Pain, Edema, and Skin Integrity Flashcards
What is the visual analog scale? (VAS)
A rating-type scale in which respondents mark a location on the scale corresponding to their perception of a phenomenon on a continuum
The verbal pain intensity scale
Similar to the Numeric Rating Scale, but words are used instead of numbers
Numeric Pain intensity scale
Rates pain on a scale of 0 (no pain) to 10 (worst imaginable pain)
Wong-Baker FACES scale
a pain assessment tool that asks patients (often children) to select one of several faces indicating expressions that convey a range from no pain through the worst pain
A pain diagram
Have the patient mark over a diagram of the body relevant to pain
What are the cardinal signs of inflammation?
-Rubor (redness)
-Calor(heat)
-Dolor(pain)
-Tumor(swelling)
-Functiona laesa (loss of function)
What are the stages of normal healing?
-Stage I: Inflammation (Day 0-3)
-Stage II: Proliferation Phase (Day 3- week 3)
-Stage III: Remodeling of maturation phase (week 3-….)
What is edema?
Edema is observable swelling caused by excess fluid trapped in the body’s tissues, most common peripherally in the feet, ankles, or hands.
What is pitting edema?
a “pit” or indentation remains after applying temporary pressure to the swollen area
what is non pitting edema?
no pit remains after applying temporary pressure to the swollen area
A +1 rating of pitting edema indicates..
indentation is barely detectable
A +2 rating of pitting edema indicates..
slight indentation is visible when the skin is depressed, but returns to normal in 15 seconds
A +3 rating of pitting edema indicates..
Deeper indentation occurs when pressed and returns to normal within 30 seconds
A +4 rating of pitting edema indicates..
indentation lasts for more than 30 seconds
What are causes of edema?
-heart disease
- chronic venous insufficiency (CVI)
-liver or renal disease
-lymphedema
-trauma
-chronic wounds
-post surgery
-inflammation, infection, or cellulitis
What is an anthropometric measurement used for?
Measures edema with a tape measurer.
How does a volumetric measurement of edema work?
Edema is measured through water displacement. Submerge the distal extremity in a container of water and note the volume of water displaced. Increased displacement indicates increased edema.
When measuring edema, it should be done _______
bilaterally
Circumferential measurement is…..
Measurement of the entire limb.
Figure 8 measurements is…
Measurements over joints
How would you do a figure 8 measurement of the hand?
-start at the radial styloid process
-Around the 5th metacarpal head
-over to the 2nd metacarpal head
- to ulnar styloid process
-back to radial styloid process
How would you do a figure 8 measurement of the foot or ankle?
-start at the medial malleolus
-go around the styloid process of the 5th ray
-go to the base of the first metatarsal
-go to the lateral malleolus
-go back around the medial malleolus
what decreases the severity/ amount of edema?
-positioning and elevation. Will facilitate movement of fluid out of the limb
- muscular activity. ankle pumps will facilitate pumping of fluid
-wrapping/taping. Unna boot will increase lymph movement.
-compression
-ice massage
-manual draining technique
What is lymphedema?
a chronic disorder characterized by an abnormal accumulation of lymph fluid in the body tissues.
Lymphedema ______ by elevation and results in progressive ______.
not relieved
loss of ROM and pain
What causes lymphedema?
mechanical insufficiency in the lymphatic drainage system. Can be congenital or acquired like through breast cancer.
One should conduct an examination of the integumentary system. You should pay closer attention to the people that are ________. Look over ________ or any areas of abnormal pressure.
immobile, insensate, have cognitve decline, or have had surgery.
bony prominences
Documentation of an inspection of the integumentary system should include…
size, color, drainage, odor, location, signs of healing, signs of inflammation
Just on observation, general assessment of a patients skin can give a lot of information like….
dryness, color, tugor (plumpness), amount of hair, bruises
Palpation of the skin can provide information on…
temperature, edema, pain or tenderness, moisture
Pressure ulcers can be acute or chronic.
Primary intention/union indicates minimal scarring because edges are _______.
Secondary intention/union indicates larger scarring because ________.
-kept close together
-edges are not kept together which leads to more collagen which creates a larger scar that takes longer to heal
The 5 cardinal signs of inflammation are
-rubor (redness)
-calor (heat)
-Dolor (pain)
-Tumor (swelling)
-Functiona laesa (loss of function)
How do pressure ulcers develop over boney prominences? (Pressure and moisture)
Body weight over a small area increases pressure which leads to hypoxia, ischemia, and eventually necrosis.
Moisture can lead to maceration (white) and a weak epidermis
A shear skin injury is when…
The underlying skin tissues move parallel to support surface. Can happen from sliding down in bed or from transfers and poor bed mobility.
A friction skin injury is when…
two surfaces rub together. For example, the skin of the heel rubbing on the sheet.
What causes pressure ulcers?(4)
friction, moisture, shearing, pressure
The Norton scale can be used to screen for risk assessment of pressure ulcers. What does it measure? How are the results interpreted?
-physical condition, mental condition, activity, mobility, and incontinence.
-lower scores indicate increase risk
- less than 10= very high risk
-between 10-14= high risk
-between 14-18 = medium risk
-greater than 18= low risk
The Braden scale can be used to screen for risk assessment of pressure ulcers. What does it measure? How are the results interpreted?
-Measures risk factors such as sensory perception, moisture, activity, mobility, nutrition, friction and shear
-Less than or equal to 9= severe risk
-between 10-12= high risk
-between 13-14= moderate risk
-between 15-18= mild risk
Stage 1 of pressure ulcer development
changes in skin color, appearance, temperature, pain, skin feels boggy, skin is still intact
stage 2 of pressure ulcer development
skin is broken through the first few layers (epidermis and dermis)
stage 3 of pressure ulcer development
full-thickness, subcutaneous structures are damaged and necrotic (maybe as deep as fascia)
Stage 4 of pressure ulcer development
extensive damage
bone, tendon, muscle or joint capsule exposed
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