1. Mark David S. Basco, PTRP Faculty Department of Physical Therapy College of Allied Medical Professions University of the Philippines Manila

2. Learning Objectives At the end of the session, you should be able to Appreciate the role of physical therapists in the care of clients presenting with impaired integumentary integrity. Determine appropriate physical therapy assessment procedures given a client with impaired integumentary integrity. Interpret the results of assessment procedures performed to a client with impaired integumentary integrity.

3. Why do we need to perform an assessment? To determine the physical therapy diagnosis To identify factors that may contribute to ulceration or abnormal wound healing To assist in making a wound healing prognosis To identify factors that may benefit from referral or consultation with another health care provider

4. What are we going to discuss? Obtaining Patient history Determining Wound Characteristics Determining Periwound and Associated skin characteristics Other tests

5. General demographics Lifestyle and Functional status Past and current general medical history Past and current wound history Systems review

6. General demographics Age Sex Occupation Ethnicity Primary language Education (patient and caregiver)

7. Lifestyle and Functional status Does the patient live alone? Is the patient independent with activities of daily living? Does the patient have sufficient vision to inspect for skin and wound changes? Is the patient ambulatory? Does the patient have adequate mobility or dexterity to perform wound care?

8. Lifestyle and Functional status Is someone available to assist with wound care, skin checks, meals, bathing & so on? Is the patient currently working & what does his job entail? Does the patient have any behavioral health risks e.g. Smoking or alcohol abuse? Does the patient have any cultural or religious beliefs that may affect therapy?

9. Past & Current Medical History Do you have a history of the following conditions? High BP Heart disease or heart condition Peripheral vascular disease Stroke / TIA Breathing difficulties Diabetes Cancer HIV / AIDS Red Flags

10. Past & Current Medical History Are you allergic to any of the following substances? Latex Adhesives Sulfa Animal products Is there any other allergies that you have?

11. Past & Current Medical History Do you smoke? Number of packs/day Number of years smoking Do you drink alcohol Number of drinks/day Do you take drugs not prescribed by a MD? Is there any medications that you’re taking?

12. Past & Current Wound History When did the wound begin? How did the wound occur? Have any tests been performed? Wound culture Blood tests Arteriogram Venous doppler Have you perviously or are you currently taking any medications for this wound?

13. Past & Current Wound History Is your wound painful? Does the pain change with elevation? dependency? activity? What is currently being done for your wound? What interventions have been done in the past? What impact does these interventions have? Is your wound improving, staying the same, or getting worse? Have you had any wounds in the past?

14. Systems Review Cardiovascular / Pulmonary Musculoskeletal Neuromuscular Gastrointestinal Urogenital Integumentary

15. Wound Location Wound Size Tunnelling / Undermining Wound Bed Wound Edges Wound Drainage Wound Odor

16. Wound Location Document Using anatomically correct terminology Side and body surface of the lesion If multiple wound exist, it may be helpful to document wounds in relation to anatomical landmarks EXAMPLE: “Wound A is located 10 cm superior to the (R) medial malleolus; Wound B is located 2 cm superior to the (R) medial malleolus ”

17. Wound Size Direct Measurement Wound Tracings Photographic Measurements Volumetric Measurements Total Body Surface Area

18. Wound Size Direct Measurement Measure the longest length and widest width perpendicular to the length Surface area = Length x Width Wound depth Place a probe in the deepest part of the wound bed Note point the probe is level with the surrounding intact skin Several depth measuements can be performed at standard wound locations Clock method

19. Wound Size Direct Measurement EXAMPLE: Wound A Width = 3.5 cm Length = 4.2 cm Surface area = 14.7 cm2 Depth= 1.4 cm (if with eschar or presence of nonviable tissue) Depth=1.4 cm; unable to determine actual depth secondary to eschar

21. Wound Size Direct Measurement Simple, fast, easy to learn, reliable, & inexpensive MOST serious problem is that it may inadequately reflect wound size, or changes in wound size in irregularly shaped or circular wounds NOT possible to accurately determine depth of wound covered with nonviable tissue

22. Wound Size Wound Tracings Materials Clean, comformable transparency Permanent, fine-tipped pen Tracing sheets Wound contact layer Adhesive outer permanent layer Improvised CLEAN, Plastic wrap folded in half

23. Wound Size Wound Tracings Surface area estimated from tracing as previously described Wound depth assessed using direct measurement Tracings SHOULD be labeled with Patient’s name Date Precise wound location Size Wound characteristics

24. Wound Size Wound Tracings 3 alternative methods of measuring wound surface area Use of transparencies with premeasure grid marks Planimetry Digitizing

25. Wound Size Wound Tracings Simple, fast, easy to learn Advantages over direct measurement More accurate representation of wound size; regular/circular wounds Retained image helpful for future comparisons Main sources of error Visualizing wound perimeter through the transparency Tracing itself

26. Wound Size Photographic Measurement Surface area determined by tracing photographic image Advantages over wound tracing Avoids contact with wound Provides additional information about periwound and wound bed characteristics Equipment available today allows clinician with minimal photographic skill & knowledge to obtain fairly consistent, high quality images

27. Wound Size Photographic Measurement Wound photographs SHOULD include Patient’s name Date Precise wound location Measurement guide (ruler for scaling reference) Results of direct wound measurements

29. Wound Size Photographic Measurement Disadvantages Prone to errors in scale Camera distance and camera angle can influence resulting image size Inconsistent lighting conditions may make wound assessment problematic Costly & time-consuming Use photography to provide supplemental information but not to determine wound size

30. Wound Size Volumetric Measurement Measuring either the amount of molding or saline required to fill the wound void Provides a more complete illustration of wound size in three dimensions Disadvantages Time consuming and painful for the patient (molding) Inaccurate and problematic (saline) Cannot be used on wounds that extend into body cavities / fascial planes Unclear if molding material may have detrimental effects to wound healing

31. Wound Size Total Body Surface Area (TBSA) Used for wounds covering large body surface areas Commonly used in patients with burn injuries Quick, inexpensive, & reliable method of estimating wound size

32. Wound Size Total Body Surface Area (TBSA) Rule of Nines American Burn Association Classification * Percentage of partial thickness burn MINORMODERATEMAJOR ADULT< 1515 - 25> 25 CHILDREN< 1010 – 20> 20

33. Wound Size Total Body Surface Area (TBSA) American Burn Association Classification * Percentage of FULL thickness burn MINORMODERATEMAJOR ADULT < 22 -10 ≥ 10 CHILDREN

34. Tunneling / Undermining Tunneling Is a narrow passageway created by the separation of, or destruction to, fascial planes Undermining Occurs when the tissue under the wound edges become eroded, resulting in a large wound with a small opening

35. Tunneling Measured by inserting a probe into the passageway until resistance is felt Tunnel depth is distance from the probe tip to the point at which the probe is level with the wound edge Use CLOCK terms to document tunnel’s position within the wound bed. EXAMPLE “Wound tunnels 1.9 cm at 3-o’ clock position”

36. Undermining Measured inserting a probe under the wound edgedirectly almost parallel to the wound surface until resistance is felt Distance from probe tip to the point at which the probe is level with the wound edge Use CLOCK terms EXAMPLE “Undermining 1.2 cm from 9- o’ clock to 1- o’ clock positions. ”

37. Wound Bed May contain varying types and amounts of granulation tissue necrotic tissue other structures

38. Wound Bed Granulation Tissue Temporary scaffolding of vascularized connective tissue that fills the wound void Beefy-red appearance Pale or dusky Document characterictics and percentage of wound bed it covers

41. Wound Bed Necrotic Tissue Described by color, consistency, and percentage of wound bed it occupies Slough Yellow or Tan in color and has stringy or mucinous consistency Eschar Black necrotic tissue; either soft or hard Either adherent or non-adherent Refers to the ease with which the necrotic tissue can be separated from the wound

43. Wound Bed Other Tissues Exposed structures e.g. Fascia, muscle, tendon, joint capsule, or bone Document Type of structure Characteristics Percent of wound bed occupied Presence of other items Sutures Staples Foreign material Implant

44. Wound Edges Tissue at the perimeter of the wound Characteristics Distinctness Thickness Attachment to the base of the wound Epithelialization / pigmentation

45. Wound Edges Distinctness Some superficial wounds present with indistinct edges; wound gradually transitions into intact skin Deeper wounds have more distinct & well-defined edges

46. Wound Edges Thickness Chronic wounds tend to have thickened or rolled wound edges

47. Wound Edges Attachment Wounds with attached edges are flush with the surrounding tissue Wound with unattached edges are deep and wound side walls are evident

48. Wound Drainage Type Color Consistency Amount

49. Type CharacteristicsInterpretation Serous -Seen in the inflammatory phase -Clear to pale yellow - Watery consistency Normal Sanguinous -Results from bleeding at the wound site - Red or Dark brown -Consistency of blood or slightly thickened water Normal Purulent -White to pale yellow -Viscous or creamy -Certain infections have a characteristic drainge color Possible Infection

50. Color Interpretation ClearNormal Pale yellowNormal RedFresh Blood Dark BrownDried Blood Blue-greenProbable Pseudomonas infection YellowPossible infection

51. Consistency Interpretation Thin, wateryNormal Thick, creamyPossible Infection

52. Amount Interpretation NoneDessicated wound bed MinimalNormal; however, wounds with drainage that is disproportionate to the amount of necrotic tissue may be infected Moderate CopiousPossible Infection, especially if out of proportion to wound size

53. Wound Odor Assessed after the wound has been debrided and rinsed Described as either present or absent Should never be used as sole indicator of wound status

54. Structure & Quality Color Epithelial Appendages Edema Temperature

55. Structure & Quality Normal age-related skin changes Periwound hydration Skin turgor Presence and location of any calluses Scar formation Assess quality of scar tissue Thickness, mobility, & color Presence of any deformity

56. Color Describe color of periwound & associated skin in relation to both neighboring and comparable skin to opposite side Erythema Blanchable Non-blanchable Indicator of inflammation If out of proportion to the size and extent of the wound, may indicate infection

58. Epithelial appendages Hair Nail Long-standing ischemia will be unable to support hair growth and increases risk of fungal infection (nails) pale and yellow

59. Edema Localized / generalized accumulation of fluid within body tissues Pitting / Non-pitting Press thumb / index to affected area If depression remains after pressure is released, pitting edema is present Circumferential measurements Volumeter

60. Temperature Prior to testing Patient should rest in supine with the area uncovered for at least 5 minutes Use dorsum of the hand to lightly palpate skin Temperature compared with more proximal body segments & contralateral side If available Thermistor Radiometer (uses IRR)

61. Circulation Sensory Intergrity

62. Circulation Peripheral circulation should be assessed in all extremity wounds Could use Doppler ultrasonography Capillary refill Push against distal tip of digit until skin blanches Remove pressure Note amount of time skin returns to normal Should be less than 3 seconds

63. Circulation Pulse GradeCharacteristics 0 Absent 1+ Diminished 2+ Normal 3+ Bounding or accentuated

64. Sensory Integrity Gold Standard for assessing light touch sensation Semmes-Weinstein monofilaments To assess Occlude patient’s vision Apply monofilament perpendicular to the skin with enough pressure to bend it Assess each location 3 times Assess non-callused skin when possible Document location and the thickest filament the patient could identify

65. Sensory Integrity MonofilamentPressure Produced (grams) Interpretation of INABILITY to perceive monofilament 4.17 1Decreased sensation 5.07 10Loss of protective sensation 6.10 75Absent sensation

66. References Myers, B.A. (2004). Wound management: Principles and practice. NJ: Pearson Education. McCulloch, J.M., Kloth, L.C., & Feedar, J.A. (1995).Wound healing: Alternatives in management. Philadelphia: F.A. Davis. Cuccurullo, S. (2004). Physical medicine and rehabilitation board review. New York: Demos Medical Publishing. Juego, J.B. (2007). PT 142 notes.