Scales Flashcards
Pulse scale:
Not palpable
0
Pulse scale:
Difficult to palpate, weak, thready
1+
Pulse scale:
Weak, light pressure causes it to disappear
2+
Pulse scale:
Normal, easily felt
3+
Pulse scale:
Bounding
4+
What is normal on pulse scale
3+
Reflex scale:
Absent
0
Reflex scale:
Weak
1+
Reflex scale:
normal
2+
Reflex scale:
hyperactive
3+
Reflex scale:
Clonus
4+
Pitting edema scale:
barely detectable
1+
Pitting edema scale:
skin takes 15 sec or less to return to normal
2+
Pitting edema scale:
skin takes 16-30 seconds to return to normal
3+
Pitting edema scale:
skin takes 30+ seconds to return to normal
4+
Stage of lymphedema:
no edema
Stage 0
Stage of lymphedema:
Pitting edema, reduces with elevation
Stage 1
Stage of lymphedema:
Irreversible edema
Stage 2
Stage of lymphedema:
Positive Stemmer’s sign
Stage 2
Stage of lymphedema:
Elephant like skin
Stage 3
Burn Scale:
Minimal pain, dry, no blisters
First degree
Burn Scale:
Blistering, web, moderate edema/pain
2nd degree superficial partial thickness
Burn scale:
mixed red with pale areas. web, blisters. insensitive to light touch, sensate to pressure
2nd degree deep partial thickness
Burn Scale:
white, charred, gray, dry, marked edema, insensate
3rd degree
Burn Scale:
charred, black, exposed bone, tendon, muscle, etc. Marked edema, insensate
4th degree
Pressure ulcer scale:
intact skin, non blanchable redness
Stage 1
Pressure ulcer scale:
shallow open ulcer, partial thickness loss of dermis
Stage 2
Pressure ulcer scale:
full thickness, subcutaneous tissue visible
Stage 3
Pressure ulcer scale:
full thickness, bone tendon, muscle exposed
Stage 4
Pressure ulcer scale:
subcutaneous tissue is exposed but not bone and tendon
Stage 3
Pressure ulcer scale:
localized purple/maroon area of intact skin
Suspected Deep tissue injury
Wagner Scale:
Intact skin
Stage 0
Wagner Scale:
Superficial Ulcer with no subcutaneous involvement
Stage 1
Wagner Scale:
Deep ulcer with involvement of ligament, tendon, or joint capsule
Stage 2
Wagner Scale:
Deep ulcer with bone involvement. abscess/osteomyelitis
Stage 3
Wagner Scale:
Forefoot gangrene
Stage 4
Wagner Scale:
Full foot gangrene
Stage 5
Pressure Ulcer Scale:
Wound bed covered with slough and eschar
Unstageable
Big difference between stage 1 and 2 on Wagner
Stage 1 has no subcutaneous involvement, stage 2 does
Big difference between stage 0 and 1 on Wagner
Stage 0 is when the skin is intact, stage 1 the skin is not intact
Big difference between stage 2 and 3 on Wagner
Stage 2 there is no osteomyelitis, stage 3 there is.
