Wound Care Skills Check

Common Wound Measurement Methods

tracing (most common)

photography

linear method/clock position

Clock Method: Length

measure wound from 12:00 (closer to head) to 6:00 (closer to foot) edge OR longest edge

Clock Method: Width

measure wound from 3:00 to 9:00 edge OR shortest edge

irregular wounds can have measurements from other positions (i.e. 2:00-8:00)

Clock Method: Depth

Gently stick a cotton tipped applicator into deepest depth (perpendicular to surface of wound)

Undermining

area of breakdown under the skin extending around the perimeter of the wound

Clock Method: Undermining

use clock positions to measure extent of undermining

3:00 has this much, 11:00 has this much, etc.

Tunneling

tract at one clock location, sometimes has an exit point

Clock Method: Tunneling

document location of tunnel (clock number) and depth

Additional Documentation: Location

be specific!!

Additional Documentation: Exudate

document type and amount

Description of Amount of Exudate

minimal, moderate, heavy/copious

Description of Consistency of Exudate

serosanguinous - bloody yellow

sanguinous - all blood

serous - clear

purulent - thick, yellow, green, or brown (usually present with odor or indicates infection)

Description of Odor of Exudate

present or absent

How to describe the wound bed?

% of different tissues

red - granulation tissue

black - eschar

yellow - slough

tendon

How to describe the periwound?

erythematous (red)

edematous (swollen)

dry

scaly

macerated (wet, whitish appearance)

callous

Partial Thickness Wound

wounds that have lost the epidermis and part of the dermis

Examples of Partial Thickness Wounds

abrasions

skin tears

Stage 2 pressure ulcer

2nd degree burn

Full Thickness Wound

Wounds that have lost the epidermis and all of the dermis, and extend into the deeper layers of the skin

Examples of Full Thickness Wounds

stage 3 and 4 pressure ulcers

3rd degree burns

Dressings: Flat or very shallow wound

protect with film, hydrocolloid

Dressings: Deep Wound

fill cavity with hydrogel, alginate, hydrofiber, or foam

Dressings: Wound with eschar

debride with enzyme (chemical) hydrocolloid (autolytic)

Dressings: Dry Wound

add moisture with hydrogel

Dressings: Heavily exudating

absorb with hydrofiber, foam, alginate

Dressings: Infected wound

disinfect with silver impregnated

Dressings: Skin Tear

protect with hydrogel sheet, film

PT interventions for wound care

besides cleaning the wound and dressing it or picking the proper wound care - ultrasound, repositioning every 2 hours, offload heels, ROM, ambulation schedule, ankle pumps, wound VAC, electrical stim (high-voltage pulsed current) i have no idea :)

Characteristics of Arterial Wounds: Pain, Location, Presentation, Periwound, Pulses

Pain: Can be severe at times

Location: dorsum of foot, toes, areas of trauma

Presentation: regular, "punched out" appearance; pale granulation tissue if at all; black eschar; gangrene; minimal drainage

Periwound: thin, shiny skin; loss of hair growth; pale dusky or cyanotic skin

Pulses: decreased or absent; ABI < 0.9

Characteristics of Venous Wounds: Pain, Location, Presentation, Periwound, Pulses

Pain: Mild to moderate; decreased with elevation or compression

Position: Medial malleolus; medial lower leg; areas of trauma

Presentation: Irregular, red wound bed; fibrous yellow or glossy coating; increased drainage

Periwound: Edema; cellulitis; hemosideric (brown staining)

Pulses: Normal to decreased

Characteristics of Pressure Ulcers: Pain, Location, Presentation, Periwound, Pulses

Pain: Can be painful (deep wounds and/or insensate patients may not have pain

Position: See location chart next slide; areas of pressure which have sustained contact with seating or lying surface

Presentation: Size and shape can vary:

• Triangular (teardrop) = shear forces

• Rounder = perpendicular forces only

• Abrasions = friction

Periwound:

• Nonblanchable erythema; Induration

• Ring of inflammation around necrosis

Pulses: Normal unless concurrent arterial insufficiency

Characteristics of Neuropathic Wounds: Pain, Location, Presentation, Periwound, Pulses

Pain: Usually not painful due to neuropathy

Position: Classic location is the plantar surface of the foot; toes are also common

Presentation: Typically round shape

Periwound: Calloused edges, dry skin, thick toenails

Pulses: Normal unless concurrent arterial insufficiency