Integumentary Flashcards
Absent pulse
0
Diminished pulse
1+
Normal pulse
2+
Accentuated pulse
3+
ABI- Vessel Calcification
1.1 - 1.3
ABI- Normal
0.9 - 1.1
ABI- mild to mod arterial insufficiency
0.7 - 0.9
ABI- Mod arterial insufficiency, intermittent claudication
0.5 - 0.7
ABI- severe arterial insufficiency, rest pain
Less than 0.5
ABI- rest pain and gangrene
Less than 0.3
Rubor of Dependency
normal = 15-20 sec
pallor within 25 sec of elevation –> severe AI
pallor after 30-45 sec –> mod AI
pallor after 45-60 sec –> mild AI
Venous Filling time
less than 5 sec= venous insufficiency
5 - 15 sec = normal
Greater than 20 sec = arterial insufficiency
Calculating ABI
ABI= Systolic LE / Systolic UE
Capillary Refill Test
Hold nail until blanchable for 5 sec
Normal arterial insufficiency –> less than 3 sec
Rubor of Dependency
normal = 15-20 sec
pallor within 25 sec of elevation –> severe AI
pallor after 30-45 sec –> mod AI
pallor after 45-60 sec –> mild AI
5 PT Method
Pain, position, presentation, periwound, pulses, temperature
Compression Level
Class 0
Nonambulatory patients
Compression Level 20-30 mmHg
Class 1
Mild VI
VI w/ mild AI
Compression Level 30-40 mmHg
Class 2
Mod VI
Compression Level 40-50 mmHg
Class 3
Severe VI
Compression Level 50+ mmHg
Class 4
Severe VI, rarely used