PTH 704 Study Guide:

PT responsibility in wound care:

 Recognize skin as a vehicle for managing pain, increasing extensibility, facilitating motor control,
improving function
 Minimal skin assessment:
o Temperature
o Coor
o Moisture
o Turgor
o Intact skin/open areas
 Aging skin
o Intrinsic- inherent physiological processes
 Epidermis:
 flattening of the dermal-epidermal junction→ altered skin permeability
 Changes in basal cells→decreased inflammatory responsivenesss
 Decreased number of Langerhan cells→ decreased immunologic
responsiveness, increased risk of skin cancer/sensitivity to allergens
 Decreased number of melanocytes→ impaired wound healing,
increased skin cancer from sun exposure
 Dermis:
 Decreased dermal thickness/degeneration of elastin fibers→ decreased
elasticity/increased wrinkling/slow wound healing/less scar tissue
 Decreased vascularization
 Appendages
 Decreased number of sweat glands→ decreased ability to
thermoregulate
 Decreased number of nerve endings→ impaired sensory
perception/increased pain threshold
 Decreased hair bulb melanocytes/hair follicles→ hair loss
o Extrinsic—environment/lifestyle
o Structural changes
o Functional loss
o Systemic effects
 Decreased melanocytes- more vulnerable to UV radiation- increased risk of
melanoma
 Decreased Vit D production- increased risk of osteoporosis
 Nutrition
o Protein
 Albumin- long half life
 Optimal range 3.5-5.5 g/dL
 Pre-albumin
 Half life 48-72 hrs
  Not affected by hydration or acute stress
 Optimal range 15-36 mg/dL

Wound Assessment

 Number and label with anatomic locations

o Keep the same numbers throughout your documentation
o Identify in your note you changed the numbering
 Measuring the wounds
o Consistency
o Start distal and work proximal
o Left then right
o Anterior then posterior
o Linear measurements (L xW x D)
 Length = longest length cephalad to caudad (12:00- 6:00)
 Width = widest width left to right (9:00 -3:00)
 Depth = deepest part of the base to the surface of the skin
o Planimetry—use of a mechanical or digital tool that measures L x W only
 Tracings
 EMR- digital photography/measuring
o Fluid instillation—filling the wound (getting the volume)
o Box method (not as common)
 Terminology:
o Sinus tract = pathway that extends in any direction from the wound surface or wall
entrance with NO exit
o Tunnel- a sinus tract WITH an exit
o Undermining = wound edge erosion where fascia separates from deeper tissue
 Tunnels, undermining, and sinus tracts are measured similar to depth/ recorded in reference to
a clock
o Measurements are recorded at the deepest depth of the tunnel, undermining or tract
o Ex: tunnels/sinus tracts 3.2 cm at 1:00
o Undermining: 4.3 cm from 3:00 to 7:00
 Planimetry: use of a mechanical or digital tool that measures Lx W only
 Wound Base- Marion Lab Red, Yellow, Black Classification system
o % Red, granulating
o % Yellow, slough/fibrous
o % Black, eschar
 Wound Base- tissues
o Exposed bone
o Exposed vascular structures
o Exposed nerves
o Exposed surgical implants
 Drainage-
o Exudate = wound drainage that contains dead cells and debris
 o Transudate = clear fluid drainage
o Pus = foul smelling and viscous yellow/gray or green exudate
o Volume Measuring/documentation
 None = 0% drainage on dressing
 Scant/Small- 1-25% of dressing has drainage on it comparable to size of wound
 Minimal = 25-50% of dressing/size of wound
 Moderate = 51-75% of dressing/size of wound
 Large = 76- 100% of dressing/size of wound
 Copious = soaked
o PUSH (pressure ulcer scale for healing) tool- estimated amount of exudate using
quadrants of wound base for reference
 Less than ¼ = scant/small
 1.4 to ½ = minimal
 M1/2- ¾ = moderate
 Greater than ¾ = large
 Drainage Consistency
o Watery- usually clear or transparent (broth)
o Creamy- can’t see through, but still very liquid-like (watery tomato soup)
o Tick- can’t see through (thick pea soup)
o Pus – thick and has odor
 Drainage exudate type
o NORMAL
 Serous- thin watery, clear
 Serosanguinous- thin, watery, pale to red to pink
 Sanguinous- thin, bloody, bright red
o NOT NORMAL
 Purulent- creamy or thick, opaque to yellow
 Pus- thick opaqueN yellow to green and foul odor
 Macerated: oversaturated tissue—generally a white color/appearance
 Drainage- Odor:
o Amount: none, some, or strong
o Type foul or sweet—most odor is sweet smelling due to pseudomonas bacteria
 Wound edges:
o Clean
o Surgical
o Rolled
o Thickened
o Detached
o Fibrotic
 Wound shape
o Linear
o Irregular
o Punched out
o Flap
o Round
 Periwound (around the wound area)
o Intact
o Scarring
o Hemosiderin stained
o Eccyhmotic (bruised)
o Inflamed
o Erythema
o Adhesive reaction
o Excoriated (scraped/abraded)
o Macerated (saturated)
o Edematous
o Indurated (hardened/ loss of elasticity-pliability)
o Fluctuant
 o Skin temp?

 Edema
o Always measure in cm.
o Use bony landmarks
o Common sites:
 Met heads
 Midfoot
 Figure 8
 10 cm up from medial malleoli
 20 cm up from medial malleoli
 Wound pain
o Presence or absence
o O-10, faces, non-verbal, dementia scale
o Changes in symptom: worse/better
o Questions to ask:
 Elevation or dependent better?
 Dressing removal: does it stick?
 If wound has been debrided, did the debridement hurt? If no, were you
medicated at the time?
o Assessment considerations:
 Eliminating the cause of pain
 Protecting wound margins
 Selecting debriding options carefully
 Control inflammation and edema
 Stabilize wound for mobility
 Address the ache and anguish
 Micorbial States in wounds
o Contamination: presence of replicating organism in wound
o Colonization: presence of organism in wound WIHTOUT hose immune response
o Infection: presence of organism in wound WITH host immune response
 Local:
 Erythema
 Pain
 Odd color
 Drainage
 Odor
 Warmth
 Systemic
 WBC
 Temp increase
 Increase glucose
  Lethargy/mental status changes
 Decreased SBP
 Swab culturing
 Z technique—10 point across entire wound
 Levine technique—1 sq cm area is tested/express exudate from wound
 Culturing only tells you what antibiotic to use—already know infection is
present
 Determining Etiology:
o Vascular? Arterial, venous, mixed
o Pressure: over bony landmarks/external objects
o Diabetes
o Surgical
o Trauma
o Other/atypical (systemic causes)

Chapter 6 Reading:

Patient Wound Assessment:

 Ability to heal
o Blood supply (pulses/doppler/ABI, TcPO2, medications, edema, anemia, comorbidities)
 Causes of tissue damage
o Pressure
o Vascular tissues
o Interventions (compression offloading)
o Blood sugar control
 Patient concerns and worries
o Pain/QOL
 The wound integrity
o History and traits (measure)
 Bioburden (presence of infection/bacteria…status?)
 Wound healing rate

Wound Bed Preparation: (“TIME”)

 Tissue
 Infection/ inflammation
 Moisture
 Edge
Wound Assessment “MEASURE”

 Measure
 Exudate
 Appearance
 Suffering
 Undermining
 Reevaluate Regularly
 Edge

Wound Classification:

 Partial thickness
o Erosion through the epidermis and possibly the superficial dermis
 Full thickness
 o Extends through the epidermis, dermis, and subcutaneous
 Stages of pressure ulcers:
o Suspected Deep Tissue Injury
 Purple or maroon localized area of discolored skin or blood-filled blister due to
damage of underlying soft tissue from pressureulcer
o Stage 1: intact skin with nonblanchable redness of a localized area- usually over a bony
prominence
o Stage II: partial-thickness loss of dermis presenting as a shallow open ulcer with a red-
pink wound bed—without slough
 Dry/shinny ulcer without slough or bruising
o Stage III: full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or
muscle aren’t exposed
 Slough may be present but doesn’t obscure depth of tissue loss
o Stage IV: full-thickness tissue loss with exposed bone, tendon, or muscle
 Slough or eschar may be present on some parts of the wound bed
o Unstageable: full thickness tissue loss which the base of the ulcer is covered by slough
and/or eschar in the wound bed—undermining and sinus tracts
 Burn Injuries “Rule of 9’s”
o Head = 9%
o B UE = 9% each
o Anterior torso = 18%
o Posterior torso = 18%
o Entire LE = 18%
o Genitals = 1%


Diabetic Ulcer Treatment

DIABETES and PT:

Diabetic foot ulcer treatment:

 If wound isn’t making progress in 4 weeks, time to re-think POC

  Topical ointments: all contain collagen, gets into the tissue and helps make the tissue healing
process stronger
 Bioengeneered Tissues: cellular matrix that are put over the wound before the dressing
 Regranex gel: gel that contains PDGF (platelet derived growth factor)—trying to create
angiogenesis—and granulation tissue formation
o Trying to draw blood flow to the healing tissue
o Increased rate of mortality secondary to malignancy d/t increased use
 Only can use up to 3 times
 4 week window

Patient Education:

 Exercise
o Can help skin: circulation, optimize collagen production, more taught skin tone, sweat
cleanses poors
 Inspect skin daily (self-care--- advocate for pt. independence)
o Bony prominence
o Skin folds
o Dryness and cracking
o Fragile skin—monitor bruising
o Temperature (abnormalities/ difference R to L)
o Sensation
o Swelling
o Other skin conditions
o Using mirrors, have someone else inspect, check bottom of feet
 Cleansing products
o Use caution in product selection
o Mild soap, fragrant-free, aoid astringents (don’t want to over-dry, irritate skin)
 Avoid exposure to hot water
o Use luke-warm waters (scald burns can occur on diabetic skin at lower water temps)
o Avoid tub baths—over hydrates which lead to increased evaporation rates
o Avoid soaking the feet
 Increases risk of dryness and cracking, increases risk of infection
 Dry between toes
 Don’t apply moisturizer between toes (warm, dark, moist = fungus and bacteria haven)
 Correct fitting shoes
o Arch collapses as you age (may need to go up a size)
o Don’t pull laces too tight
o Toe box with ½ in space in front of toes
o Arch shape that supports foot
o No more than 1.5 in heels
o Smooth lining and no rough seams
o Good tread to prevent slipping
o Have both feet measured in standing each time you buy new shoes
  Time of day can make a difference
 May need to have custom shoes
 Medicare will pay for 1 pair of diabetic shoes and 4 inserts per year
 If pt. is followed by a PCP for diabetes and have either calluses, prior
ulcer, foot deformity, impaired circulation
o Go shopping for shoes late in the day (dependent edema)
o Trying on both sides, with orthotics, shoes that fit purpose
o Don’t buy shoes that doesn’t match foot shape,
 Turn down temperature of household eating to lowest temperature that is still comfortable
o Supplement with humidifies
o Extra care around fireplaces and woodstoves
 Don’t’ smoke
o Dries skin, prevents blood flow to skin and wounds, gives the skin a grey/dull
appearance, can get a yellow/brown discoloration of the fingers
 Get adequate sleep
o Average 7-9 hrs, avoid napping esp. > 1hr/day, est. a sleep schedule

Pressure Ulcers/Injuries:

 What is it?
o Localized injury to the skin/tissue usually over a BONY prominence
 As a result of pressure/in combination with shear
 Where?
o Most common ischium/sacrum/ greater troch/ heel
o Babies in the NICU have the highest incidence of occiput pressure injuries
 Quality of life
o Painful/odor/drainage
o Costly
 Development
o Time + pressure = damage
 Lower pressure for longer duration = more damage than higher
pressure/shorter duration
 Has to do with blood flow to the tissues
o How much should you move then
 Every 30 minutes (laying down)
 Every 2 hours in sitting?
o External pressure > capillary perfusion pressure
 Capillary leakage + increased interstitial pressure
o Tissue deprived of blood and oxygen
o Once you see the damage at the skin level the damage is already extensive underneath
 Mm and subcutaneous tissue are less tolerant of interruptions in BF than skin
 Stage 4 ulcer- can probe to bone
 Extrinsic factors
 o Shear, moisture, friction
 Intrinsic factors
o Age (skin changes/mm loss), malnutrition, vascular compromise, loss of sensation, meds
 Reactive hyperemia
o Areas of red due to pressure—transient increase in blood flow following period of
ischemia
 Normal = Blanchable
 Abnormal = non-blanchable erythema
 Stage 1:
o Skin color
o Skin temp (warm or cool)
o Tissue consistency- boggy or firm
o Sensation- pain or itchy
o No disruption in integrity of skin at this point
 Stage 2:
o Crater like lok
o Partial thickness wound that presents as abrasion, blister, or
shallow crater
 Stage 3:
o Full thickness
 Damage or necrosis down to but not through fascia
 Will not hit bone if probed
 Stage 4
o Damage to structural tissue- mm/tendon/ligament
o High risk for osteomyelitis
 Can potentially lead to amputation if in the LE
o Undermining and sinus tracts
 Unstageable
o Most likely a full thickness
o Necrotic tissue not being removed
o May have vascular compromise
o Most likely will need some sort of surgical debridement to see
what is underneath
 Deep tissue injury
o Depth unknown
o No open area
o More severe than non-blanchable erythema
 When you give a diagnosis/category to the ulcer then that stays with the injury even while
healing
o Aka if a stage 4 ulcer you would say a healing stage 4 (not stage 3/2….etc)
 Infections:
o Don’t typically show classic signs
o Staph is a common
 o Need to get a tissue sample to be most accurate—can’t just swab
o No healing in 2 wk time period
o Malodor
o Increased pain/drainage/necrotic tissue
o New tunneling/sinus tracts/undermining
 Braden Scale (only used to evaluate an at risk individual)—SCORE of 18 or Less = RISK
o Sensation
o Moisture
o Activity
o Mobility
o nutrition
o shear/friction
 Who is at risk for pressure ulcers? 5 I’s….
o Immobility
o Incontinence
o Inactivity
o Impaired mental status/ sensation
o Improper nutrition
 Recommendations for positioning
o Bed-bound person at least every 2 hours
o Chair bound person—every 30 min-1 hour (depending on frequency?)
o Consider postural alignment, distribution of weight, balance and stability, pressure
redistributions
o Teach pt. to weight shift every 15 min if in a w/c
o Us a written repositioning schedule
o Don’t use donut type decives
o Use lifting devices to move pt. rather than drag
o Avoid positioning directly on the trochanter
 In S/L – 30 degrees from horizontal
o Maintain HOB at or below 30 degrees
 Prevention
o Skin checks
o Bathing- mild cleansers
o Moisturize dry skin
o Bowel/bladder program—toileting schedule
o Mepilex—layered silocone foam
 Reducing incidence
o Dua derm—polyurethane film (most effective)
 Nutrition
o Prealbumin—16-40 mg/dL
o Serum albumin- norm 3.5- 5.5
o Malnutritioned <2.5 g/dL
 Support surfaces
 o Reactive support surface vs. active
 Active continuous rhythm of change
o Integrated bed system
o Non-powered vs powered
o Overlay
 4-inch much better than 2 inch
o OR could just be mattress alone

Modalities:

 E-stim:
o Cellular level of tissue repair
 Communicate both chemically (chemotaxis)
 Excreting hormones/proteins
 Swapping of DNA
 and electrically (galvanotaxis)
 directional migration of cells to an electric field
 advocating for moist wound healing
 senescence
 slow/sluggish cells that don’t respond well to communication
o skin battery
 current of injury—est. with the break of the skin
 chronic/ senescent wound—little/no measureable electric current at the site
o estm- provides an external source to re-est. the current
 supplement what should be happening normally from a bioelectric standpoint
 tell the cells they should be in a state of repair
 should also encourage galvanotaxis (electric current that should be attracting
something) of wound healing cells
o indications:
 encourage cell migration- enhance healing phase
 where is it stalled?
 increase angiogenesis and microvascular BF
 reduce local edema
 possible reduction of bioburden?
 Management of hematoma
 Adjunct to topical wound management
 Still need to find the root of the problem and fix first
o Contraindictions
 Heart/cardiac
 Phrenic nerve
 Laryngeal mm
 Malignancy
 Over exposed bone/ untreated osteomyelitis
o Parameters
  High volt pulsed current
 Leads to deeper tissue penetration
 Direct current- unidirectional
 W/ pulsed current you don’t see changes in tissue pH/temp
 80-150 v (below mm contraction)
 30 min- 1 hr, 3-7x/week
o Max benefit- 60 min, 5-7x/week
 Monopolar Set up-- Active electrode directly on the wound
o Saline soaked gauze over wound bed and secure electrode
 Generally choose a negative charge to start and if it is making progress
you stay with that and then if it stalls out you try positive charge and go
from there
 Negative pressure wound therapy (ex. Wound vac)
o “suction”—neg. pressure/vacuum to an open wound to facilitate healing
o Placement of a closed system dressing on a wound then application of controlled
negative pressure
 125 mmHg below pressure (typically)
o Mechanisms of action
 Fluid balance—moist wound helaing
 Reduction in tissue edema
 Cell proliferation- angiogenesis
 Pull on the cells- creating a cell stretch—excites the cell = more
proliferation on the local level
 Speeds wound contraction
o Indications by dx.
 Stage 3-4 pressure elcers, DFU, trauma wounds, open abdominal wounds, sx.
Wounds, partial-thickness burns
o Indications by clinical presentation
 wounds w/ significant tissue deficit
 Exposed vital structures—want to cover w/ granulation tissue as quick as
possible
 Secure grafts and flaps—helps adhere to tissue underneath
 Reduce frequency of dressing changes—esp. w/ copious drainage
o Contraindications
 Malignancy/osteomyelitis
 Exposed blood vessels
 >20% necrosis—need debridement in order to transition to heeling process
 Bleeding disorders/inadequate hemostasis
o Wound Prep:
 Complete wound exam
 Periwound/measurements etc
 Debride the wound
 Make sure they have tx. If infected/ comorbid.
 Assess for adequate blood supply
  Pain management
 Protect periwound
 Avoid placement TRAC pad (insertion of the tube) over bony prominence
 Put polyurethane foam between dressing and wound if worried about
adherence
 Typically left on for 38-42 hours
 No more than 72 hrs
o Hyperbaric Oxygen
 On senescence wounds that may be related to wound hypoxia
 Poor O2 perfusion of wound site and surrounding tissue
 Tested by Trancutaneous O2 Mapping (TCOM)
 Norm O2 pressure = 60 mmHg at room air
 Less than 30-40 mmHg indicates impaired healing
 Norm tissue oxygenation is essential for:
 Collagen synthesis
 Angiogenesis
 Epithelizliation
 Management of bioburden
o Mechanism of action
 Increase the amount of O2 dissolved in plasma
 Induces neovascularization of hypoxic tissue
 Improves leukocytes funciton
 Increased fibroblast replication
 Cumulative effects
o Clinical parameters
 90-120 min
 2 atmospheres
 20-35 treatment session (cumulative effect)
 Typically 5x/week

PVD:

Debridement and Dressings:

Lymphedema:

Rehab of persons with burns: