Assessment of the Integument

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Assessment of the Integument

• Veronica Southard PT MS GCS

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Review

• Structure and function of Skin.

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Layers of Epidermis

• Stratum Corneum outermost horney layer (dead
  cells). Dry waterproof and rich in pr- keratin
  that serves to protect
• Stratum lucidum
• Stratum basale
• Stratum granulosum
• Stratum germinativum

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Epidermal Wound Healing

• Depth may include the superficial layer of the
  Dermis.
• Designated as partial thickness wounds.
• Heal by a process known as re-epithelialization
• Epidermal wounds heal without scars and the
  duration of healing is much shorter than dermal
  wound healing

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DERMAL Wound Healing

• Involvement of the complete epidermis, dermis and
  subcutaneous tissues. Bone and muscle may also be
  involved.
• Referred to as Full Thickness Wounds
• Heal by scar formation

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Three Phases of Healing

• Inflammatory prep for healing, clean up debris
• Fibroplastic Rebuilds damaged structures and
  provides strength to the wound.
• Remodeling Modifies scar from immature to
  mature. Provides strength to wound.

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Wound contraction

• Occurs during the fibroplastic phase. Wound
  remodels secondary to mobilization of surrounding
  tissues that serves to decrease the size of the
  wound. A centripedal movement of the normal full
  thickness skin occurs. The end result is a
  smaller wound to heal by scar formation.
• Is affected by the shape of the wound.

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Strengthening the wound

• Collagen molecules crosslink intramuscularly and
  intermolecularly to provide strength to a wound.
• Crosslinking provides the tensile strength to a
  wound

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Remodeling Phase

• Scar changes in form, bulk and strength
• Keyloids occur secondary to overabundant
  collagen deposition and extend beyond the margin
  of the wound.
• Hypertrophic Scar formation scar is raised, stays
  in original wound boundry and gradually abates.
  Pressure applied over time improves hypertrophic
  scar

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Alignment of Collagen

• Theories
• Induction scar attempts to mimic the tissue it
  is healing. The tissue structure induces the
  collagen weave.
• Tension Refers to the internal and external
  stresses that affect the wound during the
  remodeling phase

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Types of Wound Healing

• Primary Closure also called healing by 1st
  intention. Surgical incision or minimal skin
  loss. Wound edges are approximated and sutured
  together. Further healing occurs by
  reepithelialization.
• Secondary Closure healing by second intention.
  Large, open full thickness wounds with soft
  tissue loss. Takes longer

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Types of healing Cont

• Delayed Primary Closure, healing by third
  intention. Happens in more extensive wounds that
  are heavily contaminated or at risk developing an
  infection during the acute phase of healing.

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FACTORS AFFECTING WOUND HEALING

• Nutrition
• Vascularity
• Medications
• Disease
• Age

• Local Factors
• Infection
• Blood supply
• Local meds
• Dressings
• Necrotic tissue/ eschar
• Desiccation

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Wound evaluation

• History
• Systems review
• Lab work
• Procedures
• Examination

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History/Subjective Exam

• Interview Pt/ Caregiver
• Cause of the wound
• PMH, Age, Sex, Occupation, Activity/Exercise
  levels

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Events leading up to wound development

• Onset
• Mechanism of injury
• Wound symptoms
• Does the pt. Have pain somewhere remote to the
  wound?
• Parasthesia

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Review of Labs

• Ascertain info re autoimmume and metabolic
  systems.
• Wound cultures- aerobic, anerobic. Causes of
  infectious processes.
• Colony count determines whether skin is infected.
  Bacterial loads of gt 100,000/gm of tissue equals
  infection
• Tissue biopsy r/o malignancy or tumor
• MRI- Xray- osteomyelitis or absess

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Objective Information

• Based on the history ,subjective exam, systems
  review, and basic observations of the wound you
  determine what is appropriate.
• Norton/Braden risk assessment will identify the
  following risk factors mobility/activity
  impairments, moisture/incontinence and impaired
  nutrition. Altered LOC and sensory perception
  are also risk factors

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Wound Classification

• Partial Thickness- epidermis and superficial
  dermis
• Full thickness- can be as deep as bone. Can be
  caused by something other than pressure.
• Wounds are described in terms of Length, Width,
  and Depth

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Color Classification

• Red- healthy and in the healing phase
• Yellow- infected or full of slough
• Black- covered with eschar

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Stages of Pressure Wound Development
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Pressure wounds use a 4 stage system
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Stages of Pressure wounds

• Stage I- Non blanchable erythema of intact skin.
• Stage II- Partial thickness loss involving
  epidermis and or dermis. Ulcer is superficial
  and presents clinically as an abrasion, blister,
  or shallow crater.
• Stage III- Damage or necrosis of subcutaneous
  tissue which may extend to but not through
  underling fascia. Deep crater with or without
  undermining of adjacent tissue.
• Stage IV- Skin loss, extensive destruction,
  tissue necrosis or damage to m or bone or
  supporting structures.

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Measuring Pressure ulcers

• Stage I Measure length and width only
• Stage II require length, width and depth msmt.

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PE and Examination

• PE includes objective msmts. That allow
  monitoring of progress towards healing.
• Wounds are measured at least weekly
• Assess changes in length, width, depth.
• Document site, shape, depth of tissue injury
• Acetate tracings are valuable with large
  irregularly shaped wounds. I.e. leg ulcers.

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Arterial
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Venous
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Venous
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Clinical Measurements

• Location Often indicative of the cause.
  Describe in terms of bony landmarks, joints, skin
  creases, folds.
• Describe the surface- volar/plantar.
• Note the location of the wound on a body diagram
  or take a polaroid

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Clinical Measurements

• Size and Depth
• Length and width document size of wound. Measure
  the wound from the longest and shortest distance
  of the wound edge. Document in cm. Use tracings
  with irregular wounds.
• Depth- insert a sterile cotton swab in to the
  deepest part of the wound and grasp the
  applicator where it meets the wounds edge. When
  the wound varies in depth, indicate the
  shallowest and deepest.

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Depth measurement cont

• Wounds that can be maintained perpendicular to
  gravity can be measured using a syringe filled
  with saline.
• Tunneling/undermining is tissue destruction
  underlying intact skin along the wound margins.
  It is described in cm. Like a clock with the pts.
  Head being 12 oclock

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Drainage

• Note any present.
• Active- free flowing fluid that can be expressed
  by moving the peripheral borders of the wound.
• Inactive- present only on the dressing, not
  during your exam.

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Describing Drainage

• Type serous, purulent, sanguineous
• Amt. none, min, mod, copious
• Color clear, red, yellow, white
• Odor absent, mild, mod, foul smelling
• Consistency thin/watery, thick/opaque
• Sudden increases in amt of drainage, accompanied
  with local signs of infection, foul odor, a
  quantitative culture is taken

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Temperature

• Severity and limits of inflammation can be
  assessed by noting the variation over the wound
  and around.
• Thermistors are unexpensive and used most
  frequently

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Girth

• Measures the extent of limb atrophy or edema
  when compared to the unaffected limb.
• Taken with a calibrated tape, use a disposable
  when the wound is draining.
• Volumetric tests are more accurate when measuring
  irregular surfaces.

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ID of Tissue Structures

• Color indicates the vascularity and viability of
  the structure.
• Color changes occur secondary to maceration,
  dehydration, or hypoxia in or around the wound.
• Wound bed may be red, yellow or black
• Tissue structures found in wounds are eschar,
  granulation tissue, adipose tissue, fascia, m,
  tendon, and bone
• Foreign matter should be removed ASAP to prevent
  bacterial colonization and infection

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Periwound tissue

• Skin around the wound.
• Red ring around wound also referred to as halo of
  erythemia is indicative of infection
• Trophic changes are indicators of poor arterial
  circulation
• Skin color changes provide info with regard to
  circ system
• Venous insufficiency pigment hemosiderin deposits

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Cutaneous Sensibility Assessment

• Skin breakbown may result from impaired sensation
  to temperature, proprioception, touch or
  pressure.
• Always perform sensory tests bilaterally
• Light touch
• Nylon filaments Semmes Weinstein filaments,
  perpendicular to area being tested. Come In
  grades. Sensation at lt/ 5.07 is WNL

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Assessing Arterial Systems

• 1. BP- used to screen pts. At risk for HTN
  ulcers. Prevention plays a big role
• 2. Pulses- Quality and presence indicates bl fl
  through the arteries.

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Rubor of Dependency Test

• Determines how adequate the bl fl is in the
  arterial system. Assesses changes in skin color
  relative to elevation and dependency of the limb.
  The test has two parts
• 1. Supine, ele 60 for 1. Examine plantar
  surface of foot. Normal will have no color
  change. Abnormal pallor secondary to inadequate
  pressure and compromised bl fl

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Rubor Cont

• 2. Look at changes in skin color with LE in
  dependent position. In arterial insufficiency,
  there is a reactive hyperemia or rubor as the
  arterial system tries to compensate for tissue
  hypoxia

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Doppler Ultrasound

• This is an effective, noninvasive dx. Means for
  determining vascular status. Cheap and easy.
  Detects abnormalities in peripheral vasculature
  and as a screen for venous obstructions and
  incompetent valves.

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What does Doppler do?

• Determines the relative velocity of bl fl in the
  major arteries and veins in the extremities.
• Has an US probe, vibrating at a frequency of
  5-10MHz, setting the piezoelectric crystals in
  the probe to vibrate and emit an US beam. Gel is
  used
• DOPPLER EFFECT is the normal mvt. of cells in the
  bl vessels causing a shift of the frequency of
  the US beam.

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Doppler cont

• The 2nd crystal in the Doppler probe receives the
  reflected sound waves. With no mvt. In a bl
  vessel, the reflected sound waves have the same
  frequency as the transmitted waves and there is
  transmission silence.
• Any frequency shift that occurs between the time
  of the US beam emission and the time the
  reflected sound waves are received, produces an
  audible signal.

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Peripheral Arterial Testing Using Doppler

• 2 measurements are performed
• 1. Ankle Arm Index ratio detects and quantifies
  arterial vascular disease
• 2. Segmental BP used to locate obstructions

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Ankle Arm Index Ratio

• Pt supine, sl knee flexion with hip ER. Post Tib
  artery is palpated. A sphygmomanometer cuff is
  put around the leg at the malleoli level. The US
  probe with gel, is held over the PTA at a 45
  angle and moved to find the loudest signal. Cuff
  is inflated until no sound is heard, next the
  cuff is slowly deflated and systolic BP is
  recorded at the 1st sound.

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A/A ratio

• The pt systolic BP is then divided by the
  brachial BP to determine the ratio. A ratio of
  1.0 or gt Is WNL

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Segmental Blood Pressures

• BP at the ankles, below the knee, AK and high on
  the thigh are taken.
• The Doppler Probe is held constant on Post Tib
  artery while the cuff is moved to testing sites.
  Any artery below the cuff can be used, usually
  Dorsalis Pedis. Segmental BP from adjacent
  levels should not vary by gt 30mmHg. If there is
  gt30mmHg, there is an obstruction between those 2
  segments.

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Assessment of Peripheral Venous Systems

• Doppler US more subjective than arterial
  testing, because there is only an auditory
  signal. Audible signals are tested over the post
  tibial v, superficial femoral v., common femoral
  v., popliteal veins.
• Position pt. Long sit or supine. It is hard to
  get popliteal veins in this position
• Auditory responses are recorded as spontaneous
• (present) or not spontaneous (not present).
  Augmentation is tested next by squeezing the calf
  distal to the probe to see if signal is enhanced

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Peripheral Venous Assessment cont

• Compression is used to assess valvular
  competency. The examiner will manually compress
  the limb prox to probe. If the valves are
  competent, compression terminates the auditory
  signal and when released, the signal resumes. If
  during compression the sound continues to be
  heard, there is malfunctioning of the valves
  allowing back flow of blood to the area

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Peripheral Venous Tests Percussion

• Used to evaluate the patency of venous valves.
• Pt. In standing, varocosities full of blood. The
  examiner places 1 hand on he dilated vein and he
  other 20 cm. Proximally on the leg. The upper
  hand percusses the prox segment on the vein,
  while the lower hand checks for impulse
  transmission of the impulse. When the impulse is
  transmitted to the lower hand it is indicative of
  bad valves.

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Trendelenburg Test

• Assesses valvular competency in the communicating
  veins and saphenous system, by measuring the
  retrograde filling time in the LEs.
• To empty venous bl of the LEs, elevate to 90 and
  a tourniquet is applied around the proximal
  thigh. Pt. Stands while the examiner observes
  the manner in which the veins refill. Normal
  refilling of veins takes about 30 sec

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Test for DVT- Homans sign

• Squeeze Gastroc while forcefully DF foot with the
  knee in extension.
• Increased firmness and tenderness elicited upon
  deep palpation of gastroc suggests DVT
• When in doubt, inflate Bp cuff around calf until
  discomfort. Normally with DVT, pressure gt 40mmHg
  cannot be tolerated

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Assessment-Evaluation

• All data is compiled and the dx, and px, is
  formulated. STG., LTG.
• Recommended positioning programs, pressure relief
  devices, edema control, methods of wound
  cleansing/debridement and dressing regimen.

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Resources

• www.medicaledu.com
• Prem Gogia. Clinical Wound Management.
• Slack Inc. NJ 1995
• Andrew Guccione. Geriatric Physical Therapy.
  Mosby 2000