Integumentary Tests and Measures

• Length

• Width

• Depth

• Length

• Width

• Depth

common areas to be measured in wound dimensions.

L x W

formula for surface area of the wound.

L x W x D

formula for volume of the wound.

Wound Measurement

is done at the initial assessment and is critical to calculate any change in wound size over time.

Epithelial Tissue

- appears pink or pearly white and wrinkles when touched

- occurs in final stage of healing

Granulating Tissue

- appears red and moist

- occurs when healthy tissue is formed in remodeling phase

Slough Tissue

- appears yellow, brown, or gray

- is devitalised tissue made of dead cells or debris

Necrotic Tissue

- appears hard, dry, and black

- is dead tissue that prevents wound healing

Hypergranulation Tissue

- appears red, uneven, or granular

- occurs in the proliferative phase when tissue is overgrown

Class 1

- clean, uninfected, no inflammation (classification of wounds)

- primarily closed

- do not enter respiratory, ailementary, genital, or urinary tracts

Class 2

- clean-contaminated (classification of wounds)

- lack unusual contamination

- enter the respiratory, ailemtary, genital, or urinary tracts

Class 3

- contaminated (classification of wounds)

- fresh, open wounds that result from insult to sterile techniques/ leakage from GIT into the wound

- incisions made that result in acute or lack of purulent inflammation

Class 4

- dirty infected (classification of wounds)

- result from improperly cared traumatic wounds

- demonstrate devitalized tissue

- result from microorganisms presented in perforated viscera or the operative field

Exudate

produces a moist environment that allows efficient migration of epidermal cells and prevents wound desiccation and further injury.

None

wound tissues dry.

Scant

- wound tissues moist

- no measurable exudates

Small

- wound tissues wet

- moisture evenly distributed in wound

- drainage involved 25% of wound dressing

Moderate

- wound tissues saturated

- drainage may or may nor be evenly distributed

- drainage involved greater than 25% to less than 75% of wound dressing

Large

- wound tissues bathed in fluid

- drainage freely expressed, may or may not be evenly distributed in wound

- drainage involved greater than 75% of wound dressing

Bloody

thin, bright red exudate.

Serosanguineous

thin, watery, pale red to pink exudate

Serous

thin, watery, clear exudate.

Purulent

think or thick, opaque tan to yellow exudate.

Foul Purulent

thick, opaque yellow to green with offensive odor exudate.

Classification by Depth of Tissue Injury

- “generic” classification system identifies specific anatomic levels of the tissues involved, but does not report their condition or color

- used for wounds that are not categorized as pressure ulcers or neuropathic ulcers

Superficial Wounds

often resolved by subcutaneous inflammatory processes.

Partial-Thickness Wounds

heal by epithelialization.

Full Thickness and Subcutaneous Wounds.

a combination of fibroplasia or granulation tissue formation and contraction.

NPUAP Pressure Ulcer Staging System

- described pressure ulcers using depth of anatomic tissue loss and the involvement of soft tissue layers and was redefined by adding two stages on deep tissue injury and unstageable

- can aid examination of the wound severity

Stage 1 Pressure Ulcers

intact skin with nonblanchable redness of a localized area usually over a bony prominence.

Stage 2 Pressure Ulcers

- the partial thickness loss of the dermis presents as a shallow open ulcer with a red-pink wound bed

- may also present as an intact or open/ruptured serum-filled blister

Stage 3 Pressure Ulcers

- full thickness tissue loss

- subcutaneous fat may be visible but bone, tendon, and muscle are not exposed

- slough may be present but does not obscure the depth of tissue loss

- may include undermining or tunneling

Stage 4 Pressure Ulcers

- full-thickness loss with exposed bone, tendon, or muscle

- slough or eschar may be present on some parts of the wound bed

- may include undermining or tunneling

Unstageable Pressure Ulcers

full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.

Wagner Ulcer Grade Classification

- used to establish the presence of depth and infection in a wound

- developed for the diagnosis and treatment of the dysvascular foot

- assessment instrument in the evaluation of diabetic foot ulcers

Grade 0

skin intact (wagner scale).

Grade 1

superficial ulcer (wagner scale).

Grade 2

deep ulcer to tendon/bone (wagner scale).

Grade 3

ulcer has abscess or osteomyelitis (wagner scale).

Grade 4

gangrene on foot (wagner scale).

Grade 5

gangrene over major portion of foot (wagner scale).

The University of Texas Treatment Based Diabetic Foot Classification System

- matrix of grades used for situations in which neuropathy is present and information is needed about infection, circulation, and the combination of infection and ischemia in order to assign risk and predict outcome

- each ulcer is given both a numeric grade and an alphabetic stage

Marlon Laboratories Red, Yellow, Black Classification System

- popular because of its simplicity and ease of use

- three colors are used - red, yellow, and black to describe the wound’s surface color, and each color corresponding to specific therapy needs

Red

clean, healing, granulating.

Yellow

signals possible infection, the need for cleaning or debridement, or the presence of necrotic tissue.

Black

necrotic and needs cleaning and debridement.

Semmes Weinstein Monofilament

- determine if the patient can detect pressure when the monofilament is placed against the skin and the force applied is sufficient to buckle the monofilament

- usually performed on the sole of the foot

0

no loss of protective sensation (Semmes Weinstein Monofilamen).

1

loss of protective sensation; no deformity or history of plantar ulceration (Semmes Weinstein Monofilament).

2

loss of protective sensation and deformity or abnormal blood flow without history of plantar ulcer (Semmes Weinstein Monofilament).

3

history of plantar ulcer (Semmes Weinstein Monofilament).

Callus Formation

is a protective function of the skin to shearing forces of a prominent bone against an unyielding surface.

Transient Erythema

can be detected in lightly pigmented skin by applying pressure to the skin.

Unblanchable Erythema

is one of the hallmarks of stage 1 pressure ulcers.

Hemosiderin Staining

- type of hemorrhagic condition

- rupture of vessels around a wound that cause deposition of blood in the subcutaneous tissues

Hemosiderosis

rust brown color skin.

Excoriation

- skin picking disorder

- is a partial thickness shearing of skin

Hyperkeratosis

callous-like tissue formation at wound edges that can extent around wound especially with diabetic ulcers

Fungal Infection

- candida infection resulting from excessive moisture

- rash is identified by the yeast buds on the periwound

- white or yellow

- redness along the wound walls

Induration

thickening and hardening of soft tissues of the body, is the result of inflammatory processes caused by various triggering factors.

Maceration

- occurs with moisture for too long, it may feel soft, wet, soggy to the touch

- associated with improper wound care

Scale

- skin appears dry and cracked

- skin flakes, peel, and scaly

Scars

form as part of the body’s healing process, it builds tissue to repair damaged skin and close gaps due to an injury.

Xerosis

- also known as dry skin

- may cause discomfort

- is linked to decrease in the oils on the surface of the skin, usually triggered by environmental factors

Edema

- occurs when fluid builds up in your tissues

- will cause parts of the body to increase in size

Tenderness

is assessed to rule out signs of inflammation.

Braden Scale

standardized, evidence based assessment tool commonly used in health care to assess and document a patient’s risk for developing pressure injuries.

Norton Scale

has been the first pressure sore risk evaluation scale to be created.

Waterlow Scale

- primary aim of this tool is to assist you to asses risk of a patient/client developing a pressure ulcer

- consists of seven items: weight, height, visual assessment of the skin, sex/age, continence, mobility, appetite, and special risk factors

Splinting

indicated for the positioning of a scar to avoid deformation or to maintain or increase the stretch on a scar.

Conforming Splint

is custom fit to a patient and matches the patient’s anatomic shape.

Static Splint

has a fixed shape and maintains a position through immobilization of the splinted part.

Dynamic Splint

apply a force, or a stretch, to a body part or allow resistance to movement for exercise.

Serial Splint

are basically static splints that are remolded to a newly achieved position of a body part.

Total Contact Casting

provided decreased plantar pressure by increasing weight bearing over the entire lower leg.

Orthotics

externally applied device used to modify the structural and functional characteristics of the neuromuscular and skeletal system.

Nutritional Screening

- is the process of identifying characteristics known to be associated with nutritional problems

- pinpoint individuals who are malnourished or at nutritional risk

Distal Pulses

- refers to pulse points that are the furthest from the trunk

- are assessed to identify the presence of arterial vascular disease and to detect abnormalities

Doppler Ultrasound

is a non invasive vascular test that uses sound waves to show blood moving through vessels.

Continuous Wave Doppler Ultrasound

- most widely used

- gives us a phasic flow pattern

Laser Doppler

- used in measuring skin perfusion pressure

- uses a low energy laser probe secured in the bladder of a blood pressure cuff

Color Doppler

- uses a computed to change sound waves into different colors

- shows the speed and direction of blood flow

Power Doppler

- can provide more detail of blood flow than standard color doppler

- cannot show the direction of blood flow

Spectral Doppler

- shows blood flow information on a graph

- shows how much of a blood vessel is blocked

Duplex Doppler

uses standard ultrasound to take images of blood vessels and organs.

Ankle Brachial Index

- noninvasive test to check for peripheral arterial disease

- compares the blood pressure in the arm to the bloop pressure in the ankle

Transcutaneous Pulse Oximetry

- a noninvasive clinically approved method to obtain skin oxygen levels

- measurements have shown to be predictive healing of ulcers and amputation wounds

Digital Photoplethysmography

- measures venous refill time

- measure the light reflected from the skin as it changes colors with filing of microvasculature

Incontinence

not able to prevent urine and stool from leaking.

Incontinence Associated Dermatitis

diaper rash, irritant dermatitis, moisture lesions, or perineal dermatitis.

Incontinence Ulcers

happens in long standing incontinence.

Functional Independence Measure

- uses the level assistance an individual needs to grade functional status from total independence to total assitance

- lists six self care activities.

Barthel Index

specifically measures the degree of assistance required by an individual on 10 items of mobility and self care ADL/

ADL Staircase

- index of four instrumental activities combined with six personal daily life activities

- ability to perform each activity is scored using a three point scaled: independent, partly dependent, and dependent