Download WOUND EVALUATION - Erie Community College

WOUND EXAMINATION
PATIENT HISTORY
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WOUND HISTORY
DURATION
ATTRIBUTING EVENT
SYMPTOMS
PAIN
PARESTHESIA/ANESTHESIA
HISTORY (cont.)
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DOES PAIN CHANGE WITH POSITION
elevation decreases pain = venous
dependency increases pain in venous
lesions
pain with rest - severe occlusive disease
intermittent pain with ambulation =
claudication
HISTORY (CONT.)
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PRES.MH, PMH, PSH (PVD, CHF, HTN,
DM, THYROID, LYMPHEDEMA,
IMMUNOSUPPRESSIVE, CA , R/A ETC.)
PAST TREATMENT & OUTCOME
MEDICATIONS
TESTS (CULTURES, DOPPLERS, BONE
SCAN, X-RAY)
HISTORY (CONT.)
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ADDITIONAL STUDIES (ARTERIOGRAM,
VENOGRAM, ABI)
SOCIAL HX
VOCATIONAL HISTORY
HOBBIES
OBJECTIVE EVALUATION
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Test & Measures
LOCATION
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HYPERTENSIVEposterio/lateral leg, onset
with infarction, very severe
pain hypertension
VENOUS-distal leg, medial
aspect, red base, wet,
periwound skin staining, no
pain, mild insufficiency
Chronic Venous
Insufficiency:
“champagne bottle”
“piano leg” appearance
Atrophie
blanche
LOCATION (CONT.)
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ARTERIAL-DISTAL LOWER
EXREMITY, LATERAL ASPECT,
TOES & FEET, PALE BASE,
ATROPHIC SKIN, DRY WOUND,
SEVERE PAIN,
ARTERIOSCLEROSIS
NEUROTROPHIC-PLANTAR
SURFACE OF FOOT, SMALL OR
DEEP, PERIWOUND CALLOUS,
INFECTION, NO PAIN
POSSIBLE DM
SIZE
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LENGTH, WIDTH, AREA, DEPTH,
VOLUME - IF REMOVE ESCHAR WOUND
WILL APPEAR BIGGER
MEASURE FROM WOUND EDGE
USE CONSISTENT TOOL & UNITS OF
MEASUREMENT
PHOTOGRAPHY, TRACING, VOLUME,
SYRINGE
UNDERMINING
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ALSO KNOWN AS RIMMING OR TUNNELING
TISSUE DESTRUCTION UNDERLYING INTACT
SKIN ALONG THE WOUND MARGINS
(HYPOGRANULATION)
MEASURE USING THE O’CLOCK SYSTEM,
HEMISPHERES
GIRTH
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EDEMA, ATROPHY
MEASURE WITH REFERENCE TO BONY
LANDMARKS USING TAPE MEASURE
VOLUMETRIC DISPLACEMENT
Edema
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Measured in a variety of ways:
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Quantifying Pitting that occurs from the
examiner’s digit
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1+ Barely perceptible depression
2+ Easily identified depression, 15 sec. to
resolve
3+ Depression takes between 15-30 sec. to
resolve
4+ Depression lasts for greater than 30 sec.
SHAPE
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TRIANGULAR- SKIN TEAR
ROUND- ARTERIAL
IRREGULAR-VENOUS
SLOPES
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ANGLES OF MARGINATION
DEPICT GRANULATION
VERY IMPORTANT MEASUREMENT
Staging of Wounds
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Stage I-IV Pressure Wounds
Wounds other than Pressure
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Superficial
Partial Thickness -epidermal layer,
superficial layer of dermis
Full-Thickness- epidermis, dermis,
subcutaneous , may also involve muscle
and bone
Stage I
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Partial Thickness, limited to
epidermis, non-blanchable
erythema (sunburn)
Stage II
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Partial Thickness
Skin Loss,
involves both
epidermis and
dermis
(abrasion, blister,
shallow crater)
Stage III
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Full Thickness Skin
Loss
Damage or Necrosis
of Subcutaneous
Tissue
May Extend to
Fascia
(deep crater, with or
without
undermining)
Stage IV
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Full-Thickness Skin
Loss
Extensive
Destruction
Necrosis
Damage to Muscle,
Tendon, Joint
Capsule, Bone
Wagner Ulcer Classification
Diabetic Ulcers
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Grade
0
1
2
3
4
5
Intact Skin
Superficial Ulcer
Deep Ulcer
Deep Infected Ulcer
Partial Foot Gangrene
Full Foot Gangrene
Tissue Composition
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RED WOUNDS- clean healthy
granulating wounds
YELLOW WOUNDS-may contain fibrous
tissue, hydrated necrotic tissue, or dead
tissue, referred to as slough
BLACK WOUNDS-dried eschar, leathery
Tissue Found in Wounds
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Eschar
Granulation
Adipose
Fascia
Muscle
Tendon
Bone
Foreign Debris & Necrotic
Tissue
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Remove as Soon as Possible
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This will prevent bacterial colonization and
infection
Peri-Wound
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Trophic Changes (dry skin, brittle nails,
hair loss)
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indicates poor arterial nutrition
Peri-Wound
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Change in skin color
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cyanotic = Arterial Compromise
Pigmentation (hemosiderin staining),
pigment is deposited from RBC = Venous
Ring of Redness or Halo of erythema
around the wound may indicate infection
Drainage
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Inactive
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found on dressing, at time of observation no drainage is
found in or near the wound
Drainage
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Active
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Free flowing, able to be milked from the
wound
Characteristics of Drainage
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Transudate (Serous): clear, watery
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Serosanguineous: tinged red/brown
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contains: H20, salts and proteins
watery, thin
contains: serum, blood
Exudate: creamy, yellowish
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moderately thick
contains: proteins, WBC
Characteristics of Drainage
(cont.)
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Purulent/Pus: yellowish/brownish
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Thick
contains: WBC, necrotic debris
Infected Pus
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yellow, green/blue
thick
contains: pathogens
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describe amount:none, min, mod, max
Odor
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Pseudomonas-sweet smell (fruity)
Garbage- rotten= infection
Proteus- ammonia
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describe; absent, mild, moderate, foul
smelling
Temperature
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systemic v. localized
measured
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touch
thermistor
thermography
radiometer
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measure infrared radiation from the body
Indications for culture
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Clinical Signs of Local
Infection by Linholm
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Signs of systemic infection
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edema, erythema, purulent or
foul smelling drainage,
increased pain, induration,
heat around the wound; IFEE
fever, abnormal CBC
Bone Involvement
(osteomyelitis)
Non-Healing Wounds (silent
infection)
Aerobic swab culture technique. The culturette
Is rotated while moving in a 10-point pattern.
Gentle pressure to express fluid is required.
From: Myers, B.A. Wound Management: Principles and Practice. Prentice Hall, Upper Saddle River, NJ. 2004: p. 94
Vasculature Examinations
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Pulses(2+Normal, 1+Diminished, 0
Absent)
Auscultation (swishing sound, only
heard in abnormal artery)
Venous Exam (venous doppler)
Vascular Exams Continued
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arterial exam
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ankle-brachial index (ABI)
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sys.pres.LE/sys.preUE (120/100=1.2 normal)
should equal 1 or greater than 1
1 or greater = no arterial occlusive disease
0.9-1.0 minimal symptoms in LE
0.5-0.9 claudication pain
0.3-0.5 ischemic rest pain
less than 0.3 ischemia with tissue necrosis
Normal ABI
Heart Level
SBP
100 mmHg
ABI
120 mmHg/100mmHg= 1.2
Doppler
Ankle
SBP
120mmHg
Doppler
ABI
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When ABI value is <.9
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95% sensitive
99% specific
For angiographically significant PVD
ABI
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Change of 0.15 correlates with disease
and symptomology
Measuring ABI
Tissue Oxygen Tension
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tc-Po2
transcutaneous oximmetry
Rubor of Dependency Test
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assess arterial flow by evaluating skin color
changes during elevation and dependency
leg elevation at 60 degrees for 1 min.
normally no significant change in color
lower the leg, record time for color return
arterial insufficiency may take longer than 30
sec.
color will be bright red (hyperemic)
VENOUS FILLING TIME
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assess arterial flow by evaluating time
veins take to fill after emptying
elevate LE for 1 min. to 60 degrees
lower the leg, record time that veins on
the dorsum of the foot take to refill
with arterial insufficiency may take 30
sec. or longer
Claudication Time
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assess arterial response by increasing
the demand to the calf musculature
during exercise
Treadmill- 1-2MPH
measure time to claudication
monitor changes in functional status
over time
Test for DVT
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Homan’s Sign
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squeeze calf while dorsiflexing the ankle,
with the knee held in an extended position
tenderness with increased firmness may
suggest DVT
confirm using blood pressure cuff
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pt. unable to tolerate 40mmHg if DVT present
normally able to tolerate much higher pressures
Test for Cutaneous Sensitivity
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perception of light touch
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perception to temperature
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use cotton ball
warm, cool
2-point discrimination
Monofilament Testing for LOPS
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Semmes-Weinstein Monofilaments
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Scale of 1.65 to 6.65 -- force required to
cause the filament to bow when pressed
against the skin
Higher the monofilament number, the more
force required for bending.
Diabetes– Standard of examination
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5.07 monofilament, on bowing exerts 10g of
force