Integ Exam/ Assessment

Question 1

What lab tests are important to look at for an integ exam?

Answer 1

blood cultures (infections)
dopplers (vascular changes)

Question 2

What are two important system reviews to look at?

Answer 2

GI, urinary- is the pt incontinent, if so could cause an infxn depending on wound site

Question 3

When doing a quick observation of the skin what things should PT be looking for?

Answer 3

skin integrity, skin color around wound, scar formation of any other wounds, hair and nail growth (clubbing- indicative of overall health)

Question 4

What are 5 most important items to document about a wound?

Answer 4

1. location
2. size
3. thickness
4. colors
5. dry/moist

objective measures

Question 5

What are other important things to document?

Answer 5

tunneling, smell, drainage, periwound

Question 6

When would you use NPUAP scale?

Answer 6

if pressure was the cause of a wound

Question 7

What are 4 stages of NPUAP?

Answer 7

1- non-blanchable erythema
2- superficial ulcer, partial thickness
3- deep ulcer, full thickness, subcutaneous or fascia (can never go back to stage 2)
4- deep ulcer with necrosis, into muscle, tendon and bone

Question 8

When is a Wagner scale used?

Answer 8

used less often but common in literature

for diabetic wounds

Question 9

What is Wagner scale?

Answer 9

0- no open lesion
1- superficial ulcer/ partial thickness
2- deep ulcer to tendon, bone
3- deep ulcer with abcess, osteomyelitis
4- localized gangrene
5- gangrene entire foot

Question 10

What is slough?

Answer 10

yellow or white clumps or string which need to be removed

Question 11

What is granulation?

Answer 11

tissue that is ususally pink or beefy red tissue, shiny, moist this is a good sign of wound healing

if still pink at end of healing that is a bad sign

Question 12

What is epithelial tissue?

Answer 12

new pink shiny tissue, grows in from edges

Question 13

What is Marion classification scale?

Answer 13

color wound classification by percentage

Question 14

What is maceration?

Answer 14

softening of tissue from liquid around peri wound

Question 15

What other terms can be used to describe periwound?

Answer 15

rolled edges, shape, tactile, color, edema, temp.

Question 16

What is exudate?

Answer 16

substance secreted from wound, document amount present (min, mod, max), can look at old dressing and note how long since last dressing change

Question 17

What is acronym used to describe exudate?

Answer 17

T- type
A- amount
C- consistency
O- odor

Question 18

What is a sanguineous consistency?

Answer 18

red thin watery usually a good sign

Question 19

Seroanguineous?

Answer 19

light red/pink watery during normal inflammation, proliferation

Question 20

Serous?

Answer 20

transudate/clear thin- normal

Question 21

Purulent?

Answer 21

yellow tan green thick (pus)- not good usually sign of infxn

Question 22

Seropurulent?

Answer 22

cloudy, yellow tan thin watery, potentially infected

Question 23

blue/green drainage?

Answer 23

bad it is infected

Question 24

What is size of wound always measured in?

Answer 24

Centimeters

Question 25

What are two main type of measurement techniques?

Answer 25

direct and clock

Question 26

What is undermining?

Answer 26

area of tissue lost under skin

Question 27

What is tunneling?

Answer 27

passageway of tissue destruction under the skin surface

Question 28

What is a sinus tract?

Answer 28

cavity at the end of a tunnel, good spot for an infxn

Question 29

Is a thin or thick consistency better for wound healing?

Answer 29

thin

Question 30

What is the Myers pitting edema scale?

Answer 30

1+ indentation is barely visible
2+ slight indentation with depression, returns to normal in less than 15 sec.
3+ deeper indent takes 15-30 sec to return to normal
4+ indentation lasts longer than 30 sec

Question 31

What is Paz pulse scale?

Answer 31

0= no pulse
1+ weak
2+ normal
3+ moderately increased
4+ bounding/ racing pulse

Question 32

What is ABI scale?

Answer 32

greater than 1.2- falsely elevated

0. 95-1.19 normal
1. 75- 0.94 mild arterial disease
2. 5- 0.74 moderate arterial disease

less than 0.5 severe arterial occlusive dz needs referal

Question 33

What are other tests for potential blood clot/ circulatory issues?

Answer 33

cap refill, wells criteria

Question 34

What is hemosiderosis?

Answer 34

staining of skin likely due to rupture of blood vessel