Term
| Integumentary Scan - what to look for (categories) (6) |
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Definition
color/texture
skin rxns/responses
nails
lesions
skin integrity/sensation
risk assessment |
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Term
| Color/Texture - look fors (4) |
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Definition
pallor/pale
jaundice
cyanosis
gangrene |
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Term
| Skin rxn/responses: examples (3) |
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Definition
lymphangitis
phlebitis
Raynaud's |
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Term
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Definition
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Term
| black nail bed signifies... |
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Definition
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Term
| 60 second foot screen: 0-15s |
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Definition
| examine callus, color, toenails, structure |
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Term
| 60 second foot screen: 15-30s |
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Definition
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Term
| 60 second foot screen: 30-60s |
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Definition
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Term
| 60 second foot screen: Q to ask |
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Definition
| feet numb, tingling, burning, crawling? |
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Term
| Integumentary tests/measures (6) |
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Definition
wound characteristics
pressure risk assessment
vascular testing
neuropathic testing
periwound tissue
infection |
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Term
| Risk assessment: primary scale used |
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Definition
Braden/Norton scale
(used to plan prevention, Rx; Norton=peds) |
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Term
| Diabetic Ulcer Risk: incr risk c: (3...) |
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Definition
monofilament insensation
hx of amputation
hx of ulcer
... |
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Term
| Vv ulcers: triggers (4...) |
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Definition
cellulitis
direct injury
dermatitis
rapid edema |
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Term
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Definition
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Term
| Phases of tissue healing (3) |
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Definition
inflammation
proliferation
maturation/remodeling |
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Term
Tissue healing: inflammation
steps involved |
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Definition
coagulation
aggregation of cells (lymphocytes, platelets, etc) |
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Term
Tissue healing: proliferation
steps involved |
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Definition
epithelialization
fibroplasia |
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Term
Tissue healing: maturation/remodeling
steps involved |
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Definition
scar tissue
wound closure
COLLAGEN remodeling |
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Term
| Chronic wounds: which healing stage is prolonged? |
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Definition
prolonged inflammatory stage
(inhibits proliferative stage) |
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Term
| Chronic wounds: causes (5) |
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Definition
repetitive trauma
local ischemia
necrotic tissue
heavy bacterial burden
tissue breakdown |
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Term
| MMPs (matrix metalloproteases) |
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Definition
pro-inflammatory substances; cause wounds to stay in inflammatory state
break down developing collagen matrix; inhibits growth factors |
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Term
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Definition
anti-inflammatory subtances (in the body)
antagonists to MMPs |
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Term
| Subjective exam: questions (20) |
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Definition
when/how wound began
precipitating event
Rx
S/Sx
pain
improving/regressing
comorbs
meds
allergies
nutrition
other substances
activity level
fxnl level
ADs
shoes
family hx
caregiver/family support
PMHx
previous wounds/infections
pt concerns/goals |
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Term
| Cardiopulmonary: effect on wounds/integument |
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Definition
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Term
| Musculoskeletal: effect on wounds/integument |
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Definition
mm pump
ROM (e.g. affects gait) |
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Term
| Neuromuscular: effect on wounds/integument |
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Definition
posture
abnormal tone
ANS dysfxn |
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Term
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Definition
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Term
| Wound exam: A MEASURES - A1 |
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Definition
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Term
| Wound exam: A MEASURES - M |
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Definition
measures (LxWxD)
*most frequently left out of pt documentation) |
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Term
| Wound exam: A MEASURES - E |
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Definition
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Term
| Wound exam: A MEASURES - A2 |
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Definition
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Term
| Wound exam: A MEASURES - S1 |
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Definition
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Term
| Wound exam: A MEASURES - U |
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Definition
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Term
| Wound exam: A MEASURES - R |
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Definition
| re-eval (onset, duration, previous Rx) |
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Term
| Wound exam: A MEASURES - E |
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Definition
| exudate (appearance, amt, odor) |
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Term
| Wound exam: A MEASURES - S2 |
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Definition
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Term
| Wound exam: edges - irregular |
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Definition
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Term
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Definition
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Term
| Wound exam: edges - rolled/closed |
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Definition
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Term
| Wound exam: edges - hyperkeratosis |
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Definition
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Term
| Wound exam: edges - macerated |
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Definition
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Term
| Wound exam: edges - inflamed |
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Definition
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Term
| Wound exam: edges - epithelialization |
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Definition
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Term
| Wound exam: surrounding skin - erythema |
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Definition
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Term
| Wound exam: surrounding skin - maceration >> |
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Definition
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Term
| Wound exam: surrounding skin - purple ulcer |
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Definition
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Term
| Wound exam: surrounding skin - hemosiderin staining |
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Definition
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Term
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Definition
| skin intact, unblanchable |
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Term
| pressure ulcers: Stage II |
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Definition
partial thickness loss
no slough |
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Term
| pressure ulcers: Stage III |
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Definition
full thickness loss
NO bone/tendon/mm visibile |
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Term
| pressure ulcers: Stage IV |
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Definition
full thickness loss
bone/tendon/mm visible |
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Term
| pressure ulcers: Unstagable |
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Definition
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Term
| CEAP classification of wounds: |
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Definition
Clinical severity
Etiology
Anatomy
Pathophysiology |
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Term
| Appearance of bone: color - healthy v infected |
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Definition
healthy: tan
infected: dark, brown |
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Term
| Infection (superficial) acronym |
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Definition
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Term
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Definition
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Term
| Infection (superficial) acronym: N |
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Definition
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Term
| Infection (superficial) acronym: E |
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Definition
| exudative wound (.74-.78) |
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Term
| Infection (superficial) acronym: R |
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Definition
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Term
| Infection (superficial) acronym: D |
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Definition
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Term
| Infection (superficial) acronym: S |
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Definition
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Term
| Infection (deep) acronym: S1 |
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Definition
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Term
| Infection (deep) acronym: T |
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Definition
| temperature (raised c systemic issue) |
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Term
| Infection (deep) acronym: O |
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Definition
| Os (osteomyelitis; very likely if probe reaches bone) |
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Term
| Infection (deep) acronym: N |
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Definition
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Term
| Infection (deep) acronym: E (3) |
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Definition
edema (.93)
exudate
erythema |
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Term
| Infection (deep) acronym: S2 |
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Definition
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Term
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Definition
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Term
| Infection: smell - putrid |
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Definition
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Term
| highest predictive value for development of infection = |
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Definition
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Term
| Exudate: descriptors to include (3) |
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Definition
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Term
| Infection: smell - ammonia |
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Definition
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Term
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Definition
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Term
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Definition
extent of damage
type of tissue
infection |
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Term
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Definition
lt touch
vibration
temp
proprio
pressure |
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Term
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Definition
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Term
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Definition
| hyperpigmented (hemosideriosis) |
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Term
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Definition
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Term
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Definition
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Term
| Vv ulcer: capillary refill |
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Definition
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Term
| Vv ulcer: ulcer appearance |
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
|
Definition
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Term
| aa ulcer: capillary refill |
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Definition
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Term
| aa ulcer: ulcer appearance |
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Definition
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Term
| Vv ulcers: Rx the cause (6) |
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Definition
R/O aa disease
check vascular flow
ankle jt mobility
vv reflux
compression
meds |
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Term
| Vv ulcers: suggested meds |
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Definition
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Term
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Definition
adherence
lifestyle changes
pain |
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Term
| Aa ulcers: Rx the cause (6) |
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Definition
vasulcar diagnositcs
endovascular intervention
sx revascularization
pharmacotherapeutics
amputation
adjunct mgmt |
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Term
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Definition
mgmt of disease process
nutritional support
mgmt of fluid/electrolytes |
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Term
| Neuropathic ulcers: Rx (4) |
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Definition
aa vascular assessment
glycemic control
offloading
sx |
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Term
| Good ability to heal: palpable pulse |
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Definition
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Term
| Good ability to heal: ABI |
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Definition
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Term
| Good ability to heal: transQ O2 tension |
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Definition
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Term
| Good ability to heal: toe pressure |
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Definition
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Term
| Factors that affect healing: acronym |
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Definition
DEAD
(drugs, edema, anemia, disease) |
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Term
| Wound appearance+Rx acronym |
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Definition
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Term
| Rx for necrotic wound (DIME) |
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Definition
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Term
| Rx for infected wound (DIME) |
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Definition
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Term
| Rx for draining/granular wound (DIME) |
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Definition
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Term
| Rx for non-healing wound (DIME) |
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Definition
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Term
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Definition
sharp
autolytic
mechanical
enzymatic
biologic |
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Term
| Types of debridement - fastest |
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Definition
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Term
| Types of debridement - most selective |
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Definition
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Term
| Types of debridement - least painful |
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Definition
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Term
| Types of debridement - best for exudate |
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Definition
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Term
| Types of debridement - best for infection |
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Definition
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Term
| Types of debridement - lowest cost |
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Definition
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Term
| DIME - infection control (4) |
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Definition
antibiotics
cytotoxic solutions
dressings
topical agents |
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Term
| DIME - moisture balance (3) |
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Definition
control & absorb
protect periwound
infection? |
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Term
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Definition
platelet-derived growth factor (PDGF)
skin substitutes
negative pressure therapy (VAC)
physical agents |
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Term
| Dressings: 3 major classes |
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Definition
uninfected
infected
alginate |
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Term
| Dressing choice for uninfected, dry wound |
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Definition
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Term
| Dressing choice for uninfected, min exudate wound (3) |
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Definition
film
thin foam
thin hydrocolloid |
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Term
| Dressing choice for uninfected, mod exudate wound (2) |
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Definition
foam
hydrocolloid c alginate |
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Term
| Dressing choice for uninfected, max exudate wound (3) |
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Definition
foam
hydrocolloid c alginate
alginate c gauze |
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Term
| Dressing choice for infected wound |
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Definition
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