Mark David S. Basco, PTRPFacultyDepartment of Physical TherapyCollege of Allied Medical ProfessionsUniversity of the Philippines Manila

Learning ObjectivesAt the end of the session, you should be able toAppreciate 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.

Why do we need to perform an assessment?To determine the physical therapy diagnosisTo identify factors that may contribute to

ulceration or abnormal wound healingTo assist in making a wound healing

prognosisTo identify factors that may benefit from

referral or consultation with another health care provider

What are we going to discuss?Obtaining Patient historyDetermining Wound CharacteristicsDetermining Periwound and Associated skin

characteristicsOther tests

General demographicsLifestyle and Functional statusPast and current general medical historyPast and current wound historySystems review

General demographicsAge Sex OccupationEthnicityPrimary languageEducation (patient and caregiver)

Lifestyle and Functional statusDoes 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?

Lifestyle and Functional statusIs 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?

Past & Current Medical HistoryDo you have a history of the following

conditions?High BPHeart disease or heart conditionPeripheral vascular diseaseStroke / TIABreathing difficultiesDiabetesCancerHIV / AIDSRed Flags

Past & Current Medical HistoryAre you allergic to any of the following

substances?LatexAdhesivesSulfaAnimal products

Is there any other allergies that you have?

Past & Current Medical HistoryDo you smoke?

Number of packs/dayNumber of years smoking

Do you drink alcoholNumber of drinks/day

Do you take drugs not prescribed by a MD?Is there any medications that you’re taking?

Past & Current Wound HistoryWhen did the wound begin?How did the wound occur?Have any tests been performed?

Wound cultureBlood testsArteriogramVenous doppler

Have you perviously or are you currently taking any medications for this wound?

Past & Current Wound HistoryIs 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?

Systems ReviewCardiovascular / Pulmonary MusculoskeletalNeuromuscularGastrointestinalUrogenitalIntegumentary

Wound LocationWound SizeTunnelling / UnderminingWound BedWound EdgesWound DrainageWound Odor

Wound LocationDocument

Using anatomically correct terminologySide 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 ”

Wound SizeDirect MeasurementWound TracingsPhotographic MeasurementsVolumetric MeasurementsTotal Body Surface Area

Wound SizeDirect Measurement

Measure the longest length and widest width perpendicular to the length

Surface area = Length x WidthWound 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 locationsClock method

Wound SizeDirect Measurement

EXAMPLE:Wound AWidth = 3.5 cmLength = 4.2 cmSurface area = 14.7 cm2Depth= 1.4 cm(if with eschar or presence of nonviable tissue)Depth=1.4 cm; unable to determine actual

depth secondary to eschar

Wound SizeDirect 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

Wound SizeWound Tracings

MaterialsClean, comformable transparencyPermanent, fine-tipped pen

Tracing sheetsWound contact layerAdhesive outer permanent layerImprovised

CLEAN, Plastic wrap folded in half

Wound SizeWound Tracings

Surface area estimated from tracing as previously described

Wound depth assessed using direct measurement

Tracings SHOULD be labeled withPatient’s name DatePrecise wound locationSize Wound characteristics

Wound SizeWound Tracings

3 alternative methods of measuring wound surface areaUse of transparencies with premeasure grid

marksPlanimetryDigitizing

Wound SizeWound Tracings

Simple, fast, easy to learnAdvantages over direct measurement

More accurate representation of wound size; regular/circular wounds

Retained image helpful for future comparisonsMain sources of error

Visualizing wound perimeter through the transparency

Tracing itself

Wound SizePhotographic Measurement

Surface area determined by tracing photographic image

Advantages over wound tracingAvoids contact with woundProvides additional information about

periwound and wound bed characteristicsEquipment available today allows clinician with

minimal photographic skill & knowledge to obtain fairly consistent, high quality images

Wound SizePhotographic Measurement

Wound photographs SHOULD includePatient’s nameDatePrecise wound locationMeasurement guide (ruler for scaling

reference)Results of direct wound measurements

Wound SizePhotographic Measurement

DisadvantagesProne to errors in scaleCamera distance and camera angle can

influence resulting image sizeInconsistent lighting conditions may make

wound assessment problematicCostly & time-consuming

Use photography to provide supplemental information but not to determine wound size

Wound SizeVolumetric 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

DisadvantagesTime consuming and painful for the patient

(molding)Inaccurate and problematic (saline)Cannot be used on wounds that extend into

body cavities / fascial planesUnclear if molding material may have

detrimental effects to wound healing

Wound SizeTotal Body Surface Area (TBSA)

Used for wounds covering large body surface areas

Commonly used in patients with burn injuriesQuick, inexpensive, & reliable method of

estimating wound size

Wound SizeTotal Body Surface Area (TBSA)

Rule of NinesAmerican Burn Association Classification

* Percentage of partial thickness burn

MINOR MODERATE

MAJOR

ADULT < 15 15 - 25 > 25

CHILDREN

< 10 10 – 20 > 20

Wound SizeTotal Body Surface Area (TBSA)

American Burn Association Classification

* Percentage of FULL thickness burn

MINOR MODERATE

MAJOR

ADULT

< 2 2 -10 ≥ 10CHILDREN

Tunneling / UnderminingTunneling

Is a narrow passageway created by the separation of, or destruction to, fascial planes

UnderminingOccurs when the tissue under the wound edges

become eroded, resulting in a large wound with a small opening

TunnelingMeasured by inserting a probe into the

passageway until resistance is feltTunnel 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”

UnderminingMeasured inserting a probe under the wound

edgedirectly almost parallel to the wound surface until resistance is feltDistance from probe tip to the point at which

the probe is level with the wound edgeUse CLOCK termsEXAMPLE“Undermining 1.2 cm from 9- o’ clock to 1- o’

clock positions. ”

Wound BedMay contain varying types and amounts of

granulation tissue necrotic tissueother structures

Wound BedGranulation Tissue

Temporary scaffolding of vascularized connective tissue that fills the wound voidBeefy-red appearancePale or dusky

Document characterictics and percentage of wound bed it covers

Wound BedNecrotic Tissue

Described by color, consistency, and percentage of wound bed it occupies

SloughYellow or Tan in color and has stringy or

mucinous consistencyEschar

Black necrotic tissue; either soft or hardEither adherent or non-adherent

Refers to the ease with which the necrotic tissue can be separated from the wound

Wound BedOther Tissues

Exposed structures e.g. Fascia, muscle, tendon, joint capsule, or bone

DocumentType of structureCharacteristicsPercent of wound bed occupiedPresence of other items

Sutures Staples Foreign material Implant

Wound EdgesTissue at the perimeter of the woundCharacteristics

DistinctnessThicknessAttachment to the base of the woundEpithelialization / pigmentation

Wound EdgesDistinctness

Some superficial wounds present with indistinct edges; wound gradually transitions into intact skin

Deeper wounds have more distinct & well-defined edges

Wound EdgesThickness

Chronic wounds tend to have thickened or rolled wound edges

Wound EdgesAttachment

Wounds with attached edges are flush with the surrounding tissue

Wound with unattached edges are deep and wound side walls are evident

Wound DrainageTypeColorConsistencyAmount

TypeCharacteristics Interpretati

onSerous -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

ColorInterpretation

Clear Normal

Pale yellow Normal

Red Fresh Blood

Dark Brown Dried Blood

Blue-green Probable Pseudomonas infection

Yellow Possible infection

Consistency

Interpretation

Thin, watery Normal

Thick, creamy Possible Infection

Amount

Interpretation

None Dessicated wound bed

Minimal Normal; however, wounds with drainage that is disproportionate to

the amount of necrotic tissue may be infected

Moderate

Copious Possible Infection, especially if out of proportion to wound size

Wound OdorAssessed after the wound has been debrided

and rinsedDescribed as either present or absentShould never be used as sole indicator of

wound status

Structure & QualityColorEpithelial AppendagesEdemaTemperature

Structure & QualityNormal age-related skin changesPeriwound hydrationSkin turgorPresence and location of any callusesScar formationAssess quality of scar tissue

Thickness, mobility, & colorPresence of any deformity

ColorDescribe color of periwound & associated

skin in relation to both neighboring and comparable skin to opposite side

ErythemaBlanchableNon-blanchableIndicator of inflammationIf out of proportion to the size and extent of the

wound, may indicate infection

Epithelial appendagesHairNailLong-standing ischemia will be unable to

support hair growth and increases risk of fungal infection (nails) pale and yellow

EdemaEdema

Localized / generalized accumulation of fluid within body tissues

Pitting / Non-pittingPress thumb / index to affected areaIf depression remains after pressure is

released, pitting edema is presentCircumferential measurementsVolumeter

TemperaturePrior 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 availableThermistorRadiometer (uses IRR)

CirculationSensory Intergrity

CirculationPeripheral circulation should be assessed in

all extremity woundsCould use Doppler ultrasonographyCapillary refill

Push against distal tip of digit until skin blanches

Remove pressureNote amount of time skin returns to normalShould be less than 3 seconds

CirculationPulse Grade Characteristics

0 Absent

1+ Diminished

2+ Normal

3+ Bounding or accentuated

Sensory IntegrityGold Standard for assessing light touch

sensationSemmes-Weinstein monofilaments

To assessOcclude patient’s visionApply monofilament perpendicular to the skin

with enough pressure to bend itAssess each location 3 times

Assess non-callused skin when possible Document location and the thickest filament

the patient could identify

Sensory IntegrityMonofilament Pressure

Produced (grams)

Interpretation of INABILITY to perceive monofilament

4.17 1 Decreased sensation

5.07 10 Loss of protective sensation

6.10 75 Absent sensation

ReferencesMyers, 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.