Examination of Patients with Open Wounds Flashcards
(103 cards)
1
Q
What are the 3 components to the physical therapy examination?
A
- Patient history
- Systems review
- Administering tests and measures
2
Q
What are the goals of the physical therapy wound examination?
A
- determine the PT diagnosis
- identify factors that may contribute to ulceration or abnormal wound healing
- to assist with making a wound healing prognosis
3
Q
When asking a patient about their medical history it is important to ask if they are allergic to what 3 things?
A
- latex
- sulfa
- adhesive
4
Q
What is the normal total RBC count for women? And for men?
A
Women: 4.0-5.5 million/mm3
Men: 4.5-6.2 million/mm3
5
Q
If total RBC count is low what may this indicate?
A
anemia or blood loss
6
Q
If total RBC count is high what may this indicate?
A
dehydration or an increased risk for blood clots
7
Q
What is the normal hematocrit for women? And for men?
A
Women: 38-46%
Men: 42-54%
8
Q
If hematocrit is low what may this indicate?
A
anemia, blood loss, or malnutrition
9
Q
If hematocrit is high what may this indicate?
A
dehydration or an increased risk for blood clots
10
Q
What is the normal hemoglobin for women? And for men?
A
Women: 12-16 g/dL
Men: 14-18 g/dL
11
Q
If hemoglobin is low what may this indicate?
A
blood loss or nutritional deficiency
12
Q
If hemoglobin is high what may this indicate?
A
dehydration or an increased risk for blood clots
13
Q
What is the normal total WBC count for both sexes?
A
4500-11,000/mm3
14
Q
If total WBC count is high what may this indicate?
A
infection, inflammatory response, or anemia
15
Q
What is the normal platelet (thrombocyte) count for both sexes?
A
150,000-400,000/mm3
16
Q
If the thrombocyte count is low what may this indicate?
A
delayed clotting is a risk
17
Q
If the thrombocyte count is high what may this indicate?
A
high potential for blood clots
18
Q
What is the normal total lymphocyte count (TLC) for both sexes?
A
> 1800 cells/mm3
19
Q
If the TLC is low what may this indicate?
A
decreased immune function, protein deficiency, delayed wound healing
20
Q
What is the normal serum albumin levels for both sexes?
A
3.5-5.5 g/dL
21
Q
If serum albumin levels are low what may this indicate?
A
malnourished, increased risk for tissue edema, metabolic stress or inflammation
22
Q
Low levels of serum albumin are correlated with what?
A
pressure ulcer severity
23
Q
If serum albumin levels are high what may this indicate?
A
dehyration
24
Q
What are the normative values for serum prealbumin?
A
16-40 mg/dL
25
If serum prealbumin levels are low what may this indicate?
malnourished, metabolic stress, inflammation
26
Mortality rate increases as prealbumin _____.
decreases
27
What are the normative values for serum trasnferin?
>170 mg/dL
28
If serum transferin levels are low what may this indicate?
protein deficiency or malnourished
29
If serum transferin levels are high what may this indicate?
iron deficiency
30
What are the normative values for blood glucose?
70-110 mg/dL
31
What may be high levels of blood glucose indicate?
poorly controlled diabetes
32
Should urine glucose testing reveal positive or negative values?
negative
33
If there is blood glucose in the urine what may it indicate?
kidney disease or poorly controlled diabetes
34
What are normative BUN (blood urea nitrogen) levels?
8.0-20 mg/dL
35
If BUN levels are high what may it indicate?
kidney disease or dehydration
36
High BUN levels are associated with what?
delayed wound healing
37
What are normative creatinine levels?
0.8-1.2 mg/dL
38
Increased levels of creatinine may indicate what?
kidney disease
39
Creatinine levels decrease with what?
malnutrition
40
How can you tell the difference between wounds caused by arterial insufficiency and venous insufficiency?
Arterial: pain with leg elevation
Venous: relief with leg elevation
41
What are the 4 main purposes of the systems review?
- helps the PT identify risk factors or impairments that may require referral to other disciplines
- allows the PT to identify risk factors or impairments in areas aside from the integument that may benefit from PT intervention to enhance wound healing
- identify signs and symptoms consistent with certain disease processes that may alter PT interventions for wound management
- the PT can determine patient and caregiver education needs
42
What 5 things should be assessed for the Cardiovascular/Pulmonary System Review?
- Heart rate
- Blood pressure
- Respiratory rate
- Edema
- Pulse oximetry
43
What 4 things should be assessed for the musculoskeletal system review?
- Structure
- Posture
- Range of motion
- Strength
44
What 4 things should be assessed for the neuromuscular system review?
- Gait
- Mobility
- Transfers
- Balance
45
What 4 things should be assessed for the GI System Review?
- Nutrition intake
- Supplementation
- Continence
- Body mass index
46
What are 2 nutritional assessment screening tools that can be used to assess the GI system?
- REAP (Rapid Eating and Activity Assessment for Patients)
| - WAVE (Weight, Activity, Variety, Excess)
47
What 3 things should be assessed for the urogenital System Review?
- incontinence
- poorly controlled diabetes
- UTIs
48
The integumentary system review consists of a gross examination of exposed skin including what 4 things?
- skin integrity
- skin color
- skin formation
- hair and nail growth
49
Why is it important to assess for scar formation?
If scarring is present you can conclude injury to the dermis occurred and can assume that dermal appendages will be missing
50
If there is reduced hair or nail growth what may you conclude?
possible malnourishment
51
What 6 things should be documented on in regards to wound characteristics?
- location
- size
- tunneling or undermining
- wound edges
- drainage
- odor
52
Where do pressure ulcers tend to form?
Over bony prominences
53
Where do arterial ulcers tend to form?
distally at the tips of the toes
54
Wounds that are located in folds of skin are typically caused by what?
friction or excess moisture
55
Wounds that are located on the toes are typically caused by what?
friction or decreased circulation
56
Wounds that are located on the bottom of the foot are typically caused by what?
trauma or pressure
57
Wounds that are located on the shin or calf are typically caused by what?
trauma or lack of circulation
58
If the wound edge is round what is most likely the cause?
pressure
59
If the wound edge has jagged edges what is most likely the cause?
shear or friction forces
60
If the wound edge is irregularly shaped what is most likely the cause?
vascular
61
If the wound edge is linear what is most likely the cause?
trauma or friction
62
What is considered to be the actual wound?
the open area only
63
What is the wound base/bed?
the bottom of the wound
64
What is considered to be the wound depth?
the vertical distance from the visible surface to the deepest area in the wound bed
65
What is considered to be the wound edges or margin?
the inside perimeter of the wound
66
The periwound area is measured at minimum _ cm surrounding the wound
4
67
Describe wound tunneling
Channel or pathway that extends in any direction from the wound through subcutaneous tissue or muscle, creating dead space with the potential for abscess formation
68
How is wound tunneling measured?
By inserting a probe into the passageway until resistance is felt.
The depth is the distance from the probe tip to the point at which the probe is level with the wound edge
69
Tunneling is common in what type of wounds?
neuropathic ulcerations and surgical wounds
70
Describe wound undermining
Tissue destruction underlying intact skin along the wound margins in which the base of the wound is larger than at the skin surface
71
How is undermining measured?
By inserting aprobe under the wound edge directed almost parallel to the wound surface until resistance is felt.
The depth is the distance from the probe tip to the point at which the probe is level with the wound edge.
72
Undermining is common in what type of wounds?
pressure or neuropathic ulcers
73
Describe the main difference between wound tunneling and undermining
Tunneling involves only a small portion of the wound edge, whereas undermining involves a large portion
74
What are the 5 ways methods for determining wound size?
- Direct measurement
- Tracings
- Photography
- Volumetric measurement
- Percent of total body surface area
75
In regards to using the clock method __ o'clock is towards the patient's head whereas __ o'clock is towards the patient's feet
12
6
76
How is direct measurement performed?
By measuring the longest length (12 o'clock to 6 o'clock) and the widest width (12 o'clock to 3 o'clock)
77
How is wound surface area calculated?
L x W x D
78
What is a disadvantage to using direct measurement to determine wound size?
It accurately determine depth in wounds covered with nonviable tissue
79
Does direct linear measurement take into account the periwound area?
No
80
How are wound tracings performed?
With a 2-layered transparent film in which the bottom layer is discarded and the top is saved in the medical record
81
What are 2 disadvantages to wound tracings?
- May be difficult to visualize wound perimeter through transparency
- Paper is directly on wound therefore cleanliness may be an issue
82
What are the advantages to photographic wound measurement?
- Digital images are high quality
- Avoids contact with patient’s wound
- Provides periwound and wound bed characteristics
83
What are the disadvantages to photographic wound measurement?
- camera angle and focal distance can influence the image therefore the size of the wound may not be accurately represented
c- Cannot use images used with a non-wound care camera
- lighting can be an issue
84
How is wound size determined through volumetric measurement?
By measuring the amount of dental, silicone molding, or saline that is required to fill the wound
85
What are the disadvantages associated with volumetric measurements?
- time consuming
- can be painful to patient
- can be detrimental to wound healing
86
In what types of wounds should total body surface area measurements be used?
Large surface area wounds, typical with burns
87
What should granulation tissue look like?
pink/red with small granulation bubs
88
What are 2 types of necrotic tissue?
- Slough
| - Eschar
89
Describe slough
yellow or tan in color and has a stringy or mucinous consistency
90
Describe eschar
black necrotic tissue that is dry and obstructs further healing
91
What 4 characteristics of the wound edge must you document on?
- Distinctness
- Thickness
- Color
- Attachment to base of wound
92
What 4 characteristics of wound drainage must you document on?
- Type
- Color
- Consistency
- Amount
93
Wound odor may be an indication of what?
infection
94
What 5 characteristics of the periwound area should be assessed?
- structure and quality
- color
- epithelial appendages
- edema
- temperature
95
In regards to the structure and quality of the periwound area what should you assess for?
- Age-related skin changes
- Periwound hydration
- Skin turgor
- Calluses
- Scar formation
96
How does long-standing ischemia effect epithelial appendages
It cannot support hair and nails tend to be thick and yellow
97
How can you determine if pitting edema is present or not?
Firmly press a thumb or index finger into the affected area and hold for 5 seconds. If depression remains upon removal of finger = positive
98
Describe grade 1+ pitting edema
There is barely a perceptible depression.
There is less than 2 mm of an indentation
99
Describe grade 2+ pitting edema
There is an easily identifiable depression that rebounds in less than 15 seconds.
Indentation is 2-4 mm
100
Describe grade 3+ pitting edema
The depression rebounds in 15-30 seconds.
The indentation is 5-7 mm
101
Describe grade 4+ pitting edema
The depression lasts for more than 30 seconds.
The indentation is greater than 7 mm
102
Define induration
swelling that is firm and does not return to its original state
103
Edema can be measured via circumference. What are the 2 best landmarks to measure this?
Lateral malleolus and ulnar styloid process
