Integ History and Exam (lecture 3)

What is the goals of a history for a patient with primary integumentary problems

understand the meaning of the patients problem in context of their lives, understand the cause and course of the wound, understand the medical management to this point, indications / precautions for interventions, prognosis and risk factors for healing

what are the four purposes of review of systems

need for referral, other contributing systems to the chief complain within PT scope of practice, precautions / contraindications, determine pt/caregiver education needs

what should you look at in CVP

HR, BP, RR, edema, Sp02, peripheral pulses, DVT risk

what integument can be a sign or symptom of CHF

apparent venous insufficiency

what should you look at for MSK

posture, ROM, strength, and how these deficits may impact the chief integumentary complaint

what should you look at for NM

gait and mobility which includes transfers and sensation. How these can impact current integ issues.

what should you look at for GI

nutrition and how it impacts healing

what should you look at for uro

urinary frequency, pain, difficulty, and continence from history. You can also use perceptive skills. Think how this impacts wounds especially those that may be in the saddle area.

what is the sacred seven of wound examination

location, size (tunneling/undermining), wound bed, edges, drainage, odor, pain

why is specific location document for wounds important

documentation, impact on prognosis, interventions

why is accuracy of wound size important

prognosis and progress / response to intervention

what are the methods of wound measurement

direct, tracing, photographic, volumetric, TBSA for burns

what are the methods for direct measurement of wounds

clock method and greatest length x width

how do you use the clock method

measure from 12-6 and 3-9

how much can greatest length x width overestimate wound area

by up to 44%

for wounds you need to measure what

surface area and depth

how do you do the tracing method

use 2 layers of plastic or non-plastic tool to trace the wound which allows direct measurement and outline of the wound.

how should you do photographic measurement

use a special grid film for polaroid, have a disposeable ruler at the edge of the wound to assess size, consider background / lighting / focus, use digital programs to calculate exact surface area

what is tunneling

destruction or separation of fascial planes

how do you measure tunneling

use a probe and measure from the length from end of tunnel to wound/skin surface

how do you note the tunneling / sinus tract location

using the lock methodology

what is underminig

erosion of wound edges under the skin/opening to the wound, measure actual edge to superficial edge, location using clock

what is pale granulation tissue

pink. it is not as healthy

what do you need to note for necrotic tissue

type, color, consistency, adherence

what is slough

yellow / tan, stringy / mucinous

what is eschar

tan / blac, soft or hard necrotic tissue

how do you measure wounds with different types of tissue (granular vs necrotic)

by percentage. be sure to document percentage of bone, muscle, tendon, fascia, joint capsule, and foreign matter

what are the type of wound edges

epithelialization, scarring, hyperkeratosis, maceration, pigment changes, rolled / closed wound edges

what does hyperkeratosis look like

callus edges

what does maceration look like

wet and wrinkly

what is serous drainage

clear / yellowish fluid. This is normal

what is sanguinous drainage

bloody. is normal acutely or in response to trauma.

what is serosanguinous drainage

clear yellow liquid plus blood which results in pink / red fluid. Is normal.

what is purulent drainage

a thick pus that is white / yellow / green. Sign of possible infection.

what is seropurulent drainage

clear pus that is thinner. sign of possible infection.

what do you need to document for wound drainage

type, color, consistency, amount

what is copious drainage a sign of

possible infection, especially if it is out of proportion to wound size

what must you consider when assessing drainage

length of time since last dressing change and absorptive qualities of dressing

when do you need to document wound odor

if there is odor after cleaning the infection

why is pain important to know when checking a wound

to take steps to ensure the patient is comfortable (pre-medication), to make sure treatment is tolerable, could be a sign of infection.

what does periwound examination include

change in skin structure and quality

what are some trophic changes of the skin

thin, shiny, hairless, thick nails, due to decreased blood flow

what is hemosiderin staining

brownish discoloration caused by blood (iron) leaked from capillaries