Wound Management 1 Flashcards
Tests and Measures
Anthropometric characteristics (height, weight, edema measures - pitting)
Assistive device/adaptive equipment
Gait, locomotion, balance (look for risk issues)
Single most important risk factor in the development of an ulcer
loss of protective sensation
Sensory integrity - protective sensation - Vibration
at 128 Hz tuning fork
Compare sides and compare to hand
If lost vibratory sensation - likely also lost prorioception
Sensory integrity - protective sensation - Monofilament testing (semmes weinstein)
4.17 (1 gram) = dec sensation
5.07 (10 gram) monofilament
6.10 (75 gram) = absent sensation
FOOT
Pain
Identify if acute or or chronic (acute = more noxious) Standardized measures Location Dependent position Movements - how do they impact your pain
Pain - standardized measures
Brief pain inventory
McGill Pain Questionnaire
Vascular exam - inspection
Color of limb in various positions
Trophic changes - skin quality, hair growth, toe nail thickening
Pigmentation
Vascular exam - palpation
Skin texture
Skin tension - Stemmers sign
Pulses - femoral, popliteal, dorsalis pedis, post tibialis
Vascular exam - auscultate
Should hear nothing
Bruits indicate arterial limitations
Special tests for vascular system - ABI - advantages
Relatively quick screening tool
No significant training needed
Reliable and reproducible
Special tests for vascular system - ABI - disadvantages
Requires Doppler probe/stethoscope
False elevation of non compressible vessels
Special tests for vascular system - ABI - Scoring
Equal to or greater than 1.0
possible calcified vessels
Special tests for vascular system - ABI - Scoring
0.9 to 1.00
Mild occlusion
Use compression cautiously
Special tests for vascular system - ABI - Scoring
0.5 to 0.8
Significant occlusion
Intermittent claudication likely
Special tests for vascular system - ABI - Scoring
less than 0.5
Significant occlusion
res pain is likely
Special tests for vascular system - ABI - Scoring
Some sources say what is normal
1.0 to 1.1
Special tests for vascular system - Transcutaneous Oxygen Measurements (tcPO2)
Series of electrode devices placed against skin
Measures oxygen tension (perfusion)
Special tests for vascular system - Transcutaneous Oxygen Measurements (tcPO2) - Scoring
No healing 20 mmHg or below
Unlikely at 30 mmHg
Need at least 35 mmHg for healing
Normal is 50 mmHg or above
Special tests for vascular system - Plethysmography
Variety of methods - air, electrical, impedance, photo
Series of cuffs with transducers are applied
As blood flows through, pressure changes are recorded
measures volume and pressure
Special tests for vascular system - Skin temperature measures
Infrared thermography
Liquid crystal thermography
Special tests for vascular system - Other tests - Rubor of dependence is for
ARTERIAL Supine, check plantar foot color Elevate 45 degrees (passively) Hold 60 sec Return to dependent position Watch color Normal is 15 sec Abnormal is more than 15, or bright red color
Special tests for vascular system - Other tests - Rubor of dependence - liklihood ratio
Not very good
1.6 to 2.8
Special tests for vascular system - Other tests - Venous filling time is for
ARTERIAL Supine Find vein on foot Elevate 45 degrees Watch for veins to disappear Return to dependent position Watch for veins to distend Normal is 15 sec Abnormal is longer than 15 sec NEED TO HAVE AN INTACT VENOUS SYSTEM
Special tests for vascular system - Other tests - Venous filling time - liklihood ratio
3.6 to 4.6
Special tests for vascular system - other tests - Claudication time
Amount of time for pain to begin when walking at a set pace on level ground
Need to note time it takes for pain relief too
Special tests for vascular system - other tests - Claudication time - Scoring
Grade 1 = definite discomfort or pain noticed, mod levels
Grade II = Mod discomfort/pain from which the pt focus can be diverted
Grade III = Intense pain from which pt cannot be diverted
Grade IV = Excruciating and unbearable pain
Special tests for vascular system - other tests - Capillary refill time
Normal is less than 2 seconds
Hold pressure on big toe for 3 to 5 sec
Special tests for vascular system - other tests - Percussion test is for
VENOUS
Standing
Palpate saphenous vein
Tap the vein with the other hand about 15 cm above
The occurrence of the shock wave confirms the venous reflex
A doppler US can be used too
You should NOT feel the vibration - if you did, the vein is incompetent
Special tests for vascular system - other tests - Trendelendburg test
Supine Elevate LE 45 degrees Hold for 60 sec Apply tourniquet around upper thigh Move to standing with tourniquet in place Watch for venous filling
If seen within 5 sec - incompetence of perforating veins
Remove tourniquet, if additional immediate filling (5 sec) then superficial veins incompetent
