Exam and Eval of Pt w/ Wound: Exam 1

Question 1

Lab values–IV

Malnutrition

*risk for not healing or bursting open

Answer 1

• Albumin
  
  • <3.5 to 5.5 g/dl
    
    • PRO that acts as building blocks for cells and tissues
    • Gross indicator of nutrition status (long term)
    • WOUNDS NEED PRO to heal!!
• Prealbumin
  
  • <16 to 40 mg/dl
    
    • indicator of nutritional status (short term)
      
      • ​3-5d

Question 2

Lab values–IV

Infection

*prevents wound healing

Answer 2

• WBCs
  
  • <5-10
    
    • if elevated IDs infection

Question 3

Lab Values
Sugar in bloodstream

Blood plasma

Clotting factors

Answer 3

• Sugar in blood
  
  • Fasting GLU–short term
  • Hb1AC–long term
• Blood plasma: anemia
  
  • HgB
  • HcT
• Clotting Factors: don’t want anyone bleeding out
  
  • Thrombocytes (platelets)
  • Partial thromboplastin time (PTT)
    
    • bleed too quickly if low

Question 4

Lab values

Wound bed

Answer 4

• blood or wound cultures/gram stains
  
  • scrape w/ q-tip
  • looking for bacteria

Question 5

PT exam wounds:

Location

Answer 5

anatomical position

be specific

Question 6

PT exam: wounds

size

Answer 6

measure in cm via clock, longest dim, tracing,

shape: irreg or round

internal comps: sinus tract, tunneling, undermining

Question 7

PT exam: wounds

tissue type

Answer 7

epithelial, granulation, necrosis (eschar or slough), hyper granulation

visible stx’s (bone, ligs, mm’s)

Question 8

PT Exam: wounds

Drainage/exudate

Answer 8

Color: serous, sanguinous, serosanguinous, pus, yellow, green, blue

amt: none, scant, min, mod, heavy or copious
odor: absent, mild, mod, strong, foul, fruity, ammonia-like

Question 9

PT exam: wounds

Periwound

Answer 9

bruised

excoriated

indurated

inflamed

intact

macerated

Question 10

PT exam: wounds

Pain lvl

Answer 10

Pain lvl!!!

Question 11

Vascular Assessments

What are we checking?

Answer 11

• periph pulses
• skin temp
  
  • NOTE: w/ peripheral wounds–> less blood flow, skin cooler
• ABI–PAD
• claudication–PAD
• blanchable toes–PAD
• edema of BOTH LE (measure girth)

*ALL wounds on LE

Question 12

Circular wound….

Answer 12

arterial

Question 13

Sensation assessments

using what?

Answer 13

• light touch
• vibration
• sharp microfilm
• temp

*to be completed w/ diabetic wounds and pressure ulcers

Question 14

Braden Pressure ulcer risk assess.

completed on those @ risk for pressure ulcers

categories?

Answer 14

• Sensory perception
  
  • verbalize pain/feel pain
• Moisture
• Mobility
  
  • how well they move
• Nutrition
  
  • eating enough?
• Friction and Shear
  
  • dragged around or properly lifted?

Question 15

Braden Pressure ulcer risk assess.

Interpreting scores

Answer 15

• >17==NO RISK
• 15-16==MILD risk
• 13-14==MOD risk
• <12==HIGH risk

the “Risk” is for getting or obtaining pressure ulcer

Question 16

Wounds and ICF

PT Eval

Assessment

Answer 16

Pt. is an X yr old female w/ medical/heatlh condition.

Pt presents w/ ICD10, X impairments, X act limits, and X participation restricts.

Clinical impression of the pt and wound.

Add. info about session w/ pt

Question 17

Wounds and ICF

PT Eval

POC/Prognosis

Answer 17

Pt will be seen for PT X times per week for X weeks for wound care mgmt of ICD10.

PT will include X interventions.

Pt will be referred to X interdisciplinary team member.

Anticipate pt to imrove X with skilled PT.