Transcript Integumentary Integrity and Wound Assessment

Mark David S. Basco, PTRP
Faculty
Department of Physical Therapy
College of Allied Medical Professions
University of the Philippines Manila
Learning Objectives
At the end of the session, you should be able to
 Appreciate the role of physical therapists in the care of
clients presenting with impaired integumentary
integrity.
 Determine appropriate physical therapy assessment
procedures given a client with impaired integumentary
integrity.
 Interpret the results of assessment procedures
performed to a client with impaired integumentary
integrity.
Why do we need to perform an
assessment?
 To determine the physical therapy diagnosis
 To identify factors that may contribute to ulceration or
abnormal wound healing
 To assist in making a wound healing prognosis
 To identify factors that may benefit from referral or
consultation with another health care provider
What are we going to discuss?
 Obtaining Patient history
 Determining Wound Characteristics
 Determining Periwound and Associated skin
characteristics
 Other tests
General demographics
Lifestyle and Functional status
Past and current general medical history
Past and current wound history
Systems review
General demographics
 Age
 Sex
 Occupation
 Ethnicity
 Primary language
 Education (patient and caregiver)
Lifestyle and Functional status
 Does the patient live alone?
 Is the patient independent with activities of daily
living?
 Does the patient have sufficient vision to inspect for
skin and wound changes?
 Is the patient ambulatory?
 Does the patient have adequate mobility or dexterity
to perform wound care?
Lifestyle and Functional status
 Is someone available to assist with wound care, skin
checks, meals, bathing & so on?
 Is the patient currently working & what does his job
entail?
 Does the patient have any behavioral health risks e.g.
Smoking or alcohol abuse?
 Does the patient have any cultural or religious beliefs
that may affect therapy?
Past & Current Medical History
 Do you have a history of the following conditions?
 High BP
 Heart disease or heart condition
 Peripheral vascular disease
 Stroke / TIA
 Breathing difficulties
 Diabetes
 Cancer
 HIV / AIDS
 Red Flags
Past & Current Medical History
 Are you allergic to any of the following substances?
 Latex
 Adhesives
 Sulfa
 Animal products
 Is there any other allergies that you have?
Past & Current Medical History
 Do you smoke?
 Number of packs/day
 Number of years smoking
 Do you drink alcohol
 Number of drinks/day
 Do you take drugs not prescribed by a MD?
 Is there any medications that you’re taking?
Past & Current Wound History
 When did the wound begin?
 How did the wound occur?
 Have any tests been performed?
 Wound culture
 Blood tests
 Arteriogram
 Venous doppler
 Have you perviously or are you currently taking any
medications for this wound?
Past & Current Wound History
 Is your wound painful?
 Does the pain change with elevation? dependency?
activity?
 What is currently being done for your wound?
 What interventions have been done in the past? What
impact does these interventions have?
 Is your wound improving, staying the same, or getting
worse?
 Have you had any wounds in the past?
Systems Review
 Cardiovascular / Pulmonary
 Musculoskeletal
 Neuromuscular
 Gastrointestinal
 Urogenital
 Integumentary
Wound Location
Wound Size
Tunnelling / Undermining
Wound Bed
Wound Edges
Wound Drainage
Wound Odor
Wound Location
 Document
 Using anatomically correct terminology
 Side and body surface of the lesion
 If multiple wound exist, it may be helpful to document
wounds in relation to anatomical landmarks
EXAMPLE:
“Wound A is located 10 cm superior to the (R) medial
malleolus; Wound B is located 2 cm superior to the (R)
medial malleolus ”
Wound Size
 Direct Measurement
 Wound Tracings
 Photographic Measurements
 Volumetric Measurements
 Total Body Surface Area
Wound Size
Direct Measurement
 Measure the longest length and widest width
perpendicular to the length
 Surface area = Length x Width
 Wound depth
 Place a probe in the deepest part of the wound bed
 Note point the probe is level with the surrounding intact
skin
 Several depth measuements can be performed at
standard wound locations
 Clock method
Wound Size
Direct Measurement
EXAMPLE:
Wound A
Width = 3.5 cm
Length = 4.2 cm
Surface area = 14.7 cm2
Depth= 1.4 cm
(if with eschar or presence of nonviable tissue)
Depth=1.4 cm; unable to determine actual depth
secondary to eschar
Wound Size
Direct Measurement
 Simple, fast, easy to learn, reliable, & inexpensive
 MOST serious problem is that it may inadequately
reflect wound size, or changes in wound size in
irregularly shaped or circular wounds
 NOT possible to accurately determine depth of wound
covered with nonviable tissue
Wound Size
Wound Tracings
 Materials
 Clean, comformable transparency
 Permanent, fine-tipped pen
 Tracing sheets
 Wound contact layer
 Adhesive outer permanent layer
 Improvised

CLEAN, Plastic wrap folded in half
Wound Size
Wound Tracings
 Surface area estimated from tracing as previously
described
 Wound depth assessed using direct measurement
 Tracings SHOULD be labeled with
 Patient’s name
 Date
 Precise wound location
 Size
 Wound characteristics
Wound Size
Wound Tracings
 3 alternative methods of measuring wound surface
area
 Use of transparencies with premeasure grid marks
 Planimetry
 Digitizing
Wound Size
Wound Tracings
 Simple, fast, easy to learn
 Advantages over direct measurement
 More accurate representation of wound size;
regular/circular wounds
 Retained image helpful for future comparisons
 Main sources of error
 Visualizing wound perimeter through the transparency
 Tracing itself
Wound Size
Photographic Measurement
 Surface area determined by tracing photographic
image
 Advantages over wound tracing
 Avoids contact with wound
 Provides additional information about periwound and
wound bed characteristics
 Equipment available today allows clinician with minimal
photographic skill & knowledge to obtain fairly
consistent, high quality images
Wound Size
Photographic Measurement
 Wound photographs SHOULD include
 Patient’s name
 Date
 Precise wound location
 Measurement guide (ruler for scaling reference)
 Results of direct wound measurements
Wound Size
Photographic Measurement
 Disadvantages
 Prone to errors in scale
 Camera distance and camera angle can influence
resulting image size
 Inconsistent lighting conditions may make wound
assessment problematic
 Costly & time-consuming
 Use photography to provide supplemental information
but not to determine wound size
Wound Size
Volumetric Measurement
 Measuring either the amount of molding or saline
required to fill the wound void
 Provides a more complete illustration of wound size in
three dimensions
 Disadvantages
 Time consuming and painful for the patient (molding)
 Inaccurate and problematic (saline)
 Cannot be used on wounds that extend into body
cavities / fascial planes
 Unclear if molding material may have detrimental
effects to wound healing
Wound Size
Total Body Surface Area (TBSA)
 Used for wounds covering large body surface areas
 Commonly used in patients with burn injuries
 Quick, inexpensive, & reliable method of estimating
wound size
Wound Size
Total Body Surface Area (TBSA)
 Rule of Nines
 American Burn Association Classification
MINOR
MODERATE
MAJOR
ADULT
< 15
15 - 25
> 25
CHILDREN
< 10
10 – 20
> 20
* Percentage of partial thickness burn
Wound Size
Total Body Surface Area (TBSA)
 American Burn Association Classification
MINOR
MODERATE
MAJOR
<2
2 -10
≥ 10
ADULT
CHILDREN
* Percentage of FULL thickness burn
Tunneling / Undermining
 Tunneling
 Is a narrow passageway created by the separation of, or
destruction to, fascial planes
 Undermining
 Occurs when the tissue under the wound edges become
eroded, resulting in a large wound with a small opening
Tunneling
 Measured by inserting a probe into the passageway
until resistance is felt
 Tunnel depth is distance from the probe tip to the
point at which the probe is level with the wound edge
 Use CLOCK terms to document tunnel’s position
within the wound bed.
EXAMPLE
“Wound tunnels 1.9 cm at 3-o’ clock position”
Undermining
 Measured inserting a probe under the wound
edgedirectly almost parallel to the wound surface until
resistance is felt
 Distance from probe tip to the point at which the probe
is level with the wound edge
 Use CLOCK terms
EXAMPLE
“Undermining 1.2 cm from 9- o’ clock to 1- o’ clock
positions. ”
Wound Bed
 May contain varying types and amounts of
 granulation tissue
 necrotic tissue
 other structures
Wound Bed
Granulation Tissue
 Temporary scaffolding of vascularized connective
tissue that fills the wound void
 Beefy-red appearance
 Pale or dusky
 Document characterictics and percentage of wound
bed it covers
Wound Bed
Necrotic Tissue
 Described by color, consistency, and percentage of
wound bed it occupies
 Slough
 Yellow or Tan in color and has stringy or mucinous
consistency
 Eschar
 Black necrotic tissue; either soft or hard
 Either adherent or non-adherent
 Refers to the ease with which the necrotic tissue can be
separated from the wound
Wound Bed
Other Tissues
 Exposed structures e.g. Fascia, muscle, tendon, joint
capsule, or bone
 Document
 Type of structure
 Characteristics
 Percent of wound bed occupied
 Presence of other items




Sutures
Staples
Foreign material
Implant
Wound Edges
 Tissue at the perimeter of the wound
 Characteristics
 Distinctness
 Thickness
 Attachment to the base of the wound
 Epithelialization / pigmentation
Wound Edges
Distinctness
 Some superficial wounds present with indistinct
edges; wound gradually transitions into intact skin
 Deeper wounds have more distinct & well-defined
edges
Wound Edges
Thickness
 Chronic wounds tend to have thickened or rolled
wound edges
Wound Edges
Attachment
 Wounds with attached edges are flush with the
surrounding tissue
 Wound with unattached edges are deep and wound
side walls are evident
Wound Drainage
 Type
 Color
 Consistency
 Amount
Type
Characteristics
Serous
-Seen in the inflammatory phase
-Clear to pale yellow
- Watery consistency
Sanguinous -Results from bleeding at the
wound site
- Red or Dark brown
-Consistency of blood or slightly
thickened water
Purulent
-White to pale yellow
-Viscous or creamy
-Certain infections have a
characteristic drainge color
Interpretation
Normal
Normal
Possible Infection
Color
Interpretation
Clear
Normal
Pale yellow
Normal
Red
Fresh Blood
Dark Brown
Dried Blood
Blue-green
Probable Pseudomonas infection
Yellow
Possible infection
Consistency
Interpretation
Thin, watery
Thick, creamy
Normal
Possible Infection
Amount
Interpretation
None
Minimal
Moderate
Copious
Dessicated wound bed
Normal; however, wounds with drainage that
is disproportionate to the amount of necrotic
tissue may be infected
Possible Infection, especially if out of
proportion to wound size
Wound Odor
 Assessed after the wound has been debrided and
rinsed
 Described as either present or absent
 Should never be used as sole indicator of wound status
Structure & Quality
Color
Epithelial Appendages
Edema
Temperature
Structure & Quality
 Normal age-related skin changes
 Periwound hydration
 Skin turgor
 Presence and location of any calluses
 Scar formation
 Assess quality of scar tissue
 Thickness, mobility, & color
 Presence of any deformity
Color
 Describe color of periwound & associated skin in
relation to both neighboring and comparable skin to
opposite side
 Erythema
 Blanchable
 Non-blanchable
 Indicator of inflammation
 If out of proportion to the size and extent of the wound,
may indicate infection
Epithelial appendages
 Hair
 Nail
 Long-standing ischemia will be unable to support hair
growth and increases risk of fungal infection (nails)
pale and yellow
Edema
 Edema
 Localized / generalized accumulation of fluid within
body tissues
 Pitting / Non-pitting
 Press thumb / index to affected area
 If depression remains after pressure is released, pitting
edema is present
 Circumferential measurements
 Volumeter
Temperature
 Prior to testing
 Patient should rest in supine with the area uncovered for
at least 5 minutes
 Use dorsum of the hand to lightly palpate skin
 Temperature compared with more proximal body
segments & contralateral side
 If available
 Thermistor
 Radiometer (uses IRR)
Circulation
Sensory Intergrity
Circulation
 Peripheral circulation should be assessed in all
extremity wounds
 Could use Doppler ultrasonography
 Capillary refill
 Push against distal tip of digit until skin blanches
 Remove pressure
 Note amount of time skin returns to normal
 Should be less than 3 seconds
Circulation
Pulse Grade
Characteristics
0
Absent
1+
Diminished
2+
Normal
3+
Bounding or accentuated
Sensory Integrity
 Gold Standard for assessing light touch sensation
 Semmes-Weinstein monofilaments
 To assess
 Occlude patient’s vision
 Apply monofilament perpendicular to the skin with
enough pressure to bend it
 Assess each location 3 times
 Assess non-callused skin when possible
 Document location and the thickest filament the
patient could identify
Sensory Integrity
Monofilament
Pressure
Produced
(grams)
Interpretation of INABILITY to
perceive monofilament
4.17
1
Decreased sensation
5.07
10
Loss of protective sensation
6.10
75
Absent sensation
References
 Myers, B.A. (2004). Wound management: Principles
and practice. NJ: Pearson Education.
 McCulloch, J.M., Kloth, L.C., & Feedar, J.A.
(1995).Wound healing: Alternatives in management.
Philadelphia: F.A. Davis.
 Cuccurullo, S. (2004). Physical medicine and
rehabilitation board review. New York: Demos Medical
Publishing.
 Juego, J.B. (2007). PT 142 notes.