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Integ. Exam LIA 3

QuestionAnswer
What is Capillary refill & what is a normal response? Capillary refill assess blood flow and is when pressure is applied to the distal toe until area blanches & hold for 5 seconds then release. Normal response <3 seconds Longer indicates arterial insufficiency
What is ABI? Compares BP at ankle to BP at arm. Should be = to 1 if it is normal <.8 = peripheral arterial disease
What is transcutaneous oxygen level? It is measurement of amount of oxygen to an area which relates to healing time. Not reliable in patients with swelling or infection TcP02 < 20mm Hg wound will not heal >30 wound should heal and is safe for debridement
Test and Measures to assess Circulation with someone who comes to your clinic with a wound? 1. Peripheral pulses 2. Skin temperature 3. Skin color 4. ABI 5. Rubor of dependency 6. Capillary refill 7. TcP02
What is the rubor of dependency? lying supine, examine the soles of their feet. Elevate foot for 60 seconds while looking at soles of feet. Place foot in dependent position and note time to return to normal. Normal = little color change/ Pink w/in 15-20sec Pale = arterial insufficiency
Characteristics of a Venous Ulcer? In gaitor area, shallow, irregular shape, lots of drainage, pain in dependent position, hemosiderin staining, dermatitis, nail changes, exhibits fibrotic changes, lots of sluff (grey/yellow/stringy necrotic tissue), beefy/red wound base
Characteristics of an Arterial ulcer? distal to medial malleolus, pain in elevated position, little drainage, dryness/desiccation, black eschar, pale wound base, trophic changes to skin and nails, absence of hair, intermittent claudication
Characteristics of Diabetic ulcers? Areas of increased pressure (heel, mid foot, met heads, sometimes between toes), callus periwound, minimal pain, no idea when it started/what caused it due to DPN, round shape, presence of foot deformities, minimal drainage, decreased perspiration
Characteristics of pressure ulcers? Areas with increased bed rest, pts. who have been confined to a bed or chair, 4 Stages
Stages of pressure ulcers? Stage 1: non blanchable erythema, first sign of underlying skin damage Stage 2: damage to epidermis (includes blisters) Stage 3: damage to epidermis/dermis but not sub dermal tissues Stage 4: damage to epidermis, dermis, and sub dermal tissues
Questions for History of present illness? When did it start? Is it painful? where is located? Have you received tx for this wound?
Types of sensory testing? Semmes Weinstein
Created by: 1310142520