Lecture 2 Integumentary Exam Flashcards
Sensation Testing is more specific to?
Wound location
Related comorbidities
what is a risk factor for ulceration and re-ulceration?
Impaired light touch sensation
What is the most significant risk factor for the development of ulcers in patients with diabetes?
Impaired sensory integrity
For light touch, which monofilament plays a significant role in determining patient is at risk for ulceration or reinjury?
5.07 monofilament
A patient who is unable to perceive the 5.07 monofilament in any portion of the test area on two or more applications has lost protective sensation.
Light touch monofilament scale
4.17 - Decreased sensation
5.07 - loss of protective sensation
6.1 - Absent sensation
Inspection
Color
Palpation
Temperature & Pulses
Arterial Tests
- Ankle-Brachial Index (ABI)
- Capillary Refill
- Rubor of Dependency
Testing for both arterial and venous?
Venous Filling Time
Venous Tests
Trendelenburg Test
Venous Dopplers
How do you assess skin temperature?
- use the back of your hand
if the skin is cool to touch, what is it indicate?
Signs of ischemia: Cyanosis, mottled erythema
Where can you assess Pulse with the patient in supine?
Femoral
Popliteal
Dorsalis pedis
Posterior tib arterials
Pulse Grade
0: Absent pulse
1+: Diminished pulse
2+: Normal pulse
3+: Bounding or accentuated pulse
ABI is the ratio of?
Systolic pressure of posterior tib artery to brachial artery
Normal interpretation for ABI?
0.9 - 1
Cut off score for ABI
0.8
Capillary refill is an indicator for?
surface arterial blood flow
- pushing the digit and observe the color change
What is the normal capillary refill time?
- less than 3 seconds
Rubor of Dependency assesses?
arterial flow in the lower extremity
color of the plantar aspect of the patient’s foot
Rubor Dependency return time
- normal arterial blood supply: return to normal 15 to 20 seconds, light red or pink
- moderate insufficiency: pallor occurs within 30 seconds of elevation
- mild arterial insufficiency: pallor occurs within 45 - 60 seconds of elevation
- severe arterial insufficiency: pallor occur within 25 seconds of elevation and a bright red color with dependency
Dependent rubor results from?
- reactive hyperemia
Prolonged venous filling time is predictive for?
- arterial insufficiency
which vein are we observing for Venous filling time test?
the superficial veins on the patient’s dorsal foot
what is the normal venous filling time?
5 - 15 seconds
Venous filling time and interpretation
< 5 second: Venous insufficiency
5-15 seconds: Normal
> 20 seconds: Arterial insufficiency
Trendelenburg test is used to?
identify vein incompetence
what would indicate deep or perforator vein incompetence?
- Venous distention occurring in less than 20 seconds
what would indicate superficial vein incompetence once tourniquet is removed?
- Venous distention occurring in less than 10 seconds
Venous Dopplers can be useful to rule out?
DVT
what is the gold standard for evaluating the venous system?
Doppler ultrasonography
what are the 3 Edema measurement components?
- Tissue texture
- Pitting
- Girth
Edema: Pitting scale
0: No pitting
1+: Tissue refills immediately
2+: Tissue refills in 15-30 seconds
3+: Tissue refills in 60-90 seconds
4+: Tissue refills in > 90 seconds
Edema Pitting edema depth
0+
1+
2+
3+
4+
0+ : no pitting edema
1+ : 2mm depression rapidly
2+ : 4mm depression in 10-15 seconds
3+ : 6mm depression that may last more than 1 minute
4+: 8mm depression that can last more than 2 minutes
The amount of erythema should be quantified by?
measuring how far the redness extends from the wound range
Induration
tissue hardened from edema, inflammation, or granulation
Inflammation
Tissue response to injury: redness, warmth, edema, pain, loss of function
Hemosiderin Staining
caused by breakdown of hemoglobin
venous insufficiency
what are signs of excessive lipids
- slightly waxy appearance
- dilated pores
- acne
Xerosis
- Scaliness from excessive dryness
Maceration
- Softening of tissue from too much moisture
What is Turgor?
- Skin elasticity
How can turgor be assessed?
- lifting up the tissue to be tested between the thumb and index finger
What quality of scar tissue should be assessed?
- thickness
- mobility
- color
Varicosities / hemosiderin staining suggest?
- venous insufficiency
Skin rashes may indicate?
- hypersensitivity or a fungal infection
Trophic changes
- areas of long-standing ischemia causing no hair growth
- can increase risk of nail fungal infections
Healthy granulation tissue
- beefy red appearance
- presence of oxygen-rich capillaries
pale or dusky color granulation indicate?
- poor blood supply
- may be infected
what are the two necrotic tissue?
- Slough
- Eschar
- presence of either one will delay healing
Slough
- yellow or tan in color
- Stringy or mucinous consistency
white blood cells, bacteria, degraded extracellular matrix
Eschar
- black necrotic tissue that may be either soft or hard
what does adherence mean for necrotic tissue
- adherence refers to the ease with which the necrotic tissue can be separated from the wound
- the greater the depth of tissue destruction, the more adherent necrotic tissue will be
Osseous Exposure
- Exposed necrotic bone
- normally white and glistening in appearance
Adipose Tissue
- yellow, globular fatty tissue
Can granulation tissue form over dead necrotic areas?
no
Tunneling definition
- a narrow passageway created by the separation of fascial planes
How is Tunneling measured?
- inserting a probe into the passageway until resistance is felt
what is the tunnel depth?
the distance from the probe tip to where the probe is level with the wound edge
Undermining Definition
- areas of tissue under the wound edges that became eroded, resulting in large wound with a small opening
How is Undermining measured?
- inserting a probe under the wound edge directed almost parallel to the wound surface until resistance is felt
What should the PT document about wound edges?
- distinctness
- thickness
- color
- attachment to the base of the wound
What should the PT document about Wound Exudate?
- type
- color
- consistency
- amount
Wound Exudate - Serous
- normal, transudate
Wound Exudate - Sanguinous
- Normal acutely or in response to trauma
Wound Exudate - Serosanguinouse
- Normal
Wound Exudate - Purulent
- Possible infection
Wound Exudate - Seropurulent
- Possible infection
Possible infection Wound Exudate appearance
- Blue Green color
- Thick in consistency
Wound Odor
- highly subjective measure, should only be described as either present or absent
- can be influenced from old bandages, body odor, or incontinence
Direct measurement techniques for wound size
- Greatest Length x Greatest Width
- Clocking method
- Tracing
What are the two key advantages that Wound Photographic Measurement provide?
- Avoids contact with the patient’s wound
- Provides additional information including periwound and wound bed characteristics
