Wound CPE Prep

Ankle Brachial Index

Is a reliable, indirect and noninvasive measurement of peripheral tissue perfusion

What does a low value for ABI correlate with

increased severity of atherosclerosis and coronary arterial disease

What does an ABI of 1.1-1.3 indicate

vessel calcification; making the ABI not a valid measurement of perfusion

What is a normal ABI score

.9-1.1

What is a mild to moderate score for ABI and its indication

.7-.9 mild to moderate arterial insufficiently meaning intermitted claudication

What ABI value is severe arterial insufficiency

less than .5 meaning they will have pain at rest and will have poor wound healing

What is the Rubor of Dependency

is a non invasive test that can be used to indirectly assess arterial flow to the LE

What is a normal presentation of the Rubor test

pt will exhibit little to no color change with elevation after 1 min, LE will have light red to pink color return after 15-20 sec

What is a normal presentation of the Rubor test for someone with mild arterial insufficiency

Pallor usually occurs within 45-60 sec of LE elevation

What is a normal presentation of Rubor test for someone with moderate arterial insufficiently

Pallor usually occurs within 45-30sec of elevation

What is a normal presentation of Rubor test for someone with severe arterial insufficiency

Pallor within 25 sec of elevation with presence of dependent rubor once they LE return to a dependent position

What is the grading scale for pulse

0 = absent pulse

1 = diminished pulse

2 = normal (easy to palpate)

3 = bounding pulse

What does the capillary refill test indicate

reliable indicator of surface arterial blood flow

What is a normal capillary refill test return time

capillary refill time is less than 3 secs

What does an abnormal capillary refill test time

Anything longer than 3 secs indicates arterial insufficiency

Doppler Ultra sound for venous system

It is the gold standard for this system but requires the PT to interpret changes in sounds

What are the 3 parts for Doppler Ultra sound test

1. at rest

2. augmentation

3. reflux

What should a normal “rest” venous doppler ultra test sound like

should have spontaneous sound (sounds like the wind blowing)

What does an abnormal “rest” venous doppler test indicate

there is no sound; indicates venous obstruction

How is the “augmentation” test performed, and what is a normal finding

For this test pressure is applied distal from the probe and in healthy veins should enhance the sounds

How is the “augmentation” test performed, and what is a abnormal finding

For this test pressure is applied distal from the probe and if the sound is not present could indicate partial venous insufficiency

How is the “Reflux” test performed, and what is a normal finding

For this test pressure is applied proximal to the probe and in healthy veins should make the signal disappear. When it is released the sound should return

How is the “Reflux” test performed, and what is a abnormal finding

For this test pressure is applied proximal to the probe and if the sound is enhanced it may indicate valve incompetence

What is a normal venous filling time

is between 5-15 secs

What does a time of less than 5 secs indicate for a venous refill test

indicates venous insufficiency

What does a time of greater than 20 secs indicate for a capillary refill test

indicates arterial insufficiency

What does Pitting edema test for

test for the amount of fluid trapped in the tissues 2/2 cardiac complications

What does a +1 pitting edema INDICATE

2mm depression with immediate rebound

What does a +2 pitting edema indicate

takes less than 15 secs to rebound

What does a +3 pitting edema edema

it takes 15-30 secs to rebound

What does a 4+ pitting edema indicate

takes greater than 30 secs to rebound

What does a positive stemmer sign indicate

when PT is unable to pinch and lift the skin indicating lymphatic insufficiency

What is the gold standard for neuropathic testing

Monofilament

What does a monofilament test for

test for the presence or absents of protective sensation and light touch

What does a monofilament of 4.17 measure in grams

1 gram of pressure produce replicating normal foot sensation detection

What doe 5.07 monofilament measure in grams

10 grams and is replicating normal foot protective sensation

What does 6.10 monofilament measure in grams

75 grams and assessing the presence of any foot sensation

What does an indication if a pt is able to perceive 10 grams

that they have intact protective sensation

what does it indicate if the pt is not able to perceive 10 grams

that they have loss of protective sensation

What does it indicate if the pt can not perceive 75 grams

that they have absent sensation and need to be tested higher up for further evaluation

What does tunning fork measure

measuring the presences of deep sensation and the presents of neuropathy

What is an abnormal finding for the tunning fork test

is it they can not feel the sensation anymore less than 4 sec it indicates severe neuropathy

What does the Wagner scale measure

it is a classification system of diabetic foot ulcers

What does a 0 Grade on the Wagner scale indicate

that there are no open lesions but may have deformity or cellulitis

What does a 1 Grade on the Wagner scale indicate

that is is a superficial ulcer involving the full skin thickness but not of the underlying tissue

What does a 2 Grade on the Wagner scale indicate

That it is a deep ulcer to tendon, capsule, or bone.

Deep ulcer, penetrating down to the ligaments and muscle, but no bone involvement or abscess formation

What does a 3 Grade on the Wagner scale indicate

Deep ulcer with abscess, osteomyelitis, or joint space

deep ulcer with cellulitis or abscess formation often with osteomyelitis

What does a 4 Grade on the Wagner scale indicate

Localized gangrene

What does a 5 Grade on the Wagner scale indicate

Gangrene of the entire foot

Wound Gel

Calcium Alginate

Foam Dressing

Film

Telfa

Hydrocolloid

Gauze

semipermeable foam

Hydrocolloid