WOUND EXAMINATION

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WOUND EXAMINATION
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PATIENT HISTORY

• WOUND HISTORY
• DURATION
• ATTRIBUTING EVENT
• SYMPTOMS
• PAIN
• PARESTHESIA/ANESTHESIA

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HISTORY (cont.)

• DOES PAIN CHANGE WITH POSITION
• elevation decreases pain venous
• dependency increases pain in venous lesions
• pain with rest - severe occlusive disease
• intermittent pain with ambulation claudication

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HISTORY (CONT.)

• PRES.MH, PMH, PSH (PVD, CHF, HTN, DM, THYROID,
  LYMPHEDEMA, IMMUNOSUPPRESSIVE, CA , R/A ETC.)
• PAST TREATMENT OUTCOME
• MEDICATIONS
• TESTS (CULTURES, DOPPLERS, BONE SCAN, X-RAY)

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HISTORY (CONT.)

• ADDITIONAL STUDIES (ARTERIOGRAM, VENOGRAM, ABI)
• SOCIAL HX
• VOCATIONAL HISTORY
• HOBBIES

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OBJECTIVE EVALUATION

• Test Measures

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LOCATION

• HYPERTENSIVE-posterio/lateral leg, onset with
  infarction, very severe pain hypertension
• VENOUS-distal leg, medial aspect, red base, wet,
  periwound skin staining, no pain, mild
  insufficiency

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Chronic Venous Insufficiency champagne
bottle piano leg appearance
Atrophie blanche
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LOCATION (CONT.)

• ARTERIAL-DISTAL LOWER EXREMITY, LATERAL ASPECT,
  TOES FEET, PALE BASE, ATROPHIC SKIN, DRY WOUND,
  SEVERE PAIN, ARTERIOSCLEROSIS
• NEUROTROPHIC-PLANTAR SURFACE OF FOOT, SMALL OR
  DEEP, PERIWOUND CALLOUS, INFECTION, NO PAIN
  POSSIBLE DM

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SIZE

• LENGTH, WIDTH, AREA, DEPTH, VOLUME - IF REMOVE
  ESCHAR WOUND WILL APPEAR BIGGER
• MEASURE FROM WOUND EDGE
• USE CONSISTENT TOOL UNITS OF MEASUREMENT
• PHOTOGRAPHY, TRACING, VOLUME, SYRINGE

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UNDERMINING

• ALSO KNOWN AS RIMMING OR TUNNELING
• TISSUE DESTRUCTION UNDERLYING INTACT SKIN ALONG
  THE WOUND MARGINS (HYPOGRANULATION)
• MEASURE USING THE OCLOCK SYSTEM, HEMISPHERES

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GIRTH

• EDEMA, ATROPHY
• MEASURE WITH REFERENCE TO BONY LANDMARKS USING
  TAPE MEASURE
• VOLUMETRIC DISPLACEMENT

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Edema

• Measured in a variety of ways
• Quantifying Pitting that occurs from the
  examiners digit
• 1 Barely perceptible depression
• 2 Easily identified depression, 15 sec. to
  resolve
• 3 Depression takes between 15-30 sec. to
  resolve
• 4 Depression lasts for greater than 30 sec.

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SHAPE

• TRIANGULAR- SKIN TEAR
• ROUND- ARTERIAL
• IRREGULAR-VENOUS

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SLOPES

• ANGLES OF MARGINATION
• DEPICT GRANULATION
• VERY IMPORTANT MEASUREMENT

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Staging of Wounds

• Stage I-IV Pressure Wounds
• Wounds other than Pressure
• Superficial
• Partial Thickness -epidermal layer, superficial
  layer of dermis
• Full-Thickness- epidermis, dermis, subcutaneous ,
  may also involve muscle and bone

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Stage I

• Partial Thickness, limited to epidermis,
  non-blanchable erythema (sunburn)

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Stage II

• Partial Thickness Skin Loss,
• involves both epidermis and dermis
• (abrasion, blister, shallow crater)

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Stage III

• Full Thickness Skin Loss
• Damage or Necrosis of Subcutaneous Tissue
• May Extend to Fascia
• (deep crater, with or without undermining)

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Stage IV

• Full-Thickness Skin Loss
• Extensive Destruction
• Necrosis
• Damage to Muscle, Tendon, Joint Capsule, Bone

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Wagner Ulcer Classification Diabetic Ulcers

• Grade
• 0 Intact Skin
• 1 Superficial Ulcer
• 2 Deep Ulcer
• 3 Deep Infected Ulcer
• 4 Partial Foot Gangrene
• 5 Full Foot Gangrene

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Tissue Composition

• RED WOUNDS- clean healthy granulating wounds
• YELLOW WOUNDS-may contain fibrous tissue,
  hydrated necrotic tissue, or dead tissue,
  referred to as slough
• BLACK WOUNDS-dried eschar, leathery

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Tissue Found in Wounds

• Eschar
• Granulation
• Adipose
• Fascia
• Muscle
• Tendon
• Bone

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Foreign Debris Necrotic Tissue

• Remove as Soon as Possible
• This will prevent bacterial colonization and
  infection

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Peri-Wound

• Trophic Changes (dry skin, brittle nails, hair
  loss)
• indicates poor arterial nutrition

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Peri-Wound

• Change in skin color
• cyanotic Arterial Compromise
• Pigmentation (hemosiderin staining), pigment is
  deposited from RBC Venous
• Ring of Redness or Halo of erythema around the
  wound may indicate infection

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Drainage

• Inactive
• found on dressing, at time of observation no
  drainage is found in or near the wound

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Drainage

• Active
• Free flowing, able to be milked from the wound

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Characteristics of Drainage

• Transudate (Serous) clear, watery
• contains H20, salts and proteins
• Serosanguineous tinged red/brown
• watery, thin
• contains serum, blood
• Exudate creamy, yellowish
• moderately thick
• contains proteins, WBC

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Characteristics of Drainage (cont.)

• Purulent/Pus yellowish/brownish
• Thick
• contains WBC, necrotic debris
• Infected Pus
• yellow, green/blue
• thick
• contains pathogens
• describe amountnone, min, mod, max

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Odor

• Pseudomonas-sweet smell (fruity)
• Garbage- rotten infection
• Proteus- ammonia
• describe absent, mild, moderate, foul smelling

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Temperature

• systemic v. localized
• measured
• touch
• thermistor
• thermography
• radiometer
• measure infrared radiation from the body

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Indications for culture

• Clinical Signs of Local Infection by Linholm
• edema, erythema, purulent or foul smelling
  drainage, increased pain, induration, heat around
  the wound IFEE
• Signs of systemic infection
• fever, abnormal CBC
• Bone Involvement (osteomyelitis)
• Non-Healing Wounds (silent infection)

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Aerobic swab culture technique. The culturette Is
rotated while moving in a 10-point
pattern. Gentle pressure to express fluid is
required.
From Myers, B.A. Wound Management Principles
and Practice. Prentice Hall, Upper Saddle River,
NJ. 2004 p. 94
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Vasculature Examinations

• Pulses(2Normal, 1Diminished, 0 Absent)
• Auscultation (swishing sound, only heard in
  abnormal artery)
• Venous Exam (venous doppler)

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Vascular Exams Continued

• arterial exam
• ankle-brachial index (ABI)
• sys.pres.LE/sys.preUE (120/1001.2 normal)
• should equal 1 or greater than 1
• 1 or greater no arterial occlusive disease
• 0.9-1.0 minimal symptoms in LE
• 0.5-0.9 claudication pain
• 0.3-0.5 ischemic rest pain
• less than 0.3 ischemia with tissue necrosis

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Normal ABI
Ankle SBP 120mmHg
Heart Level SBP 100 mmHg
ABI 120 mmHg/100mmHg 1.2
Doppler
Doppler
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ABI

• When ABI value is lt.9
• 95 sensitive
• 99 specific
• For angiographically significant PVD

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ABI

• Change of 0.15 correlates with disease and
  symptomology

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Measuring ABI
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Tissue Oxygen Tension

• tc-Po2
• transcutaneous oximmetry

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Rubor of Dependency Test

• assess arterial flow by evaluating skin color
  changes during elevation and dependency
• leg elevation at 60 degrees for 1 min.
• normally no significant change in color
• lower the leg, record time for color return
• arterial insufficiency may take longer than 30
  sec.
• color will be bright red (hyperemic)

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VENOUS FILLING TIME

• assess arterial flow by evaluating time veins
  take to fill after emptying
• elevate LE for 1 min. to 60 degrees
• lower the leg, record time that veins on the
  dorsum of the foot take to refill
• with arterial insufficiency may take 30 sec. or
  longer

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Claudication Time

• assess arterial response by increasing the demand
  to the calf musculature during exercise
• Treadmill- 1-2MPH
• measure time to claudication
• monitor changes in functional status over time

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Test for DVT

• Homans Sign
• squeeze calf while dorsiflexing the ankle, with
  the knee held in an extended position
• tenderness with increased firmness may suggest
  DVT
• confirm using blood pressure cuff
• pt. unable to tolerate 40mmHg if DVT present
• normally able to tolerate much higher pressures

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Test for Cutaneous Sensitivity

• perception of light touch
• use cotton ball
• perception to temperature
• warm, cool
• 2-point discrimination

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Monofilament Testing for LOPS

• Semmes-Weinstein Monofilaments
• Scale of 1.65 to 6.65 -- force required to cause
  the filament to bow when pressed against the skin
• Higher the monofilament number, the more force
  required for bending.
• Diabetes Standard of examination
• 5.07 monofilament, on bowing exerts 10g of force

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