Wound Management 1

Question 1

Tests and Measures

Answer 1

Anthropometric characteristics (height, weight, edema measures - pitting)
Assistive device/adaptive equipment
Gait, locomotion, balance (look for risk issues)

Question 2

Single most important risk factor in the development of an ulcer

Answer 2

loss of protective sensation

Question 3

Sensory integrity - protective sensation - Vibration

Answer 3

at 128 Hz tuning fork
Compare sides and compare to hand
If lost vibratory sensation - likely also lost prorioception

Question 4

Sensory integrity - protective sensation - Monofilament testing (semmes weinstein)

Answer 4

4.17 (1 gram) = dec sensation
5.07 (10 gram) monofilament
6.10 (75 gram) = absent sensation
FOOT

Question 5

Pain

Answer 5

Identify if acute or or chronic (acute = more noxious)
Standardized measures
Location
Dependent position
Movements - how do they impact your pain

Question 6

Pain - standardized measures

Answer 6

Brief pain inventory

McGill Pain Questionnaire

Question 7

Vascular exam - inspection

Answer 7

Color of limb in various positions
Trophic changes - skin quality, hair growth, toe nail thickening
Pigmentation

Question 8

Vascular exam - palpation

Answer 8

Skin texture
Skin tension - Stemmers sign
Pulses - femoral, popliteal, dorsalis pedis, post tibialis

Question 9

Vascular exam - auscultate

Answer 9

Should hear nothing

Bruits indicate arterial limitations

Question 10

Special tests for vascular system - ABI - advantages

Answer 10

Relatively quick screening tool
No significant training needed
Reliable and reproducible

Question 11

Special tests for vascular system - ABI - disadvantages

Answer 11

Requires Doppler probe/stethoscope

False elevation of non compressible vessels

Question 12

Special tests for vascular system - ABI - Scoring

Equal to or greater than 1.0

Answer 12

possible calcified vessels

Question 13

Special tests for vascular system - ABI - Scoring

0.9 to 1.00

Answer 13

Mild occlusion

Use compression cautiously

Question 14

Special tests for vascular system - ABI - Scoring

0.5 to 0.8

Answer 14

Significant occlusion

Intermittent claudication likely

Question 15

Special tests for vascular system - ABI - Scoring

less than 0.5

Answer 15

Significant occlusion

res pain is likely

Question 16

Special tests for vascular system - ABI - Scoring

Some sources say what is normal

Answer 16

1.0 to 1.1

Question 17

Special tests for vascular system - Transcutaneous Oxygen Measurements (tcPO2)

Answer 17

Series of electrode devices placed against skin

Measures oxygen tension (perfusion)

Question 18

Special tests for vascular system - Transcutaneous Oxygen Measurements (tcPO2) - Scoring

Answer 18

No healing 20 mmHg or below
Unlikely at 30 mmHg
Need at least 35 mmHg for healing
Normal is 50 mmHg or above

Question 19

Special tests for vascular system - Plethysmography

Answer 19

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

Question 20

Special tests for vascular system - Skin temperature measures

Answer 20

Infrared thermography

Liquid crystal thermography

Question 21

Special tests for vascular system - Other tests - Rubor of dependence is for

Answer 21

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

Question 22

Special tests for vascular system - Other tests - Rubor of dependence - liklihood ratio

Answer 22

Not very good

1.6 to 2.8

Question 23

Special tests for vascular system - Other tests - Venous filling time is for

Answer 23

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

Question 24

Special tests for vascular system - Other tests - Venous filling time - liklihood ratio

Answer 24

3.6 to 4.6

Question 25

Special tests for vascular system - other tests - Claudication time

Answer 25

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

Question 26

Special tests for vascular system - other tests - Claudication time - Scoring

Answer 26

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

Question 27

Special tests for vascular system - other tests - Capillary refill time

Answer 27

Normal is less than 2 seconds

Hold pressure on big toe for 3 to 5 sec

Question 28

Special tests for vascular system - other tests - Percussion test is for

Answer 28

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

Question 29

Special tests for vascular system - other tests - Trendelendburg test

Answer 29

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