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Equipment, Devices, Modalities, Wounds > Wounds and Gait AD > Flashcards

Wounds and Gait AD Flashcards

1
Q

Suspected Deep Tissue Injury

A

Blood filled blister
Purple or maroon area of discolored, intact skin
Tissue is painful, firm, mushy, boggy, warmer/cooler than adjacent tissue

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2
Q

Stage 1 Pressure Ulcer

A

Non blanchable erthema of intact skin

Firm or boggy skin

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3
Q

Stage 2 Pressure Ulcer

A

Partial thickness skin loss involving epidermis and or/dermis
Abrasion, blister, shallow cratter
Red/pink bed NO slough
Serum-filled blister

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4
Q

Stage 3 Pressure Ulcer

A 
Full thickness tissue loss
Damage of subcutaneous tissue that may extend down to fascia
Fibrin or Slough
Can have undermining/tunneling
Deep crater
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5
Q

Stage 4 Pressure Ulcer

A

Damage to muscle, bone, supporting structures
Slough/eschar can be present
Undermining Tunneling

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6
Q

Unstageable

A

Full thickness loss persumed

Base of wound bed filled with slough or eschar

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7
Q

Goals: ABCDEF

A 
Audience
Behavior
Condtion
Duration
Endpoint
Functional Purpose
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8
Q

FIM: 7

A

complete independence

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9
Q

FIM: 6

A

modified independence (more time/assistive device/safety)

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10
Q

FIM: 5

A

Supervision or set up

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11
Q

FIM: 4

A

minimal assistance

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12
Q

FIM: 3

A

moderate assistance

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13
Q

FIM: 2

A

maximal assistance

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14
Q

FIM: 1

A

total assistance/dependence

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15
Q

Balance: Normal (4)

A

No external support, tolerates maximal challenge, wt shift all directions = no risk for falls

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16
Q

Balance: Good (3)

A

No external support, mod challenges, wt shift with limitations - Minimal risk for falls

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17
Q

Balance: Fair (2)

A

no external support, tolerates no challenges, can’t wt shift = moderate risk for falls

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18
Q

Balance: Poor (1)

A

Requires external support/assistance = high risk for falls

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19
Q

Balance: Zero (0)

A

Requires max assistance

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20
Q

4 Point Gait

A

1 thing at a time.

Devices: Bilateral crutches, bilateral canes, reciprocal walker

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21
Q

2 Point Gait

A

1 things more at a time.

Devices: bilateral crutches, bilateral canes, reciprocal walker

22
Q

Mod 2, Mod 4

A

Only one device

23
Q

3 Point

A

Non-weight bearing.

Bilateral crutches, standard walker

24
Q

Dermal Appendages

A

Hair follicles
Sebaceous Glands
Sweat Glands

25
Q

Epidermis

A

Cellular and avascular

26
Q

Epidermis Functional Components

A

Stratum Corneum: top layer
Keratinocytes: keratin
Melanocytes: melanin
Basal cells: basement membrane

27
Q

Dermis major components

A

Collagen and elastin

28
Q

Inflammatory Phase

A

4 days

29
Q

Proliferative Phase

A

Collagen phase
4-21 days
Fibroblasts

30
Q

Granulation

A

tissue fills in hole with collagen (bumpy)

31
Q

Epitheliazation

A

sliding of cells

32
Q

Wound Contraction

A

myofibril pulls cells together

33
Q

Maturation Phase

A

Remodeling Phase
1-2 years (longer in kids/old)
80% of original strength

34
Q

Hypertrophic scar

A

stays within boundaries of original wound

35
Q

Keloid

A

Outside borders of original wound

36
Q

Primary Intention

A

spontaneous closure of wound

37
Q

Partial Thickness heal by

A

epithelialization

38
Q

Full thickness heal by

A

granulation and contraction

39
Q

Wound: Partial Thickness

A

Epidermis and portion of dermis

40
Q

Wound: Full Thickness

A

Entire epidermis and dermis. Extends into subcutaneous tissue and possibly beyond fascial plane

41
Q

Serous Drainage

A

clear/transparent

42
Q

Serosanguinous drainage

A

serum and blood

43
Q

Fibrous Slough Tissue Color

A

Yellow/clear

44
Q

Necrotic Tissue Color

A

Black

45
Q

Epithelium Tissue - New Growth

A

Translucent to white

46
Q

Granulation Tissue

A

red

47
Q

Purulence

A

Green

48
Q

Silver Impregnated Gauze

A

Controls bacteria in wound

49
Q

Transparent Film

A

maintains moist healing environment

50
Q

Alginate

A

Absorbs copious amounts of drainage

51
Q

Hydrogel

A

Adds moisture to a wound

Equipment, Devices, Modalities, Wounds (4 decks)

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