Pain, Edema, and Skin Integrity

Question 1

What is the visual analog scale? (VAS)

Answer 1

A rating-type scale in which respondents mark a location on the scale corresponding to their perception of a phenomenon on a continuum

Question 2

The verbal pain intensity scale

Answer 2

Similar to the Numeric Rating Scale, but words are used instead of numbers

Question 3

Numeric Pain intensity scale

Answer 3

Rates pain on a scale of 0 (no pain) to 10 (worst imaginable pain)

Question 4

Wong-Baker FACES scale

Answer 4

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

Question 6

A pain diagram

Answer 6

Have the patient mark over a diagram of the body relevant to pain

Question 7

What are the cardinal signs of inflammation?

Answer 7

-Rubor (redness)
-Calor(heat)
-Dolor(pain)
-Tumor(swelling)
-Functiona laesa (loss of function)

Question 8

What are the stages of normal healing?

Answer 8

-Stage I: Inflammation (Day 0-3)
-Stage II: Proliferation Phase (Day 3- week 3)
-Stage III: Remodeling of maturation phase (week 3-….)

Question 9

What is edema?

Answer 9

Edema is observable swelling caused by excess fluid trapped in the body’s tissues, most common peripherally in the feet, ankles, or hands.

Question 10

What is pitting edema?

Answer 10

a “pit” or indentation remains after applying temporary pressure to the swollen area

Question 11

what is non pitting edema?

Answer 11

no pit remains after applying temporary pressure to the swollen area

Question 12

A +1 rating of pitting edema indicates..

Answer 12

indentation is barely detectable

Question 13

A +2 rating of pitting edema indicates..

Answer 13

slight indentation is visible when the skin is depressed, but returns to normal in 15 seconds

Question 14

A +3 rating of pitting edema indicates..

Answer 14

Deeper indentation occurs when pressed and returns to normal within 30 seconds

Question 15

A +4 rating of pitting edema indicates..

Answer 15

indentation lasts for more than 30 seconds

Question 16

What are causes of edema?

Answer 16

-heart disease
- chronic venous insufficiency (CVI)
-liver or renal disease
-lymphedema
-trauma
-chronic wounds
-post surgery
-inflammation, infection, or cellulitis

Question 17

What is an anthropometric measurement used for?

Answer 17

Measures edema with a tape measurer.

Question 18

How does a volumetric measurement of edema work?

Answer 18

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.

Question 19

When measuring edema, it should be done _______

Answer 19

bilaterally

Question 20

Circumferential measurement is…..

Answer 20

Measurement of the entire limb.

Question 21

Figure 8 measurements is…

Answer 21

Measurements over joints

Question 22

How would you do a figure 8 measurement of the hand?

Answer 22

-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

Question 23

How would you do a figure 8 measurement of the foot or ankle?

Answer 23

-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

Question 24

what decreases the severity/ amount of edema?

Answer 24

-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

Question 25

What is lymphedema?

Answer 25

a chronic disorder characterized by an abnormal accumulation of lymph fluid in the body tissues.

Question 26

Lymphedema ______ by elevation and results in progressive ______.

Answer 26

not relieved
loss of ROM and pain

Question 27

What causes lymphedema?

Answer 27

mechanical insufficiency in the lymphatic drainage system. Can be congenital or acquired like through breast cancer.

Question 28

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.

Answer 28

immobile, insensate, have cognitve decline, or have had surgery.
bony prominences

Question 29

Documentation of an inspection of the integumentary system should include…

Answer 29

size, color, drainage, odor, location, signs of healing, signs of inflammation

Question 30

Just on observation, general assessment of a patients skin can give a lot of information like….

Answer 30

dryness, color, tugor (plumpness), amount of hair, bruises

Question 31

Palpation of the skin can provide information on…

Answer 31

temperature, edema, pain or tenderness, moisture

Question 32

Pressure ulcers can be acute or chronic.
Primary intention/union indicates minimal scarring because edges are _______.
Secondary intention/union indicates larger scarring because ________.

Answer 32

-kept close together
-edges are not kept together which leads to more collagen which creates a larger scar that takes longer to heal

Question 33

The 5 cardinal signs of inflammation are

Answer 33

-rubor (redness)
-calor (heat)
-Dolor (pain)
-Tumor (swelling)
-Functiona laesa (loss of function)

Question 34

How do pressure ulcers develop over boney prominences? (Pressure and moisture)

Answer 34

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

Question 35

A shear skin injury is when…

Answer 35

The underlying skin tissues move parallel to support surface. Can happen from sliding down in bed or from transfers and poor bed mobility.

Question 36

A friction skin injury is when…

Answer 36

two surfaces rub together. For example, the skin of the heel rubbing on the sheet.

Question 37

What causes pressure ulcers?(4)

Answer 37

friction, moisture, shearing, pressure

Question 38

The Norton scale can be used to screen for risk assessment of pressure ulcers. What does it measure? How are the results interpreted?

Answer 38

-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

Question 39

The Braden scale can be used to screen for risk assessment of pressure ulcers. What does it measure? How are the results interpreted?

Answer 39

-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

Question 40

Stage 1 of pressure ulcer development

Answer 40

changes in skin color, appearance, temperature, pain, skin feels boggy, skin is still intact

Question 41

stage 2 of pressure ulcer development

Answer 41

skin is broken through the first few layers (epidermis and dermis)

Question 42

stage 3 of pressure ulcer development

Answer 42

full-thickness, subcutaneous structures are damaged and necrotic (maybe as deep as fascia)

Question 43

Stage 4 of pressure ulcer development

Answer 43

extensive damage
bone, tendon, muscle or joint capsule exposed

Question 44

g

Answer 44

g