INTEGUMENTARY

PHYSICAL THERAPY

Dr Mehwish Saghir
Assistant professor
UIPT,UOL
Wound Assessment
Initial patient assessment

 Past medical (lab findings, systemic disease, exposure to radiations

 Family history
 Previous wound healing concerns
 Social history, family support
Initial examination
The nine C’s of wound assessment
Wound assessment is needed for the following nine reasons:
• Cause of the wound
• Clear picture of what the wound looks like
• Comprehensive picture of the patient
• Contributing factors
• Components of the wound care plan
• Communication to other healthcare providers
• Continuity of care
• Centralized location for wound care information
• Complications from the wound.
Physical Examination

 A head-to-toe physical examination should be

performed.
 Evaluation of the skin,
 including any skin folds,
 pressure points,
 old scars or lesions,
 indications of previous surgeries,
 .
 the presence of vascular,
 neuropathic,
 or pressure ulcers, should be
noted.
 The appearance of the skin,
nails, and hair on the
extremities should be assessed.
 Appraisal of skin
 color,
 temperature,
 capillary refill,
 pulses, and
 edema are also important elements.
 It can give us information about the
cause of wound and prognosis of
wound healing
Types of Wounds

 Dehisced surgical wounds may have opened due to an

infection or may heal poorly due to underlying disease
processes, current medications (such as steroids), or
malnutrition.
Types of wounds

 Arterial ulcers
often present with the classic signs of hair
loss , weak or absent pulse, and very thin,
shiny skin
 Diabetes
prone to callus formations and pressure points
 Others
Wound Assessment

Wound assessment—a written record and

picture of the current status and progress
of a wound—is a cumulative process of
observation , data collection, and
evaluation.
Elements of wound Assessment

 Wound etiology
surgical
arterial
venous
Pressure ulcer
diabetic ulcer/neuropathic
skin tear/trauma
others
Assessment

 A… anatomical location of the wound

 Age of the wound..acute/chronic
 S… size , shape , stage
 Sinus track , tunneling
 E…exudate
 S…sepsis
 S…surrounding skin
Assessment

 M..maceration
 E…edges..epithilialization
 N…necrotic tissue
 T…tissue of wound…tenderness/pain
Pain score..pain timings
 S… status
Wound Picture

 When assessing wounds in your patient , use the mnemonic, WOUND

PICTURE, for a fast and accurate assessment.
 Wound or ulcer location
 Odor Assess before and during all dressing changes
 Ulcer category, stage (for pressure ulcer) or classification (for diabetic
ulcer), and depth (partial-thickness or full-thickness)
 Necrotic tissue
 Dimension of wound (shape, length , width , depth); drainage color,
consistency, and amount ( moderate, large )
Wound Picture

 Pain (When it occurs, what relieves it, patient’s description, patient’s rating on
scale of 0 to 10)
 Induration (Surrounding tissue hard or soft)
 Color of wound bed (Red-yellow-black or combination)
 Tunneling (Record length and direction—toward patient’s right, left, head, feet)
 Undermining (Record length and direction, using clock references to describe)
 Redness or other discoloration in surrounding skin
 Edge of skin loose or tightly adhered?
 Edges flat or rolled under
History of Present Illness (HPI) and
Past Medical History (PMH)
 • Reason for admission
• Onset and duration of symptoms
including mechanisms of injury
 • Previous or current medical and/or
surgical treatments
• PMH with specific attention to a
history of diabetes,
 peripheral vascular disease,
coronary artery disease,
congestive heart failure,
spinal cord injury,
 malnutrition, and
 a history of smoking
Social History •
Prior functional level,
use of assistive devices and/or adaptive
equipment •
 Home environment and current/potential
barriers to returning home •
 Family/caregiver support system • Family,
professional, social, and community roles •
 Patient’s goals and expectations of
returning to previous life roles
Hospital Course •
 New or ongoing medical intervention
Pertinent lab values (i.e. White Blood Count
(WBC),
 Hematocrit (Hit),
 INR,
 albumin,
 glucose) •
 Diagnostic testing (i.e. X-ray or
MRI for osteomyelitis,
angiography for circulation,
doppler ultrasound) •
 Overall nutritional status
 Other Consults: Plastics,
Vascular,
 Ostomy Nurse,
 Nutrition
 Potential impairments
Potential impairments include, but are not
limited to:
• Impaired skin integrity
• Impaired sensation
• Impaired circulation
• Edema
• Impaired ROM
• Impaired strength
• Impaired balance •
Impaired motor function
• Impaired tone
• Impaired functional mobility including bed
mobility, transfers, ambulation
• Impaired endurance and activity tolerance
• Impaired mental status (cognition, arousal,
attention, memory, barriers to learning)
• Pain
Medications

Given that integument issues can arise in

any patient determined to be at risk for skin
breakdown or potential healing issues,
patients may be treated with numerous
pharmacological agents that may vary
greatly among the individual patients.
 Patient / Family Education

•Instruct patient/family/caregiver in
following:
o Pressure relief and appropriate
positioning
o Appropriate skin care and frequent skin
checks
o Smoking cessation
o o Independent therapeutic
exercise, ROM, and endurance
programs
o o Safe mobility techniques
(including precautions),
o activity progression, encouraging
maximal independence
o • Discuss realistic expectations
regarding wound healing,
functional level, appropriate level
of assist required by patient,
anticipated rehabilitation
Progression
• Provide emotional support to
patient and family as needed
• Consider a patient’s learning
style for most effective
communication and instruction
Dressing choice

 What is available?
 How do we choose?
 Does the patient have a say?
 Do we consider cost?
 Are choices restricted by a protocol?
 How do we evaluate?
 Dressing choice
The ideal dressing
The purpose of
A dressing that
dressings: creates the optimum
1. To aid debridement
2. To remove excess exudate environment
3. To control bleeding
4. To protect a wound
Wound debridement
5. To support healing Wound cleansing
Alternative therapies
 Dressing choice

 Non-adherent wound contact materials

 Films
 Hydrogels
 Hydrofibre dressings
 Hydrocolloids
 Foams
 Alginates
 Miscellaneous
 Dressing choice
1. Film dressings
• Semi-permeable primary or
secondary dressings
• Clear polyurethane coated with adhesive
• Conformable, resistant to shear and tear
• Do not absorb exudate
• Examples: Tegaderm
 Dressing choice


Hydrocolloids
• Pectin, gelatin,
carboxymethylcellulose and
elastomers
• Environment for autolysis to debride
sloughy or necrotic wounds
• Waterproof
• Different presentations e.g. Urgotul
 Dressing choice

Foam dressings
1. Advanced polymer technology
2. Non-adherent wound contact layer
3. Highly absorptive
4. Semi-permeable
5. Various types
6. Adhesive and non-adhesive
 Dressing choice

Hydrogels
• Sheets or gels
• Starch and polyacrylamide
(94% water)
• Low exudate, shallow wounds
• Re-hydrates necrotic tissue
 Dressing choice

Alginates
• Form a gel over the wound
• Moderate to high exudate wounds
• Easily removed
• Can cause pain
• Help to debride a wound
• Different presentations
 Debridement methods

 Hydrogels
 Hydrocolloids
 Alginates
 Hydrofibre dressings
 Surgical
 Wet to dry dressings
 Tissue Viability

Documenting wound care

• Potential for heal
• Good staff communication
• Continuity of care
• To assess progress or deterioration
• Should be factual not subjective
• Wound assessment charts
Conclusion

 Wound care is becoming more complex as the range of wounds increases

 Correction of the underlying causative factors is essential
 Key principles must be adhered to with regard to basic patient and wound
assessment
 REFRENCES

Principles of wound assessment

Mick Miller Assistant Director, Of Clinical Research & Clinical Nurse Specialist,
Wound Healing, at the Tissue Repair Research Unit, Division of Anatomy and Cell
Biology, UMDS, Guy's Hospital, London
THANK YOU