Midterm Flashcards
1
Q
The skin is divided into what two layers?
A
-The dermis and epidermis
2
Q
What is just deep to the dermis and allows it to move freely over internal organs?
A
-The hypodermiS
3
Q
What are the layers of the epidermis from deep to superficial?
A
-Basale, Spinosum, Granulosum, lucidum, corneum
4
Q
What layer of the epidermis houses active keratinocytes?
A
-The Stratum Basale
5
Q
Which layer of the epidermis helps the skin withstand friction and shear force?
A
-Stratum Spinosum
6
Q
What layer of the epidermis helps the skin prevent water loss?
A
-The stratum Granulosum
7
Q
What is contained in the stratum granulosum that prevents water loss?
A
-Intercellular space comprised of lipid rich material
8
Q
What layer of the epidermis provides protection from the environment?
A
-Stratum lucidum
9
Q
In what areas of the body in the stratum lucidum visible?
A
-The palms and bottoms of feet
10
Q
What layer of the epidermis do keratinocytes become corneocytes?
A
-The stratum Conreum
11
Q
What layer of the epidermis forms an acid mantle to make the skin more resistant to infection?
A
-The stratum corneum
12
Q
Where are melanocytes located?
A
-Between the straum basale and the stratum spinosum
13
Q
What type of cells are located in the stratum spinosum and provide an immune response?
A
-Langerhan cells
14
Q
What type of cells are located in the stratum basale and detect light touch and tactile sensation?
A
-Merkel cells
15
Q
Where does blood flow run in the dermis?
A
-Just deep to the basement membrane, to be able to supply the epidermis; allowing nutrition to the active keratinocytes
16
Q
What are the name of the shunts of blood flow that run through the dermis?
A
-ateriovenous anastmoses
17
Q
what does the dermis contain to help carry out excess fluid?
A
-lymphocytes
18
Q
Where do nerve running through the dermis become free nerve endings?
A
-Just before the epidermal junction
19
Q
What is the more superficial layer of the dermis?
A
-The papillary dermis
20
Q
What do fibroblasts in the papillary dermis create?
A
-Elastin and type I collagen
21
Q
The collagen and elastin made in the papillary dermis are responsible for giving what characteristics to skin?
A
-Turgor and toughness
22
Q
What do the firbroblasts in the papillary dermis create that helps aid wound closure?
A
-Hyaluronic acid
23
Q
What is the deep layer of the dermis that is located over the subcutaneous fat?
A
-The reticular Dermis
24
Q
What is found in the reticular dermis that detects light touch and vibration
A
-Meisner’s Corspuscle
25
What is the term for skin loss only on the epidermis?
-Erosion
26
What type of wounds are erosion wounds?
-1st degree burns and pressure sores
27
Partial thickness wounds involved what layers?
-The epidermis and papillary dermis (demonstrate bleeding)
28
What type of wounds are partial thickness wounds?
-2nd degree burns and pressure sores
29
What wounds involve the dermis, epidermis and hypodermis?
-Full thickness wounds
30
What is the first phase of skin healing?
-Hemostasis
31
How long does hemostasis last?
-less than 1 hour
32
What is hemostasis directed by?
-platelet aggregation
33
What occurs during hemostasis?
-The wound stops bleeding and scab begins to form
34
Clinical signs of hemostasis are similar to the inflammation stage, but what is the factor that distinguishes between the two?
-clot formatoin
35
What is the inflammation stage of wound healing also known as?
-scavenger or neogenesis
36
What does the inflammation stage of wound care mainly invole?
-cleaning the wound
37
What begins immediately after the injury to get rid of necrotic tissue?
-autolytic dedridement
38
What does the proliferation stage of wound healing entail?
-injured tissue being replaced by healthy cells undergoing mitosis
39
What is needed to provide nutrients to the wound and remove waste and deris?
-Angiogenesis
40
What is granulation tisse characterized by?
-Beefy Red appearance
41
What is the final stage of wound healing that begins after wound closure?
-Maturation/remodeling phase
42
What occurs in the maturation stage?
-A aggregation of cells that increases the strength of the wound
43
When a wound heals, how much strength does it retain from the original skin?
-80%
44
What is the term for the recurrence of wounds in the same area due to the decreased in tensile strength?
-Recidivism
45
What are the 3 classifications of wound response?
- Healing by primary intenetion
- Healing by delayed primary intention
- Healing by secondary intention
46
What type of healing will you typically see after surgury?
-primary intention (miminal scaring)
47
What is the example of a wound healing by primary intention?
-Those that have been surgically closed and are free from bacteria or pathogens
48
Wounds the heal by primary intention typically heal by when?
-2 weeks
49
What are wounds healing by delayed primary intention characterized by?
-wounds that have some sort of problem on the inside that prevent the edges from approximating; can be debris
50
What can result due to a delayed primary intention wound?
-A granuloma
51
How do delayed primary intention wounds normally resolve?
-Surgically
52
What is the usual wound healing process for non-surgical wounds?
-Secondary intention (progress through all wound stages)
53
Wounds seen in the clinic will be what two types of wounds?
-Delayed primary intention or sedondary
54
Cells communicate in the matrix to provide a better environment for what?
-wound healing
55
What breaks up the wound matrix to enhance the surrounding wound bed allowing for epithelial migration?
-Plasminogen activators and Mixed metalloproteinases (MMPs)
56
The majority of the drainage that leaves wounds consists of what?
-Proteins
57
What is the ECM of the skin comprised of?
-Collagen, elastin, proteoglycans and GAGs
58
What type of wounds occur with inadequate healing and may take months or years to close?
-Chronic wounds
59
What do chronic wounds typically occur because of?
- Foreign debris
- bacterial disruptions
- disease processes (circulatory disorders)
60
What are the most common chronic wounds?
-Venous insufficiency wounds
61
What 7 factors can impead healing?
-Infection, medications, comobities, cancer/radiation, autoimmune disorders, stress, lack of sleep
62
What can be applied to wounds that are being delayed by infection?
-antimicrobials
63
Fungal infections most commonly occur where?
-in moist environments under dressings
64
How can corticosteroids delay wound healing?
- allows for a lag time for inflammatory cells and fibroblasts to occupy the area
65
What can be given to those with prolonged steroid use the allow for better wound healing?
-ZMAC (zinc, magnesium, Vitamin A, Vitamin C)
66
What effects to NSAIDs have on wound healing?
-Decrease platelet aggregation, decrease tensile strength, and decrease granulation formation during the proliferation stage
67
How does diabetes delay wound healing?
-it increase glucose levels and impairs leukocyte function
68
How does arterial insufficiency delay wound healing?
-limits the ability to remove waste and provide nutrients
69
What is a large indicator of wound healing?
-cardiac function
70
What type of cells are particularly effected by ionizing radiation therapy and causes decreased tensile strength of the tissue and delayed healing?
-Fibroblasts
71
Why does chemotherapy cause poor wound healing?
-it kills good wound healing cells as well as cancer cells
72
What cancer treatment can cause decrease blood flow and sensation to the extremites and may lead to further tissue degeneration?
-CIPN
73
What cancer treatment may cause nutrional deficits and cause poor healing?
-Chemoside
74
Stress causes the release of what that will impair the response to injury?
-epi and norepi
75
How does smoking impair healing?
-it causes vasoconstriction and decreases the healing response
76
What can lead to insulin resistance and high glucose levels that can inhibit healing in all phases?
-alcohol consumption
77
What is the normal what blood cell count?
-4.5-11
78
What may lead to increased WBC count?
-infection or trauma
79
What does a low WBC count mean?
-decrease immune response to bacteria
80
What is the normal levels of hemoglobin?
-12-18 g/dL
81
Increased of decrease levels of hemoglobin will cause what?
-The inability of the wound to progress
82
What is the normal level of hematocrit?
-36-50%
83
What is increased hematocrit a sign of?
-thrombi/emboli
84
What is normal prothrombin time?
-2.5 seconds
85
What does increased prothrombin time cause?
-easy bleeding
86
What does decrease prothrombin time cuase?
-increased clotting
87
What is the normal HbA1C range?
-less than or equal to 5.7 percent
88
increase HbA1C will cause what?
-Delayed wound healing
89
What is the average glucose levels?
-less than 100 mg/dL
90
What dictates the type of wound healing?
-Tissue loss
91
What is the name for the Red Yellow and Black Classification system?
-Marion Lab Scale
92
What is the Marion Lab scale used to describe?
-the wound surface that correlates with the specific therapy needs
93
What are Red wounds described to be?
-Healthy, cleaning, healing and granulating
94
What is a yellow wound indicative of?
-A possible infection, or presense of necrotic tissue
95
What are black wounds characterized as?
-Necrotic or dead
96
What is the most widely known wound classification system used for pressure ulcers?
-National Pressure Ulcer Advisory Panel Pressure Ulcer Staging System
97
What does the NPUAP used to describe?
-The severity of the wound in order to dictate treatment protocols for reimbursement with regard to treatment products
98
What is the wagner scale used to classify?
-ulcers
99
What was the wagner scale originally used to diagnose and treat?
-the dysvascular foot
100
How does the wagnar scale describe a wound?
-The depth of the injury and presence of infection on a 0-6 scale
101
What is a grade 0 ulcer on the wagner scale?
-A pre or postulcerative site
102
How is a grade 1 ulcer on the wagner scale described?
-Superficial wounds through the epidermis or also the dermis, but no subcutaneous involvement
103
How is a grade 2 ulcer on the wagner scale desribed?
-penetrates through then tendon and capsule but the done and joint is not effected; full thickness wound
104
What is a grade 3 ulcer on the wagner scale?
-ulcer that affects joint and bone with abscess or osteomyelitis
105
What is a grade 4 on the wagner scale?
-forefoot gangrene within a digit
106
What is a grade 5 on the wagnar scale?
-Whole foot gangrene, requires amputation proximal to the digit
107
What is the University Texas system used to classify?
-Diabetic foot ulcers when a diabetic nephropathy is present
108
What 4 things does the UT scale grade?
-(A) wound depth; (B) infection, (C) Ischemia, (D) infection
109
What is step 1 in the wound care process?
-General assessment (regular PT exam)
110
What is step 2 in the wound care process?
-Diagnosis
111
What is step 3 of the wound care process?
-Prognosis and goal
112
What is step 4 of the wound care process?
-Re-evaluation
113
What things are important to ask the patient regarding a wound?
-onset, appearance, signs and symptoms, medication, and psycho-social history
114
What is part A of the diagnosis proccess of wound assessment?
-an in depth examination of testing for related factors and co-morbities, and focused wound examination
115
What is part B of the diagnosis of wound assessment?
-Forming the diagnosis from the info gathered in part A
116
What should to do before asessing a wound?
-Clean it to give a clear picture
117
What is the most commonly used method to document wound deminsions?
-The clock method
118
How is the perpendicular method of wound deminsions performed?
-Take the longest measure then measure perpindicular to that
119
What is considered the 12 position with the clock method?
-The head
120
Where is the width of the wound measured with the clock method?
-Perpindicular to the length, usualy at its maximum width
121
What is the disruption in the attachment of the skin to underlying structures?
-Undermining
122
What is undermining typically noticed as?
-dark, discolored tissues surrounding the periwound
123
What should you use to note the location of undermining?
-Clock position
124
Where can tunneling occur?
-Between two wound, or within the same wound
125
Where can tunneling not occur?
-it cannot span under around the wound
126
What type of non-viable tissue is describes are nercrotic and brown and black color?
-Ecshar
127
How does eschar often appear?
-Flat and shiny, with a hard and dry texture
128
What type of tissue is described as non-viable subcutaneous tissue that is the result of autolytic debridement?
-Slough
129
What is the appearance of slough?
-Soft and yellow
130
What stage of wound healing is granulation tissue seen?
-Proliferation
131
How does viable muscle tissue in a wound present?
-striated and red and is painful to tactile sensation
132
How does non-viable muscle in a wound present?
-greyish, cannot contract and is not painful
133
What need to be kept moist at all times to prevent infection if is exposed in a wound?
-periosteum
134
What must you do to rule out osteomyelitis?
-Perform a biopsy
135
What type of wounds are tendons seen in?
-full thickness wounds
136
How does viable tendon appear in a wond?
-shiny due to the paratendon sheath
137
Why must exposed tendons in a wound be kept moist?
-to maintain the viability
138
What type of viable tissue is described as shiny globules with a dull yellow appearance?
-Adipose
139
Why is the window viability of adipose typically short?
-It has poor blood supply
140
What type of tissue is described as granulation tissue that overides the surface
-Hypergranulation
141
What is hypergranulation a sign of?
-abnormal healing
142
What will hypergranulation prevent?
-Wound edges from approximating
143
What may be used to caogulate tissue and promt proper healing?
-Silver nitrate
144
What has been shown to decrease the incidence of hypergranulation?
-Foam dressings with pressure, or topical corticoids
145
Why is proper documentation of drainage neccesary?
-to recognize the phase of healing and allow for a clear picture of healing status
146
What is a scant amount of drainage?
-A small amount of drainage on dressing after removal
147
What is minimal drainage?
-25% of the dressing is covered
148
What is moderate dressing?
-50% of the dressing is covered
149
What is heavy drainage?
-100% of the dressing is covered
150
What is copious drainage?
-Multiple layers of the dressing are covered
151
What is strike through drainage?
-Visible through the last layer of dressing
152
What type of drainage is described a clear serum?
-Serous
153
What type of drainage is described as bloody?
-sanguinous
154
What type of drainage is described as bloody and clear?
-Serosanguinous
155
what type of drainage is is described as a viscous puss?
-Purulent
156
What is characteristic of drainage is indicative of infection?
-Bad odor
157
If the periwound is red what would that be described?
-Erythema
158
If the periwound is pale, what what would that be described as?
-Ischemic
159
The brown/purple stain that is typical with venous insufficiency is known as what?
-Hemosiderin
160
When should wound odor be assessed?
-After cleaning
161
What type of infects has characteristically sweet odor like corn tortillas?
-Psueomonas
162
Malignancy has what type of odors?
-varying
163
What type of infection has a foul odor?
-Wet Gangrene
164
Where does the arterial system begin?
-The ascending aorta
165
What are the symptoms of Claudications?
-heavy legs with cramping in the calf that increases with exertion
166
When will individual with PAD have pain during rest?
-when laying horizontally or when they are propped up
167
What are 7 risk factors for arterial wounds?
-Artherosclerosis, Smoking, Obesity, Diabetes Mellitus, Hypertension, Hypercholesteremia, Family History, Nutrtition
168
What test uses a doppler and BP cuff to calculate the systolic pressures and compare to normal values?
-ABI
169
What is an expansion of the ABI and require pressures taken at various points along the limb to better localize the ischemia?
-Segmental plethysmography
170
What combines ABI and SP and uses ultrasound to show details of the specific vessels that may be occluded?
-Arterial duplex loans
171
What test allows for the measurement of oxygen delivery to the site to be measured and has been show to help determine the amount of ischemia in the limb?
-Transcutaneous oxygen measures
172
What does Magnetic Resonance Radiography Angiography help visualize?
-The vessels and ischemia
173
What is the Ankle Brachial Index?
-the ratio of brachial Systolic BP to Ankle Systolic BP
174
When you obtain the BPs on the LEs, what side should you use?
-The one with the highest value, or one with a wound on it
175
What UE value should you use?
-The highest
176
An ABI >1.3 means what?
-False Elevation; heavy vessel calcification
177
What is normal ABI?
-1.0-1.29
178
What is considered borderline ABI?
-.091-1.0
179
What ABI value indicated mild PAD?
-.7-.9
180
What ABI values indicates moderate PAD?
-0.4-0.69
181
What ABI value is considered severe PAD?
-<0.4
182
What is the rubor of dependency test?
-Screens for artery insufficiency or ischemia
183
How do you perform the Rubor Dependency Test?
-Start with patient in supine, then elevate legs to 30 Degrees; wait for palor to be observed; then drape legs off the edge of table
184
What are normal results For the Rubor Dependency test?
-When you drape leg off table, it should return to a pinkish color
185
What are abnormal results for the rubor test?
-The foot will appear bright red
186
What causes the abnormal response in rubor test?
-Rapid dilation of the arteries to try to reprofuse the extremity quickly
187
How do arterial insufficiency wounds present?
-Small round and regular borders- like a punch hole
188
How does the wound bed appear with a vascular insufficiency wound?
-usually is pale due to imapired blood flow (dont heal)
189
Where do vascular insufficiency wounds normally occur first?
-on the digits
190
When do vascular insufficiency wounds become painful?
-when blood flow is gravity assisted
191
What might occur if a vascular insufficiency wound exposes bone?
-osteolyelitis
192
What is vital in treating arterial insufficiency wounds?
-Protection and ensuring blood flow
193
What type of therapy has been shown to increase blood flow and and help heal arterial insufficiency wounds?
-infrared lights
194
If an arterial insufficiency wound is stable with eschar and does not appear to have infection what should you not do?
-debride it
195
How does a stable wound present?
-hard to touch, no drainage and no redness
196
How do veins differ from arteries?
-they do not contain as much smooth muscle or elstin; allows them to withstand greater volumes of fluid
197
What occurs if there is a pathology in the venous system?
-Edema
198
What results from leaky valves?
-Variscosities
199
How do hemosiderin stains develope?
-Leaky valves leak blood into interstitial spaces and die, once they die the release hemoglobin into the fluid and turns a dark brown
200
Venous insufficiency normally causes edema where?
-in the lower leg
201
Edema expanding outside of the lower leg is normally caused by what?
-lymphadema
202
What position is normally used to assess increased venous distention?
-Standing
203
What test measures refill time by performing ankle pumps using a diode?
-photothysmography
204
What invansive procedure calls for a needle to be stuck into the pedal vein and measures pressure at rest and after exercise?
-Ambulatory venous pressure
205
Where do venous insufficiency normally occur?
- in the gaiter area of the medial lower leg
206
How do venous insufficiency wounds normally occur?
-insidously and are preceded by initial skin changes
207
How do venous insufficiency wounds normally present?
-shallow with little to no eschar formation
208
How will the periwound look like with a venous insufficiency wound?
-thickened skin or varicosities and hemosiderin staining
209
What will be present in a venous insufficiency wound if there is not arterial insufficiency?
-Drainage
210
What is the gold standard for treating venous insufficiency wounds?
-Compression
211
What type of patient should you not use compression on?
-CHF
212
For ambulatory patients with a venous insufficiency wound, what type of wrapping should you use?
-Figure 8 (provides twice as much compression)
213
What was an issue with the unna boot to treat venous insufficiency wounds?
-it does not change size onces edema goes down
214
What is the preferred compression technique for venous insufficiency wounds?
-4 layer compression
215
What is the 1st layer of the 4 layer compression?
-soft rolling of padding to build up the LE to assure a conical shape
216
What is the 2nd layer of the 4 layer compression?
-A non-eleastic layer providing the first layer of compression
217
What layer of the 4 layer compression provides the figure 8 pattern?
-The 3rd
218
What is the 4th layer of the 4 layer compression?
-adheres the wrapping together
219
How often must a 4 layer compression dressing be changed?
-3-7 days
220
What is the removal of dead, damaged or devitalized tissue from a wound bed?
-Debridement
221
What is the foundation behind debridement?
-to encourage wound healing in order to prevent infection, reduce chronic inflammation process when necrotic tissue is in the wound bed and promote growth in order to jumpstart the wound healing process in the acute stage
222
When should you debride a wound?
-to remove necrotic tissue if it is warranted, the perform maintenance throughout the healing process
223
What does necrotic tissue look like?
-brown/black eschar or yellow slough
224
What should the INR be at to perform debridement?
-2.5 (higher would cause more bleeding)
225
What is a precaution to debridement?
-blood thinners
226
What is a good indicator or wound prognosis?
-Pain
227
What should you always perform before debridement?
-if the ABI is low, you must refer
228
Those with ABIs less than what is contraindicated for debridement?
-.4
229
What type of wounds will need a vascular consult prior to debridement?
-Dry gangrene or dry ischemic wounds
230
What needs to be treated before debridement can occur?
-infection (fever)
231
What bacterial skin infection is characterized by severely inflamed, painful limbs, with heavy odor and drainage?
-Cellulitis (must treat with antibiotics before debridement)
232
What must you do if there is is exposed bone, tendon or any prosthetic device?
-Refer out to determine viability of the structure
233
Should you debride a wound with stable eschar and no signs of infection?
-NO
234
Where is stable eschar likely to present?
-on the heel
235
What type of debridement uses the bodies natural healing mechanism to debride non-viable tissue?
-Autolytic
236
How must the wound be prepared for autolytic debridement?
-need to be cleaned, and kept at the proper moisture
237
What can you do to eschar to promote healing from the inside out?
-Cross hatch it
238
What are some advantages for autolytic debridement?
-It is selective, improves rapidly and can be combined with other debridement types
239
What disadvatages come with autolytic debridement?
-may have to educated caregiver repeatedly, slower than sharp, and increased risk of infection
240
What type of debridement uses a collagenase to selectively break up non-viable tissue?
-Enzymatic
241
What is the common enzyme used to perform debridement?
-Santyl
242
What must you perform before enzymatic debridement?
-Clean it with a neutral pH cleaner
243
What type of debridement refers to some outside scource for debridement?
-mechanical
244
What type of dressings can be place on a wound, for non0viable tissue to attach to, to then be removed?
-wet to dry dressings
245
Why should you moisten the wet to dry dressing before remove?
-To limit the amount of granulation tissue that is taken with the dressing
246
What type of debridement uses pulses of water to gently clean the wound or debride it?
-Pulse Lavage
247
What range of PSI should be used for Pulse Lavage?
- 4-9 PSI
248
What PSI should you avoid to prevent tissue injury?
-15
249
What is the mos rapid form of debridement?
-Sharp
250
What are the disadvantages to sharp debridement?
-Pain, increased potentiol for complications
251
What should you checl before performing autolytic debridement?
-Lab values
252
What is the first step in managing excess bleeding?
-applying hard pressure for 10-15 minutes
253
What can you do to slow the rate of perfusion and prevent bleeding?
-Elevate the limb about the heart
254
What surgical procedure can be performed to stop excessive bleeding?
-Electro-caudery
255
What Is licalized damage to the skin and underying soft tissue usually over a boney prominence or related to a medical or other surface
-A pressure wound
256
How can a pressure wound present?
-as intact skin or an open ulcer
257
What is the authoritaive voice for pressure injuries?
-The NPUAP (National PRessure Ulcer Advisory Panel
258
What diagnosis has an increased liklihood of pressure injury?
-SCI, acute pediatrics, CVD and neonatal patients
259
What is the average cost to treat a full thickness pressure injury?
-$70,000
260
How can impaired lymphatic flow cause pressure injuries?
-causes the accumulation of metabolic waste products
261
How can repurfusion cause a pressure injury?
-by an inflammatory response due to return of blood to an ishemic area
262
What are the 4 proposed MOIs for pressure injuries?
-Ischemic, Reperfusion, Impaired lymphatic flow, and deformation of underlying tissue
263
How long does it take to for hyperemia to be observed with constant pressure?
-30 minutes
264
What are the clinical signs of hyperemia?
-Redness in the area up to 1 hour after the pressure is removed
265
How long does it take for tissue ischemia to occur under constant pressure?
-2-6 hours
266
What is a sign of tissue ischemia?
-Erythema; A dark red/purple color
267
How long does it take for necrosis to occur under constant pressure?
-6 hours
268
What is the final clinical step observed with pressure injuries?
-Ulceration
269
How long does it take for ulceration to occur?
-About 2 weeks
270
What type of wounds can you use the NPUAP scale to stage?
-ONLY pressure wounds
271
What is stage I of the NPUAP scale?
-nonblanchable erythema of intact skin
272
What is stage II of the NPUAP Scale?
-Partial thickness, with the dermis exposed; no signs of necrosis
273
How will a stage II pressure injury present?
-as an open shallow wound that is pinkish in color
274
What is a stage III pressure injury?
-Full thickness wound, no bone/tendon/fascia exposed with evidence of necrosis
275
What is a stage IV pressure injury?
-Full thickness with underlying structures exposed and necrosis
276
What is an unstagable pressure injury?
-When the wound cannot be staged prior to debridement
277
What is a suspected deep tissue injury?
-persistant, nonblanchable erythema and may be boddy of soft
278
What is a mucousal membrane pressure injury?
-Pressure injury on a mucous membrane with a history of medical device use
279
How do you stage a muscous membrane pressure wound?
-you cant
280
Stage I pressure ulcers account for what percent of pressure injuries in the geriatric population?
-47%
281
What are the risk factors for pressure injuries?
-Immobility, inactivity, sensory loss, shear friction force
282
What pressure injury risk assessment tool uses subscales of consistant physical condition, mental state, activity, mobility, and incontinence
-The norton scale
283
What is considered low risk on the norton scale?
-17 to 20
284
What is considered high risk for the norton scale?
-14 to 10
285
What is considered very high risk on the norton scale?
-Less than 10
