1 / 49

WOUND EXAMINATION

WOUND EXAMINATION. PATIENT HISTORY. WOUND HISTORY DURATION ATTRIBUTING EVENT SYMPTOMS PAIN PARESTHESIA/ANESTHESIA. HISTORY (cont.). DOES PAIN CHANGE WITH POSITION elevation decreases pain = venous dependency increases pain in venous lesions pain with rest - severe occlusive disease

arissa
Télécharger la présentation

WOUND EXAMINATION

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. WOUND EXAMINATION

  2. PATIENT HISTORY • WOUND HISTORY • DURATION • ATTRIBUTING EVENT • SYMPTOMS • PAIN • PARESTHESIA/ANESTHESIA

  3. 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

  4. 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)

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

  6. OBJECTIVE EVALUATION • Test & Measures

  7. 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

  8. Chronic Venous Insufficiency: “champagne bottle” “piano leg” appearance Atrophie blanche

  9. 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

  10. 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

  11. UNDERMINING • ALSO KNOWN AS RIMMING OR TUNNELING • TISSUE DESTRUCTION UNDERLYING INTACT SKIN ALONG THE WOUND MARGINS (HYPOGRANULATION) • MEASURE USING THE O’CLOCK SYSTEM, HEMISPHERES

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

  13. Edema • Measured in a variety of ways: • Quantifying Pitting that occurs from the examiner’s 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.

  14. SHAPE • TRIANGULAR- SKIN TEAR • ROUND- ARTERIAL • IRREGULAR-VENOUS

  15. SLOPES • ANGLES OF MARGINATION • DEPICT GRANULATION • VERY IMPORTANT MEASUREMENT

  16. 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

  17. Stage I • Partial Thickness, limited to epidermis, non-blanchable erythema (sunburn)

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

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

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

  21. 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

  22. 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

  23. Tissue Found in Wounds • Eschar • Granulation • Adipose • Fascia • Muscle • Tendon • Bone

  24. Foreign Debris & Necrotic Tissue • Remove as Soon as Possible • This will prevent bacterial colonization and infection

  25. Peri-Wound • Trophic Changes (dry skin, brittle nails, hair loss) • indicates poor arterial nutrition

  26. 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

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

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

  29. 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

  30. Characteristics of Drainage (cont.) • Purulent/Pus: yellowish/brownish • Thick • contains: WBC, necrotic debris • Infected Pus • yellow, green/blue • thick • contains: pathogens • describe amount:none, min, mod, max

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

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

  33. 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)

  34. 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

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

  36. Vascular Exams Continued • arterial exam • ankle-brachial index (ABI) • sys.pres.LE/sys.preUE (120/100=1.2 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

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

  38. ABI • When ABI value is <.9 • 95% sensitive • 99% specific • For angiographically significant PVD

  39. ABI • Change of 0.15 correlates with disease and symptomology

  40. Measuring ABI

  41. Tissue Oxygen Tension • tc-Po2 • transcutaneous oximmetry

  42. 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)

  43. 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

  44. 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

  45. Test for DVT • Homan’s 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

  46. Test for Cutaneous Sensitivity • perception of light touch • use cotton ball • perception to temperature • warm, cool • 2-point discrimination

  47. 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

More Related