Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Integumentary > Lecture 2 Integumentary Exam > Flashcards

Lecture 2 Integumentary Exam Flashcards

1
Q

Sensation Testing is more specific to?

A

Wound location
Related comorbidities

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

what is a risk factor for ulceration and re-ulceration?

A

Impaired light touch sensation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is the most significant risk factor for the development of ulcers in patients with diabetes?

A

Impaired sensory integrity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

For light touch, which monofilament plays a significant role in determining patient is at risk for ulceration or reinjury?

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Light touch monofilament scale

A

4.17 - Decreased sensation
5.07 - loss of protective sensation
6.1 - Absent sensation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Inspection

A

Color

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Palpation

A

Temperature & Pulses

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Arterial Tests

A
  • Ankle-Brachial Index (ABI)
  • Capillary Refill
  • Rubor of Dependency
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Testing for both arterial and venous?

A

Venous Filling Time

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Venous Tests

A

Trendelenburg Test
Venous Dopplers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

How do you assess skin temperature?

A
  • use the back of your hand
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

if the skin is cool to touch, what is it indicate?

A

Signs of ischemia: Cyanosis, mottled erythema

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Where can you assess Pulse with the patient in supine?

A

Femoral
Popliteal
Dorsalis pedis
Posterior tib arterials

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Pulse Grade

A

0: Absent pulse
1+: Diminished pulse
2+: Normal pulse
3+: Bounding or accentuated pulse

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

ABI is the ratio of?

A

Systolic pressure of posterior tib artery to brachial artery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Normal interpretation for ABI?

A

0.9 - 1

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Cut off score for ABI

A

0.8

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Capillary refill is an indicator for?

A

surface arterial blood flow
- pushing the digit and observe the color change

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is the normal capillary refill time?

A
  • less than 3 seconds
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Rubor of Dependency assesses?

A

arterial flow in the lower extremity
color of the plantar aspect of the patient’s foot

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Rubor Dependency return time

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Dependent rubor results from?

A
  • reactive hyperemia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Prolonged venous filling time is predictive for?

A
  • arterial insufficiency
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

which vein are we observing for Venous filling time test?

A

the superficial veins on the patient’s dorsal foot

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

what is the normal venous filling time?

A

5 - 15 seconds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Venous filling time and interpretation

A

< 5 second: Venous insufficiency
5-15 seconds: Normal
> 20 seconds: Arterial insufficiency

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Trendelenburg test is used to?

A

identify vein incompetence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

what would indicate deep or perforator vein incompetence?

A
  • Venous distention occurring in less than 20 seconds
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

what would indicate superficial vein incompetence once tourniquet is removed?

A
  • Venous distention occurring in less than 10 seconds
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Venous Dopplers can be useful to rule out?

A

DVT

31
Q

what is the gold standard for evaluating the venous system?

A

Doppler ultrasonography

32
Q

what are the 3 Edema measurement components?

A
  • Tissue texture
  • Pitting
  • Girth
33
Q

Edema: Pitting scale

A

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

34
Q

Edema Pitting edema depth
0+
1+
2+
3+
4+

A

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

35
Q

The amount of erythema should be quantified by?

A

measuring how far the redness extends from the wound range

36
Q

Induration

A

tissue hardened from edema, inflammation, or granulation

37
Q

Inflammation

A

Tissue response to injury: redness, warmth, edema, pain, loss of function

38
Q

Hemosiderin Staining

A

caused by breakdown of hemoglobin
venous insufficiency

39
Q

what are signs of excessive lipids

A
  • slightly waxy appearance
  • dilated pores
  • acne
40
Q

Xerosis

A
  • Scaliness from excessive dryness
41
Q

Maceration

A
  • Softening of tissue from too much moisture
42
Q

What is Turgor?

A
  • Skin elasticity
43
Q

How can turgor be assessed?

A
  • lifting up the tissue to be tested between the thumb and index finger
44
Q

What quality of scar tissue should be assessed?

A
  • thickness
  • mobility
  • color
45
Q

Varicosities / hemosiderin staining suggest?

A
  • venous insufficiency
46
Q

Skin rashes may indicate?

A
  • hypersensitivity or a fungal infection
47
Q

Trophic changes

A
  • areas of long-standing ischemia causing no hair growth
  • can increase risk of nail fungal infections
48
Q

Healthy granulation tissue

A
  • beefy red appearance
  • presence of oxygen-rich capillaries
49
Q

pale or dusky color granulation indicate?

A
  • poor blood supply
  • may be infected
50
Q

what are the two necrotic tissue?

A
  • Slough
  • Eschar
  • presence of either one will delay healing
51
Q

Slough

A
  • yellow or tan in color
  • Stringy or mucinous consistency
    white blood cells, bacteria, degraded extracellular matrix
52
Q

Eschar

A
  • black necrotic tissue that may be either soft or hard
53
Q

what does adherence mean for necrotic tissue

A
  • 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
54
Q

Osseous Exposure

A
  • Exposed necrotic bone
  • normally white and glistening in appearance
55
Q

Adipose Tissue

A
  • yellow, globular fatty tissue
56
Q

Can granulation tissue form over dead necrotic areas?

A

no

57
Q

Tunneling definition

A
  • a narrow passageway created by the separation of fascial planes
58
Q

How is Tunneling measured?

A
  • inserting a probe into the passageway until resistance is felt
59
Q

what is the tunnel depth?

A

the distance from the probe tip to where the probe is level with the wound edge

60
Q

Undermining Definition

A
  • areas of tissue under the wound edges that became eroded, resulting in large wound with a small opening
61
Q

How is Undermining measured?

A
  • inserting a probe under the wound edge directed almost parallel to the wound surface until resistance is felt
62
Q

What should the PT document about wound edges?

A
  • distinctness
  • thickness
  • color
  • attachment to the base of the wound
63
Q

What should the PT document about Wound Exudate?

A
  • type
  • color
  • consistency
  • amount
64
Q

Wound Exudate - Serous

A
  • normal, transudate
65
Q

Wound Exudate - Sanguinous

A
  • Normal acutely or in response to trauma
66
Q

Wound Exudate - Serosanguinouse

A
  • Normal
67
Q

Wound Exudate - Purulent

A
  • Possible infection
68
Q

Wound Exudate - Seropurulent

A
  • Possible infection
69
Q

Possible infection Wound Exudate appearance

A
  • Blue Green color
  • Thick in consistency
70
Q

Wound Odor

A
  • highly subjective measure, should only be described as either present or absent
  • can be influenced from old bandages, body odor, or incontinence
71
Q

Direct measurement techniques for wound size

A
  • Greatest Length x Greatest Width
  • Clocking method
  • Tracing
72
Q

What are the two key advantages that Wound Photographic Measurement provide?

A
  • Avoids contact with the patient’s wound
  • Provides additional information including periwound and wound bed characteristics
73
Q
A

Integumentary (4 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions