Integ Exam/ Assessment Flashcards
What lab tests are important to look at for an integ exam?
blood cultures (infections) dopplers (vascular changes)
What are two important system reviews to look at?
GI, urinary- is the pt incontinent, if so could cause an infxn depending on wound site
When doing a quick observation of the skin what things should PT be looking for?
skin integrity, skin color around wound, scar formation of any other wounds, hair and nail growth (clubbing- indicative of overall health)
What are 5 most important items to document about a wound?
- location
- size
- thickness
- colors
- dry/moist
objective measures
What are other important things to document?
tunneling, smell, drainage, periwound
When would you use NPUAP scale?
if pressure was the cause of a wound
What are 4 stages of NPUAP?
1- non-blanchable erythema
2- superficial ulcer, partial thickness
3- deep ulcer, full thickness, subcutaneous or fascia (can never go back to stage 2)
4- deep ulcer with necrosis, into muscle, tendon and bone
When is a Wagner scale used?
used less often but common in literature
for diabetic wounds
What is Wagner scale?
0- no open lesion 1- superficial ulcer/ partial thickness 2- deep ulcer to tendon, bone 3- deep ulcer with abcess, osteomyelitis 4- localized gangrene 5- gangrene entire foot
What is slough?
yellow or white clumps or string which need to be removed
What is granulation?
tissue that is ususally pink or beefy red tissue, shiny, moist this is a good sign of wound healing
if still pink at end of healing that is a bad sign
What is epithelial tissue?
new pink shiny tissue, grows in from edges
What is Marion classification scale?
color wound classification by percentage
What is maceration?
softening of tissue from liquid around peri wound
What other terms can be used to describe periwound?
rolled edges, shape, tactile, color, edema, temp.
What is exudate?
substance secreted from wound, document amount present (min, mod, max), can look at old dressing and note how long since last dressing change
What is acronym used to describe exudate?
T- type
A- amount
C- consistency
O- odor
What is a sanguineous consistency?
red thin watery usually a good sign
Seroanguineous?
light red/pink watery during normal inflammation, proliferation
Serous?
transudate/clear thin- normal
Purulent?
yellow tan green thick (pus)- not good usually sign of infxn
Seropurulent?
cloudy, yellow tan thin watery, potentially infected
blue/green drainage?
bad it is infected
What is size of wound always measured in?
Centimeters
What are two main type of measurement techniques?
direct and clock
What is undermining?
area of tissue lost under skin
What is tunneling?
passageway of tissue destruction under the skin surface
What is a sinus tract?
cavity at the end of a tunnel, good spot for an infxn
Is a thin or thick consistency better for wound healing?
thin
What is the Myers pitting edema scale?
1+ indentation is barely visible
2+ slight indentation with depression, returns to normal in less than 15 sec.
3+ deeper indent takes 15-30 sec to return to normal
4+ indentation lasts longer than 30 sec
What is Paz pulse scale?
0= no pulse 1+ weak 2+ normal 3+ moderately increased 4+ bounding/ racing pulse
What is ABI scale?
greater than 1.2- falsely elevated
- 95-1.19 normal
- 75- 0.94 mild arterial disease
- 5- 0.74 moderate arterial disease
less than 0.5 severe arterial occlusive dz needs referal
What are other tests for potential blood clot/ circulatory issues?
cap refill, wells criteria
What is hemosiderosis?
staining of skin likely due to rupture of blood vessel
