher than 1.0-1.4, what are the implications

A

Refer to refer to a vascular specialist because calcified vessels are present

58
Q

What are segmental and digital plethysmography

A

Expansions of the ABI that utilize BP along the entire leg

59
Q

Where are pressures obtained from with segmental and distal plethysmography

A

high thigh, low thigh, below the knee, above the ankle

60
Q

What is an arterial and venous duplex

A

a combination of ultrasound and color flow doppler that indicates blockage if reversal of flow is present.

61
Q

What is the venous duplex scanning using to detect?

A

It detects any echogenic material such as thrombus

62
Q

What does transcutaneous oxygen measure and what are do the pressure amounts indicate?

A

It measures diffusion of oxygen from the capillary level to the skin level. Less than 20mmHg the wound/ulcer won’t heal. Measurements above 30mmHg indicate wound healing without difficulty and safe debridement can take place

63
Q

What is a Magnetic Resonance Angiography?

A

A cheaper, noninvasive technique that uses a non-nephrotoxic contrast to identify target vessels.

64
Q

What is a computed tomography angiography

A

A new technique that obtains multiple serial images enhance with contrast and reconstructed into 3D images. It is fast for the patient but a lot longer for the 3D image to appear

65
Q

What are the 6 types of venous imaging discussed in the Vascular Evaluation PowerPoint

A

Venous Pressure Measurements, photo plethysmography, light reflective rhenography, string gauge plethysmography, air photo plethysmography, and duplex ultrasound

66
Q

Which venous imaging records the true pressure that is seen in the veins while the patient ambulates

A

venous pressure measurements

67
Q

Which venous imaging measure the venous refill time

A

photo plethysmography

68
Q

Which venous imaging is more accurate than photo plethysmography because overall effect of external light and surface reflection have been reduced

A

Light reflective rhenography

69
Q

which venous imaging measures venous refill time and overall venous emptying

A

string gauge plethysmography

70
Q

Which venous imaging uses air cuffs volumetric changes in the leg to be quantified to measure venous reflux time

A

air photo plethysmography

71
Q

which venous imaging is a continuous doppler ultrasound along with color flow

A

duplex ultrasound

72
Q

Which tool used to monitor wound healing describes 10 tissue attributes and 9 descriptive attributes of size

A

sussman wound healing tool

73
Q

What type of would healing tool is used to measure pressure injuries only

A

PUSH

74
Q

Which wound healing tool incorporates surface area, exudate amount, and surface appearance?

A

PUSH

75
Q

Which would healing tool evaluates 13 wound characteristics

A

BWAT

76
Q

What is claudication

A

Pain typically in the calf due to low oxygen after some amount of physical activity. The pain goes away when the physical activity stops

77
Q

What is resting pain

A

Pain that affects an individual typically across the forefoot when they are lying down doing nothing

78
Q

How do you resolve resting pain

A

Swings the legs over the bed and let the blood run down to the lower extremities.

79
Q

What is dependent rubor

A

Typically occurs in resting pain. A patients leg is raised to 30 degrees and the foot turns pale, but when you move the foot off the bed all of the blood rushes to the foot and it turns red

80
Q

Distinguish whether the description falls under arterial insufficiency or venous insufficiency and also what category the description is (i.e. pain, color, edema)

Intermittent claudication may progress to rest pain. Chronic, dull aching pain, progressive throughout the day

A

Arterial pain

81
Q

Distinguish whether the description falls under arterial insufficiency or venous insufficiency and also what category the description is (i.e. pain, color, edema)

Pale to dependent rubor, a dull to bright, reddish color, more common with advanced disease

A

arterial color

82
Q

Distinguish whether the description falls under arterial insufficiency or venous insufficiency and also what category the description is (i.e. pain, color, edema)

Normal to cyanotic, more common with advanced disease

A

venous color

83
Q

Distinguish whether the description falls under arterial insufficiency or venous insufficiency and also what category the description is (i.e. pain, color, edema)

Piokilothermic, taking on the environmental temperature. Much cooler than normal body temp

A

arterial skin temp

84
Q

Distinguish whether the description falls under arterial insufficiency or venous insufficiency and also what category the description is (i.e. pain, color, edema)

Usually no effect on temperature

A

venous skin temp

85
Q

Distinguish whether the description falls under arterial insufficiency or venous insufficiency and also what category the description is (i.e. pain, color, edema)

Diminished to absent without Doppler stethoscopre

A

arterial pulses

86
Q

Distinguish whether the description falls under arterial insufficiency or venous insufficiency and also what category the description is (i.e. pain, color, edema)

Usually normal, may be difficult to palpate, secondary to significant edema

A

venous pulses

87
Q

Distinguish whether the description falls under arterial insufficiency or venous insufficiency and also what category the description is (i.e. pain, color, edema)

Usually not present unless combined disease or can be relate to cardiac disease and congestive heart failure

A

arterial edema

88
Q

Distinguish whether the description falls under arterial insufficiency or venous insufficiency and also what category the description is (i.e. pain, color, edema)

Present from mild to severe pitting edema. Can have weeping edema fluid from open wounds

A

venous edema

89
Q

Distinguish whether the description falls under arterial insufficiency or venous insufficiency and also what category the description is (i.e. pain, color, edema)

Thin and shiny. Hair loss. Tropic changes of the nails. Muscle wasting

A

arterial tissue changes

90
Q

Distinguish whether the description falls under arterial insufficiency or venous insufficiency and also what category the description is (i.e. pain, color, edema)

Stasis dermatitis with flaky, dry, scaling skin. Hemosiderin deposits-brownish discoloration. Fibrosis with narrowing of the lower legs, “bottle legs”

A

Venous tissue changes

91
Q

What is the most commonly used noninvasive test instrument for vascular testing

A

continuous wave doppler

92
Q

A continuous wave doppler is used to determine the _____ and _____ of blood flow

A

velocity and direction

93
Q

Invasive studies and contrast angiography involves the puncture of which arerty

A

femoral artery

94
Q

During invasive contrast angiography, cathers are manipulated which can potentially cause _____ to break off and _____ or even sustain permanent damage to the vessel walls

A

plaques, embolize

95
Q

What is the Gold Standard for vascular evaluation

A

invasive contrast angiography

Wound Care (8 decks)

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