Scales Flashcards
List and describe the stages of Rutherford’s classification of peripheral artery disease
Stage 0: Patient is asymptomatic
Stage 1: Mild intermittent claudication is present
Stage 2: Moderate intermittent claudication is present
Stage 3: Severe intermittent claudication
Stage 4: Ischemic rest pain is present
Stage 5: Patient has minor tissue loss
Stage 6: Patient has major tissue ulceration/gangrene
List and describe the pulse scale
0: Absent pulse
1+: Thready pulse
2+: Weak pulse
3+: Normal pulse
4+: Strong/Pounding pulse
Describe the rubor of dependency test
Elevate legs while supine for 45-60 seconds, then return to a normal position
Check plantar surface of foot to observe how long it takes for it to become pink again
- Normal: 15-20 secs
- Severe Arterial Insufficiency: >30 seconds or dark red
Describe the capillary refill test
Compress fleshy part of big toe until it blanches (turns white)
- Should return within 3 seconds for capillary refill
Describe the ABI test
A test that measures the blood pressure difference between the arm and ankle
(use posterior tibial artery or dorsal pedis artery when checking pulse)
To get the number, divide the ankle systolic pressure by brachial systolic pressure
1.1 to 1.3: Vessel calcification
.9 to 1.1: Normal
.7 to .9: Mild to moderate arterial insufficiency
.5 to .7: Moderate arterial insufficiency, intermittent claudication
<.5: Severe arterial insufficiency, rest pain
<.3: Rest pain and gangrene
What is the buerger allen exercise?
Goal: Promote blood flow
Elevate legs (60-90 degrees) for 30-180 seconds (or until blanching) while having the patient dorsi and plantarflex, then have patient dangle legs over the table for 2-5 mins until hyperemia is achieved, then add one minute
Describe the venous refill time test
The “gold standard” test to predict venous insufficiency
Have patient in a supine position, then observe the superficial veins on the dorsal aspect of the foot
AI: Blood takes >20 secs to return
Normal: Blood returns within 5-15 secs
VI: Blood takes <5 secs to return
List the Edema Scale grades
0: No clinical edema
1+: Barely noticeable depression (<2mm)
2+: Easily noticeable depression, takes <15 secs to return to normal (2-4mm)
3+: Depression rebounds in 15-30 secs (5-7mm)
4+: Depression lasts for >30 secs (>7mm)
Describe and list the Clinical Etiology - Anatomy - Pathophysiology (CEAP) classification system
A classification system used to assess chronic venous insufficiency
C0: Asymptomatic
C1: Spider veins <3mm
C2: Varicose veins >/= 3mm
C3: Leg edema
C4: Skin pigmentation
C5: Healed venous ulcer
C6: Current venous ulcer
CS: Symptoms of leg achiness, heaviness, tightness, and/or pain caused by venous dysfunction
Explain the compression standard table
Class 0 (<20mmHg): Non-ambulatory patients
Class 1 (20-30mmHg): Mild venous insufficiency, or venous insufficiency with mild arterial insufficiency
Class 2 (30-40mmHg): Moderate venous insufficiency
Class 3 (40-50mmHg): Severe venous insufficiency
Class 4 (>50mmHg): Severe venous insufficiency (compression rarely required)
List the scoring of the Wagner scale
0 – no open lesion, may have cellulites
1 – superficial ulcer/partial thickness
2 - deep ulcer to tendon or bone
3 – deep ulcer with abscess or osteomyelitis
4 – localized gangrene
5 – gangrene of the entire foot
List the Braden scale score ranges and what they indicate
<18: At risk
15-16: Mild risk
13-14: Mod risk
<13: High risk
</=9: Very high risk
Who is suited for a group 1 mattress?
Patient Population: Those “at-risk” on the braden scale (or have stage 1 or 2 ulcer)
Who is suited for a group 2 mattress?
Patient Population: Multiple Stage 2 ulcers on trunk/pelvis
Who is suited for a group 3 mattress?
Patient Population: (Individuals must have all of the following)
- Multiple Stage 3 or 4 ulcers
- Entirely bed ridden
- “Group 2” mattresses did not work
