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822: Integumentary > Examination of Patients with Open Wounds > Flashcards

Examination of Patients with Open Wounds Flashcards

1
Q

What are the 3 components to the physical therapy examination?

A
  • Patient history
  • Systems review
  • Administering tests and measures
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2
Q

What are the goals of the physical therapy wound examination?

A
  • determine the PT diagnosis
  • identify factors that may contribute to ulceration or abnormal wound healing
  • to assist with making a wound healing prognosis
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3
Q

When asking a patient about their medical history it is important to ask if they are allergic to what 3 things?

A
  • latex
  • sulfa
  • adhesive
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4
Q

What is the normal total RBC count for women? And for men?

A

Women: 4.0-5.5 million/mm3
Men: 4.5-6.2 million/mm3

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5
Q

If total RBC count is low what may this indicate?

A

anemia or blood loss

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6
Q

If total RBC count is high what may this indicate?

A

dehydration or an increased risk for blood clots

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7
Q

What is the normal hematocrit for women? And for men?

A

Women: 38-46%
Men: 42-54%

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8
Q

If hematocrit is low what may this indicate?

A

anemia, blood loss, or malnutrition

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9
Q

If hematocrit is high what may this indicate?

A

dehydration or an increased risk for blood clots

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10
Q

What is the normal hemoglobin for women? And for men?

A

Women: 12-16 g/dL
Men: 14-18 g/dL

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11
Q

If hemoglobin is low what may this indicate?

A

blood loss or nutritional deficiency

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12
Q

If hemoglobin is high what may this indicate?

A

dehydration or an increased risk for blood clots

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13
Q

What is the normal total WBC count for both sexes?

A

4500-11,000/mm3

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14
Q

If total WBC count is high what may this indicate?

A

infection, inflammatory response, or anemia

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15
Q

What is the normal platelet (thrombocyte) count for both sexes?

A

150,000-400,000/mm3

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16
Q

If the thrombocyte count is low what may this indicate?

A

delayed clotting is a risk

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17
Q

If the thrombocyte count is high what may this indicate?

A

high potential for blood clots

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18
Q

What is the normal total lymphocyte count (TLC) for both sexes?

A

> 1800 cells/mm3

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19
Q

If the TLC is low what may this indicate?

A

decreased immune function, protein deficiency, delayed wound healing

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20
Q

What is the normal serum albumin levels for both sexes?

A

3.5-5.5 g/dL

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21
Q

If serum albumin levels are low what may this indicate?

A

malnourished, increased risk for tissue edema, metabolic stress or inflammation

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22
Q

Low levels of serum albumin are correlated with what?

A

pressure ulcer severity

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23
Q

If serum albumin levels are high what may this indicate?

A

dehyration

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24
Q

What are the normative values for serum prealbumin?

A

16-40 mg/dL

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25
Q

If serum prealbumin levels are low what may this indicate?

A

malnourished, metabolic stress, inflammation

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26
Q

Mortality rate increases as prealbumin _____.

A

decreases

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27
Q

What are the normative values for serum trasnferin?

A

> 170 mg/dL

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28
Q

If serum transferin levels are low what may this indicate?

A

protein deficiency or malnourished

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29
Q

If serum transferin levels are high what may this indicate?

A

iron deficiency

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30
Q

What are the normative values for blood glucose?

A

70-110 mg/dL

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31
Q

What may be high levels of blood glucose indicate?

A

poorly controlled diabetes

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32
Q

Should urine glucose testing reveal positive or negative values?

A

negative

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33
Q

If there is blood glucose in the urine what may it indicate?

A

kidney disease or poorly controlled diabetes

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34
Q

What are normative BUN (blood urea nitrogen) levels?

A

8.0-20 mg/dL

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35
Q

If BUN levels are high what may it indicate?

A

kidney disease or dehydration

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36
Q

High BUN levels are associated with what?

A

delayed wound healing

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37
Q

What are normative creatinine levels?

A

0.8-1.2 mg/dL

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38
Q

Increased levels of creatinine may indicate what?

A

kidney disease

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39
Q

Creatinine levels decrease with what?

A

malnutrition

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40
Q

How can you tell the difference between wounds caused by arterial insufficiency and venous insufficiency?

A

Arterial: pain with leg elevation
Venous: relief with leg elevation

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41
Q

What are the 4 main purposes of the systems review?

A
  • helps the PT identify risk factors or impairments that may require referral to other disciplines
  • allows the PT to identify risk factors or impairments in areas aside from the integument that may benefit from PT intervention to enhance wound healing
  • identify signs and symptoms consistent with certain disease processes that may alter PT interventions for wound management
  • the PT can determine patient and caregiver education needs
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42
Q

What 5 things should be assessed for the Cardiovascular/Pulmonary System Review?

A
  • Heart rate
  • Blood pressure
  • Respiratory rate
  • Edema
  • Pulse oximetry
43
Q

What 4 things should be assessed for the musculoskeletal system review?

A
  • Structure
  • Posture
  • Range of motion
  • Strength
44
Q

What 4 things should be assessed for the neuromuscular system review?

A
  • Gait
  • Mobility
  • Transfers
  • Balance
45
Q

What 4 things should be assessed for the GI System Review?

A
  • Nutrition intake
  • Supplementation
  • Continence
  • Body mass index
46
Q

What are 2 nutritional assessment screening tools that can be used to assess the GI system?

A
  • REAP (Rapid Eating and Activity Assessment for Patients)

- WAVE (Weight, Activity, Variety, Excess)

47
Q

What 3 things should be assessed for the urogenital System Review?

A
  • incontinence
  • poorly controlled diabetes
  • UTIs
48
Q

The integumentary system review consists of a gross examination of exposed skin including what 4 things?

A
  • skin integrity
  • skin color
  • skin formation
  • hair and nail growth
49
Q

Why is it important to assess for scar formation?

A

If scarring is present you can conclude injury to the dermis occurred and can assume that dermal appendages will be missing

50
Q

If there is reduced hair or nail growth what may you conclude?

A

possible malnourishment

51
Q

What 6 things should be documented on in regards to wound characteristics?

A
  • location
  • size
  • tunneling or undermining
  • wound edges
  • drainage
  • odor
52
Q

Where do pressure ulcers tend to form?

A

Over bony prominences

53
Q

Where do arterial ulcers tend to form?

A

distally at the tips of the toes

54
Q

Wounds that are located in folds of skin are typically caused by what?

A

friction or excess moisture

55
Q

Wounds that are located on the toes are typically caused by what?

A

friction or decreased circulation

56
Q

Wounds that are located on the bottom of the foot are typically caused by what?

A

trauma or pressure

57
Q

Wounds that are located on the shin or calf are typically caused by what?

A

trauma or lack of circulation

58
Q

If the wound edge is round what is most likely the cause?

A

pressure

59
Q

If the wound edge has jagged edges what is most likely the cause?

A

shear or friction forces

60
Q

If the wound edge is irregularly shaped what is most likely the cause?

A

vascular

61
Q

If the wound edge is linear what is most likely the cause?

A

trauma or friction

62
Q

What is considered to be the actual wound?

A

the open area only

63
Q

What is the wound base/bed?

A

the bottom of the wound

64
Q

What is considered to be the wound depth?

A

the vertical distance from the visible surface to the deepest area in the wound bed

65
Q

What is considered to be the wound edges or margin?

A

the inside perimeter of the wound

66
Q

The periwound area is measured at minimum _ cm surrounding the wound

A

4

67
Q

Describe wound tunneling

A

Channel or pathway that extends in any direction from the wound through subcutaneous tissue or muscle, creating dead space with the potential for abscess formation

68
Q

How is wound tunneling measured?

A

By inserting a probe into the passageway until resistance is felt.
The depth is the distance from the probe tip to the point at which the probe is level with the wound edge

69
Q

Tunneling is common in what type of wounds?

A

neuropathic ulcerations and surgical wounds

70
Q

Describe wound undermining

A

Tissue destruction underlying intact skin along the wound margins in which the base of the wound is larger than at the skin surface

71
Q

How is undermining measured?

A

By inserting aprobe under the wound edge directed almost parallel to the wound surface until resistance is felt.
The depth is the distance from the probe tip to the point at which the probe is level with the wound edge.

72
Q

Undermining is common in what type of wounds?

A

pressure or neuropathic ulcers

73
Q

Describe the main difference between wound tunneling and undermining

A

Tunneling involves only a small portion of the wound edge, whereas undermining involves a large portion

74
Q

What are the 5 ways methods for determining wound size?

A
  • Direct measurement
  • Tracings
  • Photography
  • Volumetric measurement
  • Percent of total body surface area
75
Q

In regards to using the clock method __ o’clock is towards the patient’s head whereas __ o’clock is towards the patient’s feet

A

12

6

76
Q

How is direct measurement performed?

A

By measuring the longest length (12 o’clock to 6 o’clock) and the widest width (12 o’clock to 3 o’clock)

77
Q

How is wound surface area calculated?

A

L x W x D

78
Q

What is a disadvantage to using direct measurement to determine wound size?

A

It accurately determine depth in wounds covered with nonviable tissue

79
Q

Does direct linear measurement take into account the periwound area?

A

No

80
Q

How are wound tracings performed?

A

With a 2-layered transparent film in which the bottom layer is discarded and the top is saved in the medical record

81
Q

What are 2 disadvantages to wound tracings?

A
  • May be difficult to visualize wound perimeter through transparency
  • Paper is directly on wound therefore cleanliness may be an issue
82
Q

What are the advantages to photographic wound measurement?

A
  • Digital images are high quality
  • Avoids contact with patient’s wound
  • Provides periwound and wound bed characteristics
83
Q

What are the disadvantages to photographic wound measurement?

A
  • camera angle and focal distance can influence the image therefore the size of the wound may not be accurately represented
    c- Cannot use images used with a non-wound care camera
  • lighting can be an issue
84
Q

How is wound size determined through volumetric measurement?

A

By measuring the amount of dental, silicone molding, or saline that is required to fill the wound

85
Q

What are the disadvantages associated with volumetric measurements?

A
  • time consuming
  • can be painful to patient
  • can be detrimental to wound healing
86
Q

In what types of wounds should total body surface area measurements be used?

A

Large surface area wounds, typical with burns

87
Q

What should granulation tissue look like?

A

pink/red with small granulation bubs

88
Q

What are 2 types of necrotic tissue?

A
  • Slough

- Eschar

89
Q

Describe slough

A

yellow or tan in color and has a stringy or mucinous consistency

90
Q

Describe eschar

A

black necrotic tissue that is dry and obstructs further healing

91
Q

What 4 characteristics of the wound edge must you document on?

A
  • Distinctness
  • Thickness
  • Color
  • Attachment to base of wound
92
Q

What 4 characteristics of wound drainage must you document on?

A
  • Type
  • Color
  • Consistency
  • Amount
93
Q

Wound odor may be an indication of what?

A

infection

94
Q

What 5 characteristics of the periwound area should be assessed?

A
  • structure and quality
  • color
  • epithelial appendages
  • edema
  • temperature
95
Q

In regards to the structure and quality of the periwound area what should you assess for?

A
  • Age-related skin changes
  • Periwound hydration
  • Skin turgor
  • Calluses
  • Scar formation
96
Q

How does long-standing ischemia effect epithelial appendages

A

It cannot support hair and nails tend to be thick and yellow

97
Q

How can you determine if pitting edema is present or not?

A

Firmly press a thumb or index finger into the affected area and hold for 5 seconds. If depression remains upon removal of finger = positive

98
Q

Describe grade 1+ pitting edema

A

There is barely a perceptible depression.

There is less than 2 mm of an indentation

99
Q

Describe grade 2+ pitting edema

A

There is an easily identifiable depression that rebounds in less than 15 seconds.

Indentation is 2-4 mm

100
Q

Describe grade 3+ pitting edema

A

The depression rebounds in 15-30 seconds.

The indentation is 5-7 mm

101
Q

Describe grade 4+ pitting edema

A

The depression lasts for more than 30 seconds.

The indentation is greater than 7 mm

102
Q

Define induration

A

swelling that is firm and does not return to its original state

103
Q

Edema can be measured via circumference. What are the 2 best landmarks to measure this?

A

Lateral malleolus and ulnar styloid process

822: Integumentary (16 decks)

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