INTEGUMENTARY PHYSICAL THERAPY ■ Wait for it to absorb the

INT1 LAB FINALS saline solution

■ Usually 1-2 minutes
PT EXAMINATION ➢ Linear method
Mr. Adriane Tuminez, PTRP ○ Measure with ruler
○ Usually in mm
○ Longest (length) and widest (width)
CHECK GENERAL APPEARANCE ○ Length x width
a. COLOR ○ Cm squared
● Ecchymosis - purple ➢ Clock method
● Cyanosis - lack of oxygen ○ Assign number like clock
b. HAIR DISTRIBUTION ○ 12 - head
● Intact hair = intact blood flow ➢ Tracing method
c. TOENAILS ○ Label edge like a clock number
● Check capillary refill ○ trace
d. CALLUS (observe and palpate)
● scaly ● Wound depth
e. MELANOMA ○ Use cotton applicator
● Check ABCDE ○ Look for deepest wound
f. BLISTER ○ Ideally, with anesthesia
● Clear - do not unroof ○ Pinch at level of wound edge
● Check resiliency ○ Measure it on the ruler
○ Put pressure then check if it bounce ○ Clock method
back = good ■ Each time, measure the depth
○ Depressed = necrosis ● Surrounding skin erythema
g. EDEMA ● Tunneling/undermining
● Pitting or non pitting ○ Undermining: look for the deepest
h. PERIWOUND ■ Pinch and measure
● Wear gloves when checking periwound ■
● Remove gauze/dressing of px ○ Tunneling: look for the tunnel and measure
● Scar with cotton tip applicator
● Turgor ○ Clock method:
● Color ■ Example: Approximate
● Temperature undermining: present in 11-12
○ Can use infrared thermometer o’clock
● Tenderness ● Tunneling: 5 o’clock
○ Palpate area j. SCAR (POSAS)
● Dryness k. SENSATION (screening test if high risk for ulcer)
○ Flaky or crusty ● Temperature
● Edema ● Vibratory perception
○ Inflamed due ○ Tuning fork
○ pitting/non-pitting ■ Start at sternum
i. WOUND ■ Toe
● Wound location ■ 8 trials each
● Wound drainage ■ Scoring: 0-8
● Wound edge ■ Count ang wala nafeel
○ Epibole - inward wound edge = bad ● Protective
prognosis ○ Use monofilament (5.07mm)
● Wound size ■ Check toes: high risk for
○ Linear or tracing ulceration
○ Clean wound with saline solution ■ If did not feel
○ Needle - 1-2 inches away from monofilament = high risk
wound bed for ulceration
○ Irrigate
○ Use gauze pad - absorb water or
saline solution
■ Put on wound
FLOW OF PHYSICAL THERAPY EXAMINATION: d. Wound depth
1. Preparation e. Surrounding skin erythema
2. Initiation f. Wound drainage
3. Observation g. Wound edges
4. Palpation
5. Wound Assessment 6. TERMINATION
6. Termination
PROCEDURES
1. Observation
1. PREPARATION 2. Palpation
a. Proper lighting 3. Wound Assessment (Linear Method)
● Avoid fluorescent light 4. Wound Depth
● Use natural or halogen lighting to 5. Surrounding Skin Erythema
assess skin tones 6. Wound Drainage
● Flash photographs are 7. Wound Edges
recommended
b. Hands should be clean, and fingernails are 1. OBSERVATION
short ● Take note: proper lighting and proper
c. Wear gloves. positioning of the patient are important
d. Instrument tools:
● Infrared thermometer a. Periwound color
● Ruler or disposable ruler i. First, you remove pressure from the
● Tuning fork (128 Hz) area and expose it to ambient room
● Cotton tip applicator temperature for 5-10 minutes.
ii. Then, observe the color of the
2. INITIATION periwound if it's red, cyanosis, or
a. Introduce yourself to the patient. purple.
b. Then, ask what he/she prefers to be called. iii. Red- erythema (but it needs to
c. After that, explain to him/her the purpose of determine if it is a reactive or
examination. persistent erythema through
d. Then, discuss the procedures and ask for palpation)
consent. iv. Cyanosis-hypoxia
v. Purple- hemorrhage (ecchymosis)
3. OBSERVATION b. Toenails
a. Observe and compare the affected limb and i. Observe the color, shape, thickness
unaffected limb. and note any irregularities of
b. Then, check for asymmetry. toenails.
c. Color (erythema, cyanosis, ecchymosis) ii. Check for ingrown toenails, color
d. Hair distribution green toenails (fungal and
e. Presence of edema pseudomonas infections)
f. Presence of scar iii. If the patient has toenail
g. Toenails abnormalities, please refer the
h. Presence of blisters patient to his/her referring
i. Presence of melanoma physician.
j. Presence of dryness (flaking or scaling) c. Blisters
k. Presence of callus (location of callus) i. Observe the patient’s blisters and
their color.
4. PALPATION: ii. Blister contains clear fluid-
a. Skin turgor epidermal blisters
b. Skin color iii. Blister contains blood or color
c. Resilience of blisters brown- deeper than epidermis
d. Pain tenderness d. Hair distribution
e. Edema (Pitting or nonpitting) i. Start observing the presence of hair
proximally up to the great toes.
5. WOUND ASSESSMENT ii. Then, assess the most distal points
a. Wound location at which hair distribution stops.
b. Wound size iii. Then, observe the skin color for
c. Undermining/Tunneling circulatory changes.
 iv. For female patients, ask them first if ii. Tenting of the skin when pinched
they shave the hair on their limbs. can be an early indicator of
e. Edema dehydration.
i. Observe and compare the limb girth iii. In older patients, it is best to check
of the affected limb to the for general skin turgor on the
unaffected limb. forehead or sternal area.
f. Scar b. Skin color
i. Observe if there is a scar of the i. First, you remove pressure from the
periwound area area and expose it to ambient room
ii. Then, identify if it is a: temperature for 5–10 minutes
1. normotrophic (no before examining.
elevation) ii. Apply gentle pressure to the skin.
2. hypertrophic (elevation iii. Observe the skin if
within the wound surface) c. Resilience of blisters
3. keloid scar (elevation and i. Gently press down with a fingertip
beyond the wound on the tissue beneath the blister
surface). roof and compress it.
g. Dryness ii. Release and feel for the resiliency
i. Observe the periwound areas if it's of the subcutaneous tissues.
flaky or scaling. iii. Good resilience, mildly congested
h. Melanoma (bounces back when the pressure
i. Observe for ABCD signs is removed)
1. A- asymmetry- uneven iv. Tissue congestion and necrosis
edges, lopsided in shape (tissue feels soft, spongy, or boggy)
2. B- borders- irregular d. Edema (Pitting or Nonpitting edema)
(scalloped, poorly defined) i. Firmly pressing a finger down into
3. C- color- black or shades the tissues and waiting 5 seconds.
of brown, red, white, ii. If the tissues fail to resume the
occasionally blue) previous position after pressure is
4. D- diameter- greater than released, and an indentation
5 mm (larger than a pencil remains, pitting edema is present.
eraser) iii. It is measured on a severity scale of
0–4
2. PALPATION 1. 0 = No edema
● Requirements for a Successful Palpatory 2. Grade 1: Slight pitting (2
Examination: mm depth) with no visible
○ Light pressure distortion that rebounds
○ Slow movement immediately.
○ Concentration 3. Grade 2: Somewhat
○ Standardized language to deeper pit (4 mm) with no
communicate findings readily detectable
● The palms of the hands are best used to distortion that rebounds in
detect changes in soft tissue contours fewer than 15 seconds.
(induration, edema). 4. Grade 3: Noticeably deep
● The thumbs are useful in applying pressure pit (6 mm) with the
to check for hardness or softness at different dependent extremity full
tissue depths. and swollen that takes up
● The finger pads are more sensitive to texture to 30 seconds to rebound.
(fibrotic tissues) and fine discrimination. 5. Grade 4: Very deep pit (8
● The back of the hands can get a sense of mm) with the dependent
temperature, warmth or coolness. extremity grossly distorted
● Follow-up with appropriate testing. that takes more than 30
seconds to rebound.
a. Skin turgor e. Skin temperature
i. Gently pinch the tissues with thumb i. Use the back portion of the hand to
and forefinger, and observe how check the skin temperature.
they respond. f. Pain tenderness
 i. Apply enough pressure on the
periwound area.
ii. Observe the reaction and/or facial
expression of your patient.
iii. 0 = none
iv. 1 = patient says it is tender
v. 2 = says it is tender and winces
vi. 3 = says it is tender, winces and
withdraws
vii. 4 = apprehensive
3. WOUND ASSESSMENT (LINEAR METHOD):
a. Wound location
b. Wound size (Surface area)
Take note: please use the method
consistently.
i. Greatest length and greatest width
method
1. Greatest length x Greatest
width= Surface area (cm2)
ii. Clock method
1. Select a 12:00 reference
position on the wound; this
position is usually toward
the patient’s head.
2. Then, take the
measurement from 12:00
to 6:00 (length) and from
3:00 to 9:00 (width).
3. Surface area=Length x
Width
iii. Step-step procedures (ideally):
1. Position the patient. It is
easier for everyone if the
patient is comfortable
during the procedure.
Some patients and some
wounds are difficult to
position for accurate
measurement.
2. Don gloves and remove
wound dressing and
packing.
3. Place dressing and
packing in disposable
infectious waste bag.
4. Clean wound with normal
saline and syringe with
18-gauge needle or
angiocatheter
5. Take measurements with a
disposable wound
measurement ruler.
6. Measure the wound using
one of the methods just
described. If
measurements are always
taken in the same order,
the tracking of wound size
will be more consistent.
7. Record each
measurement as it is
taken.
8. Dispose of measurement
instrument and gloves in
infectious waste container.
9. Dispose of syringe with
18-gauge needle in sharps
container.
10. Apply fresh dressing.
11. Calculate wound SA.
12. Repeat weekly or more
frequently, if indicated.
c. Undermining/Tunneling
i. Method 1
1. Map undermining around
the entire wound perimeter
by inserting a moist,
cotton-tipped applicator
into the length of the
undermined/tunneled
space and continuing
around the perimeter. Dip
the cotton tip into normal
saline before insertion, so
it slides in easier and is
less likely to cause tissue
trauma.
2. At the end point, do not
force further entry, but
gently push upward until
there is a bulge in the skin.
Mark the points on the skin
with a pen and connect
them. Measure the length
and width, and multiply
these measurements to
calculate the overall
undermined estimate
ii. Method 2:
1. The Sussman method for
wound measurement
applies the four cardinal
points of the clock method
to measurement of
undermining and
tunneling. The 12:00
position is toward the head
unless otherwise noted.
2. Wet the cotton-tipped
applicator with normal
saline and insert gently
into the tunnel. Mark the
place on the skin where
the cotton tip causes a
 bulge, and withdraw the
cotton-tipped applicator.
3. Grip the cotton-tipped
applicator at the point at
which the skin and wound
edge meet, and withdraw
it. This is the length of the
tunnel.
4. Place the length of the
cotton-tipped applicator up
to the withdrawal point
against a centimeter ruler
or measure from wound
edge to mark on skin as in
method 1. Record the
length measurement.
iii. Method 3
1. Test the perimeter for
undermining with a
cotton-tipped applicator,
and then select the longest
tunnel to measure.
2. Use the clock method to
identify the location(s) on
the wound perimeter
where tunneling is present,
and then track the tunnel
over time.
iv. Calculating the Overall Estimated
Size (with undermining/tunneling)
1. First, solve the overall
length
a. =length (wound
edges) + length
of undermining
2. Next, solve the over all
width
a. =width (wound
edges) + width of
undermining
3. Then, solve the overall
estimated area (cm2 )
a. =overall length x
overall width
v. For example:
1. 12:00-6:00 length is 10
cm;
2. 3:00-9:00 width is 10 cm;
3. 12:00 undermining length
is 4 cm
4. 9:00 undermining width is
2 cm
● Overall length=10 cm + 4 cm = 14
cm
● Overall width= 10 cm + 2 cm = 12
cm
● Overall estimated area (cm2) = 14
cm x 12 cm = 168 cm2
4. WOUND DEPTH
a. Cleanse the wound thoroughly before
measuring.
b. Take depth measurements at the 12:00,
3:00, 6:00, and 9:00 positions.
c. Insert a cotton-tipped applicator
perpendicular to the wound edge.
d. Hold the stick of the applicator with fingers at
the wound skin surface edge.
e. Holding this position on the applicator stick,
place the applicator stick along a
centimeter-ruled edge. Record for each of
the four positions.
f. These depth measurements may or may not
be at the deepest area of the wound.
g. A separate measurement may be taken and
noted at the deepest area.
5. SURROUNDING SKIN ERYTHEMA
a. Measure across the wound SA from the
12:00 to the 6:00 position and to the outer
margin of the periwound erythema.
b. Measure across the wound SA from the 3:00
to the 9:00 position and to the outer margin
of the periwound erythema.
c. Compute the periwound area of erythema:
12:00 to 6:00 length × 3:00 to 9:00 width =
_____ cm2.
6. WOUND DRAINAGE
a. Observe the color and check the odor.
*INSERT TABLE 14.2
DESCRIPTION OF DRAINAGE BY COLOR AND
THICKNESS
DRAINAGE TYPE COLOR THICKNESS
TRANSUDATE Clear Thin, watery
SEROSANGUINE Clear or tingle of Thin watery
OUS red/brown
EXUDATE Creamy, Yellowish
PUS Yellow, Brown
INFECTED PUS Hues of yellow,
blue, green
7. WOUND EDGES
a. Palpate wound edges for firmness and
texture.
b. Characteristics
 i. Indistinct, diffuse—unable to
distinguish wound outline clearly
ii. Attached—even or flush with wound
base, no sides or walls present, flat
iii. Not attached—sides or walls are
present; floor or base of wound is
deeper than edge
iv. Rolled under, thickened—soft to
firm and flexible to touch
v. Hyperkeratosis—callus-like tissue
formation around wound and at
edges
vi. Color—intensified color, increased
pigmentation with grey hue at edge
How to calculate the percentage rate of change in wound size
to determine the progress of your patient’s wound?
*INSERT EXHIBIT 4.4
ADDITIONAL TEST AND MEASURES
1. SENSORY
a. TEMPERATURE SENSATION
i. It is performed using test tubes or
small narrow bottles filled with
warm water.
ii. Normal areas first before the
affected area.
iii. Testing for cold can be performed
by applying a cold tuning fork.
b. VIBRATORY PERCEPTION THRESHOLD
i. Before testing the VPT (128 Hz
tuning fork) at the foot, give the
patient a preliminary test by placing
the vibrating tuning fork on the
sternum, so that the vibratory
sensation can be readily
recognized.
ii. Ask the patient to shut the eyes and
keep them closed.
iii. Ask the patient to report the start of
the vibration sensation and the
cessation of vibration (on-off).
iv. Strike the tuning fork and place it on
the bony prominence on the
dorsum of the great toe proximal to
the nail bed.
v. Repeat the test eight times at the
same location, recording the on/off
report.
vi. VPT is defined as “the total number
of times the application of the
vibrating tuning fork and the
damping of vibration was NOT felt.
Scores can range from 0–8.
c. PROTECTIVE SENSATION
i. Use Semmes-Weinstein
monofilaments.
ii. The monofilaments come in
different force levels. Levels 4.17,
5.07, and 6.10 are used to check
for protective sensation.
iii. It is performed on the sole of the
foot.
iv. The monofilament is placed against
the skin and the force applied is
sufficient to buckle the
monofilament.
v. The inability to sense the 5.07
monofilament is the threshold for
loss of protective sensation and
indicates a limited ability to use
protective sensations
d. SCAR PLIABILITY
i. Pliability is evaluated by picking up
a scar, pinch it between thumb and
index finger, and rolling it between
the fingers like normal skin. Scar
tissue is normally less supple than
normal skin.
1. Supple- means flexible;
easily move
2. Stiff- not easily move
ULTRASOUND
1. US without undermining
a. Put US gel on periwound area
b. US machine
i. US
ii. Manual
iii. Frequency: 3 MHz
iv. Time: 2 mins
v. Pulsed
vi. Intensity: 1 or less
1. if px feels hot, lower
intensity
vii. Speed: 3-4 cm/sec
viii. Mov’t perpendicular to skin
ix. Aftercare:
1. Wipe US head
2. Remove gel on px skin w/
tongue depressor
3.
2. US with undermining
a. Put US gel on periwound area
b. US machine
i. US
ii. Manual
iii. Frequency: 1 MHz
iv. Time: 2 mins
v. Pulsed
vi. Intensity: 1 or less
1. if px feels hot, lower
intensity
 vii. Speed: 3-4 cm/sec SELECTIVE
viii. Mov’t perpendicular to skin ● Only necrotic, non-viable tissue is removed from the
ix. Aftercare: wound bed (BEA)
1. Wipe US head ○ Biologic Debridement
2. Remove gel on px skin w/ ○ Enzymatic Debridement
tongue depressor ○ Autolytic Debridement

ELECTRICAL STIMULATION NON-SELECTIVE

1. ES Monopolar ● Remove both necrotic tissue and viable living tissue
a. Stage 4 ulcer (MS)
i. Pea-sized amount of gel on pads ● Broad way of debridement
(no logo) ○ Mechanical Debridement
ii. Active electrode – red ○ Sharp/Surgical Debridement
iii. Inactive electrode – black
iv. Open dressing BIOLOGIC DEBRIDEMENT
1. Clean wound ● Using sterile medical maggots to remove necrotic
v. Put active electrode directly on the tissue
wound ● Necrotic tissue is liquefied and digested
vi. Inactive electrode 10-30 cm away ● Bacteria is ingested and killed
from the wound ● Stimulates wound healing
1. Placed proximal to the ○ Maggots - high maintenance form of
wound debridement
vii. ES machine
1. Page 2 of machine ENZYMATIC DEBRIDEMENT
a. Electrotherapy ● Most cost-effective method for treating
b. 1 = High voltage well-perfused partially necrotic pressure ulcers
c. Timer: 20 mins ○ Collagenase - MC ointment used
d. Negative ■ Santyl - generic name
e. Gradual increase ○ 2mm thick; apply to wound bed
of intensity ○ Avoid applying on the edges and skin; might
viii. Ask px if they feel the sensation result to maceration
ix. Tell px don’t sleep ○ Choose wet or dry dressing depending on
b. Aftercare the type of wound
i. Clean the pads ● Applied with daily change of dressings until wounds
2. ES Bipolar are free of slough and eschar
a. Put pads on each side of the wound ○ Disadvantage: Might increase pain and
b. ES machine drainage (frequently changing of bandage;
i. Page 2 of machine will lead to skin maceration if no changing)
1. Electrotherapy ● Efficiency of agents is increased by "cross-hatching"
2. 1 = High voltage the eschar with a scalpel - helps increase the
3. Timer: 20 mins effectiveness of the ointment
4. Negative ● FASTER than autolytic but SLOWER than sharp
5. Gradual increase of debridement
intensity
c. Ask px if they feel the sensation AUTOLYTIC DEBRIDEMENT
d. Tell px don’t sleep ● Use of natural proteases and collagenases in wound
fluid to digest nonviable tissue
● Very effective when used under semi occlusive or
occlusive dressings
● Contraindications:
○ Infections (high with bacterial count)
WOUND DEBRIDEMENT ○ high bacterial colony
Miss Michaela Angelica Tajanlangit, PTRP ○ thick necrotic tissue and slough

- To avoid further infection ● RULE OF THUMB:

- To promote epithelialization ○ Initiated in a Healing wound and the area
- Process of clearing and removing dead tissue of viable granulating tissue is greater than
50%
MECHANICAL DEBRIDEMENT ★ Sharp and surgical debridement are the fastest
● Use of external force to separate necrotic tissue from debridement method
the wound
● Whirlpool treatment, forceful irrigation, or use of Factor to consider in choosing the BEST debridement:
wet-to-dry dressings ➔ Characteristics of wound
○ Use of irrigation ➔ Levels of exudate
● MC used: Wet-to-dry dressings ➔ Infection
○ Place an unraveled moist gauze into the ➔ Cost (enzymatic:most cost-effective)
lesion, then allow the dressing to dry. ➔ Healing period
○ When the dry dressing is removed, necrotic
tissue is removed with it SCAR MANAGEMENT

● Contraindications: SCAR
○ Wound is in proliferative (healing) phase - ● Tissue left behind after wound heals
skin undergoes granulation (epithelializing) ● Part of dermal healing
● NORMAL
TWO TYPES OF SHARP DEBRIDEMENT: ● Deep wounds heal but would leave a scar
1. Surgical debridement
2. Conservative debridement TYPES OF SCARS

SURGICAL DEBRIDEMENT
TYPE DESCRIPTION
● Well-established approach to the care of pressure
ulcers and other chronic wounds 1. ATROPHIC ➔ Depressed
● Under general or regional anesthesia
● Excessive blood loss may happen 2. KELOID ➔ Go pass the wound
● Only for surgeons or physicians; in a sterilized boundaries
operating rooms (OR) ➔ More common in individuals
● Moderate to high risk for significant bleeding with darker skin color
➔ Angry red (rorroror)
○ Anesthesia is needed
○ Larger areas are involved
3. CONTRACTURE ➔ Grow over joints
■ Use of scalpel, forceps, and other ➔ Disabling: impaired ROM
sharp sterile tools and reduces functional
● Indications capacity
○ Deep wounds ➔ Positioning (for prevention)
○ Patients with abcesses ➔ Z-plasty surgery for severe
contracture
● Contraindications:
4. STRETCH ➔
○ Impaired wound healing MARKS

CONSERVATIVE SHARP DEBRIDEMENT 5. HYPERTROPHIC ➔ Raised scars, the rate of

● Part of routine wound care in outpatient settings collagen production exceeds
(OPDs) collagen breakdown
● May be performed at the bedside by a clinician, or ➔ Red scars
➔ Form within the boundary
professionals who have the credentials
● Uses Topical analgesia (5% lidocaine, 5-15 mins
prior) ★ ABNORMAL pathologic scar
○ Can use oral opioids/painkillers prior to ○ Rate of collagen production EXCEEDS
minor surgery collagen breakdown
● Should be done regularly to ward off infection
○ Serial type of debridement, should be done ★ NORMAL
multiple times to be effective ○ Rate of collagen breakdown exceeds
collagen production
● Indications
○ Neuropathic ulcers PRESSURE THERAPY
○ Ischemic wounds - Debride with care to ● Pressure should be applied as soon as tolerated by
avoid destruction of blood vessels in the the healing skin
area ● Be worn 23 hours per day through scar maturation
 ● Be fitted by a trained professional
● Modified or replaced every 2-3 months as needed TECHNIQUES
1. Zigzag mobilibility
● AKA cross fiber massage
TYPE DESCRIPTION
2. Zigzag with friction technique
1. ELASTIC ➔ MC used 3. Pinch and Roll technique
BANDAGES ➔ During the initial phase ● (used without lubrication)
➔ Initial form of pressure 4. Pinch and Zigzag Technique
therapy 5. Pinch and Traction Technique
◆ UE - spiral technique 6. Stretch Massage Technique
◆ LE - figure of 8 7. Circular and Mobility Technique
◆ Trunk - circular
8. Circular Friction Technique
2. SELF ADHERENT ➔ For hands, wrap each fingers 9. Torsion Massage Technique
BANDAGES ◆ Individually wrapped ● w/o lubrication
10. Palm Effleurage Technique
3. TUBULAR ➔ Best used for Drexxy and
BANDAGE other children ● RULE OF THUMB:
➔ Provides moderate ○ Apply force perpendicular to the scar
compression
◆ Use for immature scars
(requires 21 days to
heal)
WOUND DRESSING AND WOUND CARE
4. PERMANENT ➔ Facial burns, customized Sir Dirk Pasquin, PTRP
PRESSURE ➔ Customize, long term,
GARMENT constant contact Drainage and Proper Way on How to Set up the Working Table
◆ Manufactured for (stainless steel)
specific body type
1. Sanitize with Alcohol (Stainless Steel tables/carts are
➔ Pressure is fixed and intense
➔ Given if the skin can tolerate used in hospital settings)
extreme shearing forces 2. Wear gloves
3. Plastic Bin (Yellow for infectious) Should be placed
near the table
FULLY-MATURED SCAR
4. Place Dental Bib
● Soft
5. Once Wound Dressing Occurs use Sterile gloves
● Flat
6. Use of sterile kidney basin
● Color is nearly the same as the adjacent areas
7. Saline Solution should be used for drainage (DO NOT
○ No definite timeline; differs from one person
DIY SO CRAZY)
to another
Wound Irrigation
★ Silicone gel
1. Open Gauze (do NOT touch the gauze directly )
○ Recommended for IMMATURE burn scars
2. Small gauzes for cleaning
■ Gel sheets can be applied to
3. Scissors can be two
actively maturing sheets
4. Cotton
○ How does it work? = mechanism is unknown
5. Open betadine and Saline Solution
○ May develop a rash or allergic reaction
6. Establish RAPPORT et ask the pain scale of px
■ Defer the tx once rash develops
7. Put saline solution on the bin
8. Use any syringe to flush/drain the wound
MASSAGE
9. Change to sterile gloves and AVOID unnecessary
● Increases tissue pliability (softens)
movement
● In deeper layer = Loosens scar tissue by mobilizing
- Only touch the sterile gloves, not the area
cutaneous tissue from underlying tissue and acting to
surrounding it
break up adhesions
- Once Sterile glove is placed on one hand, it
can now help the other hand
● May benefit:
10. Irrigation stops when the saline solution remains the
○ Firm scars
same color; NOT RED, BROWN, ETC
○ Edges or seams of grafts
11. Use gauze to wipe the residue (with forceps)in one
○ Any raised and firm area
direction then throw
12. Should be Dry AVOID MACERATION
● Always apply lubrication to avoid friction
Wound Cleaning
1. Dip cotton in saline solution then swipe cotton from
proximal to distal (One side=One
Cotton=Discar=Repeat)
2. Place Gauze on Wound (Hands or Forceps)
3. Can now touch other items since Wound is closed
with Gauze
4. Put Micropore on the sides of Gauze to Secure

Clean Up/ Discharge

1. Use the end of the glove to take off gloves
2. Sanitize hands with Alcohol
3. For Disposing we can use another set of gloves
4. When taking of gauze we can use ANOTHER PAGID
nga non-sterile gloves (Make sure to alcohol hands
before using new gloves)
5. To take off micropore, do it slowly (water can be
applied)
6. Discard everything

Wound packing - for px with pressure ulcer

● Count how many gauze filled within the pressure ulcer

Aseptic technique - for less contamination; sterile is different

WOUND DRESSING AND WOUND CARE

Sir Tuminez, PTRP

General color
Hair
Toenail
callus
Melanoma
Blister
Edema

Periwound:
Scan
Color
Turgor
Temperature
Tenderness
Dryness
Edema

Wound:
Location drainage edge size depth surrounding skin erythema
tunneling/undermining

Posas

Sensation
Vibratory
Protective