Mark David S. Basco, PTRPFacultyDepartment of Physical TherapyCollege of Allied Medical ProfessionsUniversity of the Philippines Manila
Learning ObjectivesAt the end of the session, you should be able toAppreciate the role of physical therapists in
the care of clients presenting with impaired integumentary integrity.
Determine appropriate physical therapy assessment procedures given a client with impaired integumentary integrity.
Interpret the results of assessment procedures performed to a client with impaired integumentary integrity.
Why do we need to perform an assessment?To determine the physical therapy diagnosisTo identify factors that may contribute to
ulceration or abnormal wound healingTo assist in making a wound healing
prognosisTo identify factors that may benefit from
referral or consultation with another health care provider
What are we going to discuss?Obtaining Patient historyDetermining Wound CharacteristicsDetermining Periwound and Associated skin
characteristicsOther tests
General demographicsLifestyle and Functional statusPast and current general medical historyPast and current wound historySystems review
General demographicsAge Sex OccupationEthnicityPrimary languageEducation (patient and caregiver)
Lifestyle and Functional statusDoes the patient live alone?Is the patient independent with activities of
daily living?Does the patient have sufficient vision to
inspect for skin and wound changes?Is the patient ambulatory?Does the patient have adequate mobility or
dexterity to perform wound care?
Lifestyle and Functional statusIs someone available to assist with wound
care, skin checks, meals, bathing & so on?Is the patient currently working & what does
his job entail?Does the patient have any behavioral health
risks e.g. Smoking or alcohol abuse?Does the patient have any cultural or
religious beliefs that may affect therapy?
Past & Current Medical HistoryDo you have a history of the following
conditions?High BPHeart disease or heart conditionPeripheral vascular diseaseStroke / TIABreathing difficultiesDiabetesCancerHIV / AIDSRed Flags
Past & Current Medical HistoryAre you allergic to any of the following
substances?LatexAdhesivesSulfaAnimal products
Is there any other allergies that you have?
Past & Current Medical HistoryDo you smoke?
Number of packs/dayNumber of years smoking
Do you drink alcoholNumber of drinks/day
Do you take drugs not prescribed by a MD?Is there any medications that you’re taking?
Past & Current Wound HistoryWhen did the wound begin?How did the wound occur?Have any tests been performed?
Wound cultureBlood testsArteriogramVenous doppler
Have you perviously or are you currently taking any medications for this wound?
Past & Current Wound HistoryIs your wound painful?Does the pain change with elevation?
dependency? activity?What is currently being done for your wound?What interventions have been done in the past?
What impact does these interventions have?Is your wound improving, staying the same, or
getting worse?Have you had any wounds in the past?
Systems ReviewCardiovascular / Pulmonary MusculoskeletalNeuromuscularGastrointestinalUrogenitalIntegumentary
Wound LocationWound SizeTunnelling / UnderminingWound BedWound EdgesWound DrainageWound Odor
Wound LocationDocument
Using anatomically correct terminologySide and body surface of the lesion
If multiple wound exist, it may be helpful to document wounds in relation to anatomical landmarks
EXAMPLE:“Wound A is located 10 cm superior to the (R)
medial malleolus; Wound B is located 2 cm superior to the (R) medial malleolus ”
Wound SizeDirect MeasurementWound TracingsPhotographic MeasurementsVolumetric MeasurementsTotal Body Surface Area
Wound SizeDirect Measurement
Measure the longest length and widest width perpendicular to the length
Surface area = Length x WidthWound depth
Place a probe in the deepest part of the wound bed
Note point the probe is level with the surrounding intact skin
Several depth measuements can be performed at standard wound locationsClock method
Wound SizeDirect Measurement
EXAMPLE:Wound AWidth = 3.5 cmLength = 4.2 cmSurface area = 14.7 cm2Depth= 1.4 cm(if with eschar or presence of nonviable tissue)Depth=1.4 cm; unable to determine actual
depth secondary to eschar
Wound SizeDirect Measurement
Simple, fast, easy to learn, reliable, & inexpensive
MOST serious problem is that it may inadequately reflect wound size, or changes in wound size in irregularly shaped or circular wounds
NOT possible to accurately determine depth of wound covered with nonviable tissue
Wound SizeWound Tracings
MaterialsClean, comformable transparencyPermanent, fine-tipped pen
Tracing sheetsWound contact layerAdhesive outer permanent layerImprovised
CLEAN, Plastic wrap folded in half
Wound SizeWound Tracings
Surface area estimated from tracing as previously described
Wound depth assessed using direct measurement
Tracings SHOULD be labeled withPatient’s name DatePrecise wound locationSize Wound characteristics
Wound SizeWound Tracings
3 alternative methods of measuring wound surface areaUse of transparencies with premeasure grid
marksPlanimetryDigitizing
Wound SizeWound Tracings
Simple, fast, easy to learnAdvantages over direct measurement
More accurate representation of wound size; regular/circular wounds
Retained image helpful for future comparisonsMain sources of error
Visualizing wound perimeter through the transparency
Tracing itself
Wound SizePhotographic Measurement
Surface area determined by tracing photographic image
Advantages over wound tracingAvoids contact with woundProvides additional information about
periwound and wound bed characteristicsEquipment available today allows clinician with
minimal photographic skill & knowledge to obtain fairly consistent, high quality images
Wound SizePhotographic Measurement
Wound photographs SHOULD includePatient’s nameDatePrecise wound locationMeasurement guide (ruler for scaling
reference)Results of direct wound measurements
Wound SizePhotographic Measurement
DisadvantagesProne to errors in scaleCamera distance and camera angle can
influence resulting image sizeInconsistent lighting conditions may make
wound assessment problematicCostly & time-consuming
Use photography to provide supplemental information but not to determine wound size
Wound SizeVolumetric Measurement
Measuring either the amount of molding or saline required to fill the wound void
Provides a more complete illustration of wound size in three dimensions
DisadvantagesTime consuming and painful for the patient
(molding)Inaccurate and problematic (saline)Cannot be used on wounds that extend into
body cavities / fascial planesUnclear if molding material may have
detrimental effects to wound healing
Wound SizeTotal Body Surface Area (TBSA)
Used for wounds covering large body surface areas
Commonly used in patients with burn injuriesQuick, inexpensive, & reliable method of
estimating wound size
Wound SizeTotal Body Surface Area (TBSA)
Rule of NinesAmerican Burn Association Classification
* Percentage of partial thickness burn
MINOR MODERATE
MAJOR
ADULT < 15 15 - 25 > 25
CHILDREN
< 10 10 – 20 > 20
Wound SizeTotal Body Surface Area (TBSA)
American Burn Association Classification
* Percentage of FULL thickness burn
MINOR MODERATE
MAJOR
ADULT
< 2 2 -10 ≥ 10CHILDREN
Tunneling / UnderminingTunneling
Is a narrow passageway created by the separation of, or destruction to, fascial planes
UnderminingOccurs when the tissue under the wound edges
become eroded, resulting in a large wound with a small opening
TunnelingMeasured by inserting a probe into the
passageway until resistance is feltTunnel depth is distance from the probe tip
to the point at which the probe is level with the wound edge
Use CLOCK terms to document tunnel’s position within the wound bed.
EXAMPLE“Wound tunnels 1.9 cm at 3-o’ clock position”
UnderminingMeasured inserting a probe under the wound
edgedirectly almost parallel to the wound surface until resistance is feltDistance from probe tip to the point at which
the probe is level with the wound edgeUse CLOCK termsEXAMPLE“Undermining 1.2 cm from 9- o’ clock to 1- o’
clock positions. ”
Wound BedMay contain varying types and amounts of
granulation tissue necrotic tissueother structures
Wound BedGranulation Tissue
Temporary scaffolding of vascularized connective tissue that fills the wound voidBeefy-red appearancePale or dusky
Document characterictics and percentage of wound bed it covers
Wound BedNecrotic Tissue
Described by color, consistency, and percentage of wound bed it occupies
SloughYellow or Tan in color and has stringy or
mucinous consistencyEschar
Black necrotic tissue; either soft or hardEither adherent or non-adherent
Refers to the ease with which the necrotic tissue can be separated from the wound
Wound BedOther Tissues
Exposed structures e.g. Fascia, muscle, tendon, joint capsule, or bone
DocumentType of structureCharacteristicsPercent of wound bed occupiedPresence of other items
Sutures Staples Foreign material Implant
Wound EdgesTissue at the perimeter of the woundCharacteristics
DistinctnessThicknessAttachment to the base of the woundEpithelialization / pigmentation
Wound EdgesDistinctness
Some superficial wounds present with indistinct edges; wound gradually transitions into intact skin
Deeper wounds have more distinct & well-defined edges
Wound EdgesThickness
Chronic wounds tend to have thickened or rolled wound edges
Wound EdgesAttachment
Wounds with attached edges are flush with the surrounding tissue
Wound with unattached edges are deep and wound side walls are evident
Wound DrainageTypeColorConsistencyAmount
TypeCharacteristics Interpretati
onSerous -Seen in the inflammatory
phase-Clear to pale yellow- Watery consistency
Normal
Sanguinous
-Results from bleeding at the wound site- Red or Dark brown-Consistency of blood or slightly thickened water
Normal
Purulent -White to pale yellow-Viscous or creamy-Certain infections have a characteristic drainge color
Possible Infection
ColorInterpretation
Clear Normal
Pale yellow Normal
Red Fresh Blood
Dark Brown Dried Blood
Blue-green Probable Pseudomonas infection
Yellow Possible infection
Consistency
Interpretation
Thin, watery Normal
Thick, creamy Possible Infection
Amount
Interpretation
None Dessicated wound bed
Minimal Normal; however, wounds with drainage that is disproportionate to
the amount of necrotic tissue may be infected
Moderate
Copious Possible Infection, especially if out of proportion to wound size
Wound OdorAssessed after the wound has been debrided
and rinsedDescribed as either present or absentShould never be used as sole indicator of
wound status
Structure & QualityColorEpithelial AppendagesEdemaTemperature
Structure & QualityNormal age-related skin changesPeriwound hydrationSkin turgorPresence and location of any callusesScar formationAssess quality of scar tissue
Thickness, mobility, & colorPresence of any deformity
ColorDescribe color of periwound & associated
skin in relation to both neighboring and comparable skin to opposite side
ErythemaBlanchableNon-blanchableIndicator of inflammationIf out of proportion to the size and extent of the
wound, may indicate infection
Epithelial appendagesHairNailLong-standing ischemia will be unable to
support hair growth and increases risk of fungal infection (nails) pale and yellow
EdemaEdema
Localized / generalized accumulation of fluid within body tissues
Pitting / Non-pittingPress thumb / index to affected areaIf depression remains after pressure is
released, pitting edema is presentCircumferential measurementsVolumeter
TemperaturePrior to testing
Patient should rest in supine with the area uncovered for at least 5 minutes
Use dorsum of the hand to lightly palpate skin
Temperature compared with more proximal body segments & contralateral side
If availableThermistorRadiometer (uses IRR)
CirculationSensory Intergrity
CirculationPeripheral circulation should be assessed in
all extremity woundsCould use Doppler ultrasonographyCapillary refill
Push against distal tip of digit until skin blanches
Remove pressureNote amount of time skin returns to normalShould be less than 3 seconds
CirculationPulse Grade Characteristics
0 Absent
1+ Diminished
2+ Normal
3+ Bounding or accentuated
Sensory IntegrityGold Standard for assessing light touch
sensationSemmes-Weinstein monofilaments
To assessOcclude patient’s visionApply monofilament perpendicular to the skin
with enough pressure to bend itAssess each location 3 times
Assess non-callused skin when possible Document location and the thickest filament
the patient could identify
Sensory IntegrityMonofilament Pressure
Produced (grams)
Interpretation of INABILITY to perceive monofilament
4.17 1 Decreased sensation
5.07 10 Loss of protective sensation
6.10 75 Absent sensation
ReferencesMyers, B.A. (2004). Wound management:
Principles and practice. NJ: Pearson Education.
McCulloch, J.M., Kloth, L.C., & Feedar, J.A. (1995).Wound healing: Alternatives in management. Philadelphia: F.A. Davis.
Cuccurullo, S. (2004). Physical medicine and rehabilitation board review. New York: Demos Medical Publishing.
Juego, J.B. (2007). PT 142 notes.