integumentary - wound care 2

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mdeguzman7
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142030
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integumentary - wound care 2
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2012-03-20 01:16:19
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wound care evaluation
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wound care evaluation
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  1. What are the steps involved in a thorough evaluation of a wound?
    • 1. Good chart Review and Medical Hx
    • 2. Time (duration of wound)
    • 3. Type of Onset (gradual, sudden)
    • 4. Current Treatment
    • 5. Vital Signs (HR, BP, spO2)
    • 6. Cognitive Status (AxOx4, person, place, time, date, situation)
    • 7. Size of wound (cm, use pics, etc)
    • 8. Location of Wound
    • 9. Depth after debridement (sterile Qtip at base)
    • 10. Note presence of Tunneling, Undermiing or Epibole
    • 11. Descrive percentage of tissue (granulation/eschar/slough)
    • 12. Shape of Wound (round, irregular)
    • 13. Drainage (amount, color)
    • 14. Odor of wound (after irrigation and aeration)
    • 15. Describe Peri-wound tissue (red, hard, hot - induration, porous drainage, staining eg hemosiderine deposits)
    • 16. Tissue turgor/ pliability test (pinch and tent tests)
  2. What are the three types of wounds?
    • Pressure ulcers/sores
    • Venous stasis wounds
    • Neuropathic wounds
  3. What are tunnelling and sinus tracks and why is it important?
    Tuneling or sinus tracks are complications that can lead to fistulas or passageways to other areas of tissue
  4. What is undermining?
    • when subcutaneous tissue doesn't heal as quickly as the superficial epidermal layer
    • Dead space/undermined area under the edges of wound
  5. What is an Epiboly?
    • An epiboly is when edges of the wound start to pull in
    • Thick rounded wound edges
  6. What are the indications of poor circulation?
    • lack of hair growth
    • edema
    • shiny thin skin
    • thick discolored nails eg yellow
    • heat in the area
  7. How can you test for poor Circulation?
    • Pitting Edema Test
    • Girth Measurements (circumferential, MTh, malleoli, 3, 12, 18 above malleoli, inferior pole of patella)
    • Temperature (via radiometer in wound and around tissue)
    • Strength of Pulse (Posterior Tibial, Dorsalis pulse)
    • Evaluate patient BMI
  8. How do you test for Pitting Edema and what is the grading criteria?
    • Push down on edema and see if tissue dents inward.
    • indicative of possible system failure

    • Grade 1: 0 - 1/4 inch
    • Grade 2: 1/4 - 1/2 inch
    • Grade 3: 1/2 - 1 inch
    • Grade 4: >1 inch
  9. What is the grading for Pulse strength (with Pulse Doppler)
    • 0 - none but look at other factors too
    • 1- barely perceptible
    • 2 - weak (compare to contralateral side, most will be weak bilaterally)
    • 3 - Normal
    • 4 - Really strong (which shouldn't be --> aneurism?)
  10. How do you calculate BMI?
    BMI = (Weight in kg) / (Height in M)2

    • Ranges
    • 18.5 or lower = Underweight
    • 18.5 - 24.9 = Normal
    • 25 - 29.9 = Overweight
    • 30 or more = Obese
  11. What are some Sensory Testing evaluations to test for touch, pressure, and temperature?
    • Monofilament test 10g (evaluates protective sense on plantar aspect of foot not on callous areas)
    • Strength Evaluations (Ambulation, Bed Mobility, Braden Scale)
    • Posture
    • Contractures deformities
  12. What are the stages for PRESSURE WOUNDS/ SORES (after nebridement)?
    • Stage 1: not a wound, beginning of possibility of a wound / no blanching with capillary refill test and stays red
    • Stage 2: shallow wound contained in skin or dermis only
    • Stage 3: extends to adipose tissue, fascia (subcutaneous only) through the skin
    • Stage 4: Extends deeper to Bone, muscle, tendon

    If discolored but skin is intact, wound cannot be staged as it only indicates precursor. Should only be staged after wound has opened up.
  13. What is the most important factor of pressure ulcer development?
    PRESSURE x TIME
  14. How are non-pressure ulcers classified?
    There are no stages with non-pressure ulcers:

    • Superficial wound: contained within epidermis
    • Partial thickness: extends into dermis but contained within
    • Full thickness: extends below the dermis
  15. What is a good scale to measure risk for predicting pressure sore?
    • BRADEN SCALE
    • used to prevent pressure ulcers or flag people at risk for developing it
    • Less < than 12 - High Risk
    • 13-14 - Moderate Risk
    • 15-17 - Low Risk
    • 17 or more – should be monitored for possibility of developing pressure ulcer

    • Categories:
    • SENSATION,
    • MOISTURE, (macerated skin is easier to tear)
    • ACTIVITY LEVEL, (can you get out of bed and move)
    • MOBILITY, (bed mobility, able to change position)
    • NUTRITION, (if someone is cachetic (cachexia - Physical wasting with loss of weight and muscle mass caused by disease.)
    • FRICTION AND SHEAR
  16. What is the PUSH tool?
    PUSH (pressure ulcer scale for healing) TOOL – evaluation scale to monitor healing process of pressure ulcer

    • 3 areas:
    • Size
    • Drainage -Amount of exudate
    • Wound Presentation - Percentages of necrotic tissue vs. granulation tissue (eschar vs beefy red)


    • SCORES decreasing indicate that pressure ulcer is healing/improving
    • - Higher numbers are bad/worse
  17. Pressure
    HARRIS MAT TEST
    an old test – ink blotter with special paper where person stands on it to show outline to show where there is excessive pressurenormally metatarsal heads and calcaneus have mostabnormal: big toe
  18. How do you classify Venous Stasis wounds?
    • Venous stasis wounds also do not have stages
    • bc they are commonly superficial with lots of exudate
  19. Non-Invasive Vascular Test (ARTERIAL)
    CLAUDICATION TIME TEST
    • tests for ischemic pain that usually occurs with exertion (but sometimes w/ rest)
    • common in calfs and quads
    • usually due to occlusion

    • 1. patient walks on treadmill at speed of 1-2 miles/hour
    • 2. note time for claudication to develop
    • (not a gold standard but good for intervention e.g. after a bypass surgery)
  20. Non-Invasive Vascular Test
    RUBOR OF DEPENDENCY
    tests for arterial insufficiency

    • 1. patients lay supine and compare color on soles of feet
    • 2. raise investigated leg to about 60o
    • 3. Hold in elevation and watch for the sole of the feet get lighter ~ 1 min
    • 4. Bring down patient leg to supine. See how long it takes for normal color to return to normal (15-20 secs)

    • positive sign (30 seconds or more: possible arterial insufficiency)
    • If color comes back but BRIGHT RED --> hypererythemia
  21. Non-Invasive Vascular Test
    VENOUS FILLING TIME TEST
    • 1. first inspect veins on dorsum of feet and feel the raises with hand while patient is sitting with feet off table
    • 2. lay patient supine
    • 3. elevate the leg up for 1 minute @ 60o
    • 4. Apply deep effleurage distal to proximal and note flattening of veins on foot, while elevated
    • 5. After 1 min, have patient sit
    • 6. Record time it takes for veins to refill
    • Normal time is 15-20 seconds

    If longer than 30 secs may indicate arterial insufficiency

    If you see an immediate refill or distension --> test is not valid and may indicate valvular incompetency
  22. Non-Invasive Vascular Test (ARTERIAL)
    CAPILLARY REFILL TEST
    • gently squeeze toes for 3 secs then release, should blanch
    • then within 3 secs red should return.
    • If darker look at plantar side
    • Small arteriole Latency – indicates presence of occlusion, so would take longer
  23. Non-Invasive Vascular Test
    DOPPLER ULTRASOUND
    • diagnostic tool
    • Sends soundwaves into body in area of blood vessels
    • - creates characteristic vascular sounds for arteries and veins
    • arteries – bounding sounds “choo ___ choo sounds
    • if occlusion – not a bouncy sound
    • venous – phasic, windstorm sounds
  24. Non-Invasive Vascular Test (ARTERIAL)
    ABI - ANKLE BRACHIAL INDEX
    • Assessment of arterial status (insufficiency indicated by abnormal ABI)
    • 1-Take blood pressure in brachial artery in both left and right arms, no stethoscope but use Doppler instead
    • - inflate until sounds goes away.
    • - 1st sound it comes back is systolic pressure (lay supine and relax for 5 mins)

    • 2 - Go to ankle of same side
    • -Place cuff about 5cm above medial malleoli
    • -take Doppler probe over dorsalis pedis or posterior tibial pulse
    • -inflate until sound goes away

    ABI = ankle systolic pressure / brachial systolic pressure

    • 1.2 - considered normal
    • 0.8 – 1.0 - mild arterial occlusive disease
    • 0.5-0.8 - Moderate arterial occlusive disease
    • 0.7 or below – don’t or reassess/modify the use of compression
    • 0.5 or below - Severe arterial occlusive disease

    • * with very High ABI values, well above 1 close to 2.0, test is not valid -> possible indication of arterial calcification in posterior tibial or dorsalis pedis artery*instead may use TBI – Toe brachial index (bc it doesn’t calcify) – infrared sensor
    • Normal ToeBI – 0.8 – 0.9
  25. Non-Invasive Vascular Test (ARTERIAL)
    SEGMENTAL SYSTOLIC PRESSURES
    • If person has a low ABI under 0.6, they’ll take a systolic pressure:
    • --> below knee/proximal lower leg
    • --> one in the distal thigh/above the knee
    • --> proximal thigh
    • --> above ankle
    • [PT, AK, BK, AA]


    • *differences greater than 20 mmHg compared to the contralateral leg and/or
    • *differences greater than 20 between pressures of adjacent segments indicates occlusion in leg

    way of localizing where occlusion may be
  26. Non-Invasive Vascular Test
    VENOUS AUGMENTATION TEST
    Place Doppler over eg brachial artery and listen to phasic windstorm, with other hand apply deep effleurage distal to probe but motion towards probe. This should augment venous sound eg get louder. If there is some type of occlusion, augmentation would not occur.
  27. Non-Invasive Vascular Test
    VENOUS REFLUX TEST
    • Put probe over vein that you are investigating e.g. saphenous vein
    • Go proximal to probe then squeeze - create blockage sound should dissappear, if it doesn’t and you still hear sounds indicates refluxes
  28. Non-Invasive Vascular Test
    Homan’s Sign (for the possible presence of thrombus)
    • Gently squeezing the gastroc while the knee in an extended knee and ankle dorsiflexed position
    • If elicits severe pain in calf -May indicate presence of a blood clot
    • Positive sign – pain even at rest, heat, deminous discontinue therapy and refer to MD for vascular tests
  29. Non-Invasive Vascular Test
    CALF CUFF TEST
    • Take blood pressure cuff over calf (bladder aligned posteriorly) and inflate
    • if person cannot tolerate 40 mmHg can also indicate presence of occlusion
  30. Non-Invasive Vascular Test
    Transcutaneous partial pressure of O2 (TcPO2)
    • special sensing device on dorsum of foot that heats up mildly, measures oxygen pressures/concentration of blood
    • Normal should be above 40 mmHg
    • 30-40: presence of arterial insufficiency BUT adequate potential for healing
    • 20 or below: severely impaired blood floow and with POOR prognosis for healing

    *test not reliable if infection or swelling is present

    can use to screen if healing is viable for something like amputation and healing

    if 20mmHg or below, may decide to move more proximal
  31. Vibratory Sense Test,
    Neuropathy
    • TUNING FORK TEST
    • place on bone to see if they can sense vibration senses


    • DEEP TENDON REFLEX (DTR) on Achilles tendon – quick plantarflexion
    • e.g. Diabetic neuropathy may indicate a lost reflex (PNS lesion)
    • e.g. CP child – may elicit a clonus or (repeated/exaggerated reflex) (CNS lesion bc of dampened control) --> hypertonicity
  32. What are the characteristics of Venous Stasis Wounds?
    • Commonly found above the malleoli (bc of the dense venous plexus concentrated at the ankle)
    • More often the medial malleoli than lateral
    • Superfical
    • Irregular and Jagged Shaped
    • Lots of Exudate
    • Surrounding skin discolorations eg Hemosiderin deposits
    • If there is no arterial involvement --> Respond normally to compression / arterial test (ABI, pulse strength, only pain in dependent positions)
  33. What is the Pathophysiology of Venous Stasis Wounds?
    • HTN in the venous system
    • repetitive trauma to the venous system
    • aging
    • History of clots/thrombus formation
    • multiple pregnancies, development invitro puts compression on the vena cava
    • obesity
    • compressive tumors
    • decreased ambulation with poor Heel--> toe gait (eg shuffling gait)
    • relatively easier to heal than the other wounds
  34. What are the 3 theories behind the formation of venous stasis wounds?
    • 1. Fibrin Cuff Theory
    • 2. WBC trapping theory
    • 3. Microangiopathy theory
  35. What is the Fibrin Cuff Theory?
    • increased pressure in venous system translated thorugh capillaries
    • excess pressure may cause fibrinogen escape from capillary into interstitial tissue
    • Fibrinogen converts to Fibin
    • forming a Fibrin cuff around capillaries preventing the delivery of blood flow
  36. What is the WBC Trapping Theory?
    • increased venous HTN which stagnates bloodflow from capillary
    • WBC adhesion to inner capillary membrane releases inflammatory chemicals into the interstitial tissue
    • thus increases tissue's need for o2 (increasing metabolism)
    • tissues then become hypoxic--> death
  37. What is the microangiopathy theory?
    • pressure in the venous system is transferred to capillaries causing direct destruction
    • fragility of the capillaries cannot maintain integrity and strength
  38. What is the treatment and care protocols for venous stasis wounds?
    • Use absorptive dressing eg FOAM, non-adherent kinds based on level of drainage
    • apply significant amount of compression over foot and ankle to augment venous return
    • can use (unna boot, profore wrap (3-5 days) but not with infection)
    • Cover 1/2 of what was already wrapper (spiral wrap)
    • Apply more pressure distally, less as you go up (proximal)
    • ---> or use more layering distally when you start
    • UNNA BOOT -> wet sealed bandage. When it dries, it compresses and shrinks
    • --> wrap staritng at the MTP heads, Heel is also covered
    • --> Roll with roll up and out so you are less likely to drop it
  39. Venous stasis wounds - PATIENT EDUCATION
    • Encourage patient to walk
    • ankle pumps in any position
    • wear compression socks even after wound heals (for entire lifespan)
    • elevate limb
    • uncross legs when you sit
    • teach self-skin inspection daily
    • clean foot/leg hygiene
    • keep skin from trauma
    • maintain good nutrition
    • limit excess sodium/salt intake
  40. What are the characteristics of Neuropathic Wounds?
    • Circular, round
    • punched out (has depth)
    • Callous in periwound tissue
    • Very Dry, cracked
    • More common in weight bearing areas
    • When wounds are not managed --> risk of osteomyelitis --> Gangrene
  41. Pathophysiology of Neuropathic Wounds?
    • common in chronic or poorly controlled Diabetes (bc of sustained hyperglycemia)
    • byproducts of metaboilsm accelerate occlusion and reduce circulation
    • Hyperglycemia causes:
    • 1. sensory neuropathy
    • 2. autonomic neuropathy
    • 3. motor neuropathy

    Normal Fasting Blood Sugar is 70-110
  42. What is sensory neuropathy?
    • degeneration affecting sensation
    • dangerous loss of protective sensation
  43. What is motor neuropathy?
    • Atrophy and degeneration in muscles
    • foot loses natural protection (fat pad atrophy)
    • can contirbute to deformity formation --> imbalances between muscle gorups
  44. What is autonomic neuropathy?
    • Cracked skin, dry
    • affects innervation to the sebaceous and eccrine (sweat glands)
    • loss of control of vasodilation/constriction tone
  45. What is Charcot Foot?
    • common in diabetics with sustained trauma
    • poor control of blood flow esp deep in the foot and skin
    • exaggerated blood flow to the bone, washing out calcium to bone
    • ---> weakens bone and collapses it
    • Leads to mis-shapen foot
    • Gold standard treatment is TCC
  46. Diabetic Neuropathic Wounds: Patient care, etc
    • If wound is dry --> use moist dressing and apply a TCC (Total Contact Cast) over the foot so it redistributes pressuress off foot up to below the fibular head (1-2 weeks)
    • -Cast also prevents too much walking for miles
    • allows time to heal
    • reduces pressure
    • prescribe UE exercises OKC, conditioning, Gait training - step to gait
  47. What is a classification system for Neuropathic wounds?
    WAGNER CLASSIFICATION (for neuropathic wounds in plantar aspects of foot)

    • Grading:
    • 0: indicates diabetic foot but skin is in tact, loss of protective sensation --> Rx of good diab shoes

    1: superficial ulcer is present --> wound care, consider TCC or special boot --> after healing diabetic shoe

    2: deeper wound extending to tendon or bone --> wound needs debridement, TCC or boot after any infx, close monitoring for infection with antibiotics

    3: wound w/ abscess and/or Osteomyelitis --> antibiotic therapy, NWB ambulation, TCC boot post antib.

    4: wound associated with Gangrene in Forefoot

    5: Wound asociated w/Gangrene in major portion of Foot --> surgical consultation, debridement and or AMputation, bypass surgery, antibiotic therapy, glucose maintenance (70-110)
  48. Patient Caution and Care for Diabetic Neuropathic Wounds
    • Maintain glucose levels (70-110) mg/dL
    • Daily skin inspection (wounds, lesions, overgrown nails, skin cracks, and fissures)
    • own long handled mirrors
    • Be aware of cllouses and have it shaved down by clnician/podiatrist
    • No barefoot walking
    • Wear white, breathable socks
    • Prevent excessive maceration/moisture between toes
    • Beware embedded objects in shoes
    • Use Non-drying alohol based soaps eg Cetaphil
    • Choose activities less pounding on feet
    • Avoid OTC hair/corn removers
    • Choose correct shoes (leave room 1/2 inch btwn longest toe)
  49. What are the characteristics of a good Diabetic Shoe?
    • Lightweight with secure closure (maybe velcro)
    • Extra depth for insoless or pressure relief inserts eg Plastazole *insert
    • Vamp - (upper portion) made of breathable material eg lycra
    • Rocker Bottom Sole (decrease MT shearing forces and pressure)
    • Raised and reinforced Toe box (protective and room for deformities)
    • Reinforced Counter to prevent excessive dorsiflexion
    • MT Pads just proximal to mt heads

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