Wounds and Gait AD Flashcards
Suspected Deep Tissue Injury
Blood filled blister
Purple or maroon area of discolored, intact skin
Tissue is painful, firm, mushy, boggy, warmer/cooler than adjacent tissue
Stage 1 Pressure Ulcer
Non blanchable erthema of intact skin
Firm or boggy skin
Stage 2 Pressure Ulcer
Partial thickness skin loss involving epidermis and or/dermis
Abrasion, blister, shallow cratter
Red/pink bed NO slough
Serum-filled blister
Stage 3 Pressure Ulcer
Full thickness tissue loss Damage of subcutaneous tissue that may extend down to fascia Fibrin or Slough Can have undermining/tunneling Deep crater
Stage 4 Pressure Ulcer
Damage to muscle, bone, supporting structures
Slough/eschar can be present
Undermining Tunneling
Unstageable
Full thickness loss persumed
Base of wound bed filled with slough or eschar
Goals: ABCDEF
Audience Behavior Condtion Duration Endpoint Functional Purpose
FIM: 7
complete independence
FIM: 6
modified independence (more time/assistive device/safety)
FIM: 5
Supervision or set up
FIM: 4
minimal assistance
FIM: 3
moderate assistance
FIM: 2
maximal assistance
FIM: 1
total assistance/dependence
Balance: Normal (4)
No external support, tolerates maximal challenge, wt shift all directions = no risk for falls
Balance: Good (3)
No external support, mod challenges, wt shift with limitations - Minimal risk for falls
Balance: Fair (2)
no external support, tolerates no challenges, can’t wt shift = moderate risk for falls
Balance: Poor (1)
Requires external support/assistance = high risk for falls
Balance: Zero (0)
Requires max assistance
4 Point Gait
1 thing at a time.
Devices: Bilateral crutches, bilateral canes, reciprocal walker
2 Point Gait
1 things more at a time.
Devices: bilateral crutches, bilateral canes, reciprocal walker
Mod 2, Mod 4
Only one device
3 Point
Non-weight bearing.
Bilateral crutches, standard walker
Dermal Appendages
Hair follicles
Sebaceous Glands
Sweat Glands
