integumentary - wound care 2

• 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)

• Pressure ulcers/sores
• Venous stasis wounds
• Neuropathic wounds

Tuneling or sinus tracks are complications that can lead to fistulas or passageways to other areas of tissue

• when subcutaneous tissue doesn't heal as quickly as the superficial epidermal layer
• Dead space/undermined area under the edges of wound

• An epiboly is when edges of the wound start to pull in
• Thick rounded wound edges

• lack of hair growth
• edema
• shiny thin skin
• thick discolored nails eg yellow
• heat in the area

• 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

• 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

• 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?)

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

• 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

• 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.

PRESSURE x TIME

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

• 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

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

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

• Venous stasis wounds also do not have stages
• bc they are commonly superficial with lots of exudate

• 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)

tests for arterial insufficiency

• 1. patients lay supine and compare color on soles of feet
• 2. raise investigated leg to about 60^o
• 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

• 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 @ 60^o
• 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

• 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

• 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

• 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

• 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

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.

• 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

• 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

• Take blood pressure cuff over calf (bladder aligned posteriorly) and inflate
• if person cannot tolerate 40 mmHg can also indicate presence of occlusion

• 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

• 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

• 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)

• 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

• 1. Fibrin Cuff Theory
• 2. WBC trapping theory
• 3. Microangiopathy 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

• 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

• pressure in the venous system is transferred to capillaries causing direct destruction
• fragility of the capillaries cannot maintain integrity and strength

• 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

• 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

• 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

• 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

• degeneration affecting sensation
• dangerous loss of protective sensation

• Atrophy and degeneration in muscles
• foot loses natural protection (fat pad atrophy)
• can contirbute to deformity formation --> imbalances between muscle gorups

• Cracked skin, dry
• affects innervation to the sebaceous and eccrine (sweat glands)
• loss of control of vasodilation/constriction tone

• 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

• 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

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)

• 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)

• 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