WOUND EXAMINATION

PATIENT HISTORY

WOUND HISTORY DURATION ATTRIBUTING EVENT SYMPTOMS PAIN PARESTHESIA/ANESTHESIA

HISTORY (cont.)

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.)

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.)

ADDITIONAL STUDIES (ARTERIOGRAM, VENOGRAM, ABI)

SOCIAL HX VOCATIONAL HISTORY HOBBIES

OBJECTIVE EVALUATION

Test & Measures

LOCATION

HYPERTENSIVE-posterio/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.)

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

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

ALSO KNOWN AS RIMMING OR TUNNELING

TISSUE DESTRUCTION UNDERLYING INTACT SKIN ALONG THE WOUND MARGINS (HYPOGRANULATION)

MEASURE USING THE O’CLOCK SYSTEM, HEMISPHERES

GIRTH

EDEMA, ATROPHY MEASURE WITH REFERENCE TO BONY

LANDMARKS USING TAPE MEASURE VOLUMETRIC DISPLACEMENT

Edema Measured in a variety of ways:

Quantifying Pitting that occurs from the examiner’s digit

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

TRIANGULAR- SKIN TEAR ROUND- ARTERIAL IRREGULAR-VENOUS

SLOPES

ANGLES OF MARGINATION DEPICT GRANULATION VERY IMPORTANT MEASUREMENT

Staging of Wounds

Stage I-IV Pressure Wounds Wounds other than Pressure

Superficial Partial Thickness -epidermal layer,

superficial layer of dermis Full-Thickness- epidermis, dermis,

subcutaneous , may also involve muscle and bone

Stage I

Partial Thickness, limited to epidermis, non-blanchable erythema (sunburn)

Stage II

Partial Thickness Skin Loss,

involves both epidermis and dermis

(abrasion, blister, shallow crater)

Stage III

Full Thickness Skin Loss

Damage or Necrosis of Subcutaneous Tissue

May Extend to Fascia

(deep crater, with or without undermining)

Stage IV

Full-Thickness Skin Loss

Extensive Destruction

Necrosis Damage to

Muscle, Tendon, Joint Capsule, Bone

Wagner Ulcer Classification Diabetic Ulcers

Grade 0 Intact Skin 1 Superficial Ulcer 2 Deep Ulcer 3 Deep Infected Ulcer 4 Partial Foot Gangrene 5 Full Foot Gangrene

Tissue Composition

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

Eschar Granulation Adipose Fascia Muscle Tendon Bone

Foreign Debris & Necrotic Tissue Remove as Soon as Possible

This will prevent bacterial colonization and infection

Peri-Wound

Trophic Changes (dry skin, brittle nails, hair loss) indicates poor arterial nutrition

Peri-Wound

Change in skin color 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

Inactive found on dressing, at time of observation no

drainage is found in or near the wound

Drainage

Active Free flowing, able to be milked from

the wound

Characteristics of Drainage

Transudate (Serous): clear, watery contains: H20, salts and proteins

Serosanguineous: tinged red/brown watery, thin contains: serum, blood

Exudate: creamy, yellowish moderately thick contains: proteins, WBC

Characteristics of Drainage (cont.) Purulent/Pus: yellowish/brownish

Thick contains: WBC, necrotic debris

Infected Pus yellow, green/blue thick contains: pathogens

describe amount:none, min, mod, max

Odor

Pseudomonas-sweet smell (fruity) Garbage- rotten= infection Proteus- ammonia

describe; absent, mild, moderate, foul smelling

Temperature

systemic v. localized measured

touch thermistor thermography radiometer

measure infrared radiation from the body

Indications for culture

Clinical Signs of Local Infection by Linholm edema, erythema, purulent or foul

smelling drainage, increased pain, induration, heat around the wound; IFEE

Signs of systemic infection fever, abnormal CBC

Bone Involvement (osteomyelitis)

Non-Healing Wounds (silent infection)

Aerobic swab culture technique. The culturetteIs 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

Pulses(2+Normal, 1+Diminished, 0 Absent)

Auscultation (swishing sound, only heard in abnormal artery)

Venous Exam (venous doppler)

Vascular Exams Continued

arterial exam ankle-brachial index (ABI)

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 LevelSBP100 mmHg

ABI120 mmHg/100mmHg= 1.2

AnkleSBP120mmHg

DopplerDoppler

ABI When ABI value is <.9

95% sensitive 99% specific For angiographically significant PVD

ABI Change of 0.15 correlates with

disease and symptomology

Measuring ABI

Tissue Oxygen Tension

tc-Po2 transcutaneous oximmetry

Rubor of Dependency Test

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

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

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

Homan’s Sign 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 pt. unable to tolerate 40mmHg if DVT present normally able to tolerate much higher

pressures

Test for Cutaneous Sensitivity perception of light touch

use cotton ball perception to temperature

warm, cool 2-point discrimination

Monofilament Testing for LOPS Semmes-Weinstein Monofilaments

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 5.07 monofilament, on bowing exerts 10g

of force