In this section, we discuss procedures that require you to use your senses to assess the physical characteristics of the skin and wound, that is, the skin and wound attributes. For instance, you will use your vision to observe surrounding tissues and the wound; smell to identify healthy from unhealthy tissues;
touch to palpate skin and soft tissue contours, temperature, and full reassessment, such as increased wound exudate or bruising of
the adjacent (i.e., tissues extending away from the periwound) or periwound skin. The periwound skin refers to the tissues imme- diately surrounding the wound. Monitoring includes gross evalu- ation for signs and symptoms of wound complications, such as erythema (redness) of nearby skin, and presence of a yellowish drainage, commonly called pus, which is indicative of infection. It should also include progress toward wound healing, such as gran- ulation tissue growth (indicated by red color of newly vascularized tissues) and reepithelialization (new skin observed as pale pink color even in darkly pigmented surrounding skin). Monitoring, unlike assessment, may be performed by unskilled caregivers, such as the patient, the patient’s family, or a nurse attendant.
Different care settings have different requirements that designate specifi c individuals to perform the assessment and monitoring functions. For example, in the home setting, a non- professional caregiver may monitor the wound attributes, but a nurse or PT assesses the fi ndings. The caregiver may gather data at dressing changes and predetermined intervals and report changes to the nurse or PT, who evaluates the results of the treatment plan. The professional wound case manager may see the patient’s wound only intermittently for a complete reas- sessment. In a skilled nursing facility, requirements by federal licensing agencies typically prescribe intervals for reassessment.
If the patient is in an acute or subacute setting where there are very short lengths of stay, there may be only a single assessment.
Data Collection and Documentation: Forms and Procedures
Data is better organized and more consistent when it is col- lected on a form, whether on paper or an electronic template.
Although many forms exist, the most common is the skin care CLINICAL WISDOM
Monitoring Wound Progress
Teach family members and other caregivers to monitor the wound at each dressing change. Help them to identify signs of wound infection, such as large amounts of purulent exudate (pus red or purplish color of nearby skin, warmth, increased tenderness or pain at the site, and elevated temper- ature). Caregivers should also be aware of healing character- istics, such as bright red color, new skin, and small amounts of clear drainage.
Dangers of Differing Clinical Procedures and Facility Policies
A PT debrided a toenail on a patient with a medical history of neuropathy associated with diabetes. The toe became infected, leading to below-the-knee amputation of the leg. The PT’s action was called into question in a malpractice lawsuit. The debridement procedure followed by the PT was acceptable and
documented, but it was the facility’s policy to have a patient with diabetic neuropathy evaluated in the vascular laboratory for transcutaneous oxygen levels before debridement. The PT did not document an evaluation of the patient for circulatory status prior to performing the debridement procedure. As a consequence, the PT’s action was called into question, and he became the defendant in a malpractice lawsuit.
CASE STUDY
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nervous system responses such as pain and guarding; and hear- ing to evaluate blood fl ow with a Doppler ultrasound and to listen to the patient’s responses to tests and questions. Note that your assessment fi ndings should refl ect a composite of wound attributes. A single attribute cannot provide the data necessary to determine the treatment plan, nor will it allow for the moni- toring of progress or degradation of the wound. The attributes for wound assessment include all of the following:
• Location
• Age of wound
• Size of the wound
• Stage or depth of tissue involvement
• Presence of undermining or tunneling
• Presence or absence of tissue attributes that prevent healing (e.g., necrotic tissue in the wound and erythema of the peri- wound tissue)
• Presence or absence of tissue attributes that aid healing (e.g., condition of the wound edges, granulation tissue, and epithelialization)
• Exudate characteristics
• Pain status
There are two schools of thought regarding tissue assessment:
The fi rst looks only at the wound tissue, whereas the second examines adjacent soft tissue structures, periwound skin, and the wound tissue. Because the adjacent and periwound skin are inti- mately involved in the circulatory response to wounds, and the risk for infection, it is prudent to evaluate all areas. The exami- nation of the wound and periwound skin provides data related to the wound healing phase diagnosis discussed in a later section.
Exhibit 3.1 lists the common indexes for wound assessment.
Assessment of the wound is separate from assessment of the etiology of the wound, although the examinations chosen for the assessment can relate to or provide clues to the etiology.
For example, wounds caused by venous insuffi ciency typically appear on the lower leg above the ankle; a brawny color is often
EXHIBIT 3.1
Indexes for Wound Assessment
● Anatomic location
● Size: length, width
● Volume: depth (also stage if initial assessment; note if unable to stage)
● Undermining/tunneling
● Age of wound in weeks or months
● Attributes preventing healing: necrotic tissue (including eschar140, hemorrhage (purple deep tissue injury), periwound erythema and edema, edges undermined (not connected)
● Attributes characteristic of healing: granulation tissue, new epithelium, attached wound edges
● Wound exudate: color, amount, odor, consistency
● Pain: to touch, pressure, tissue tension, all of the time or only during treatment
● Temperature: excess warmth, coolness, normal body temperature for the area
CLINICAL WISDOM
Assessment Toolbox
A penlight, small mirror with a long handle, infrared and/or liquid crystal thermometer, and tuning fork are handy items to keep in the assessment toolbox.
Begin the tissue examination by evaluating for symme- try with the contralateral limb and adjacent structures, using both observation and palpation. Look for symmetry of tis- sue color, texture, contour, hardness/softness, and tempera- ture. When compared with an area of normal skin and soft tissue, any differences in the skin, subcutaneous tissue, fas- cia, and muscle should be noted.
In palpation, the hands are important, sensitive diagnos- tic instruments. Your hands should be clean, and your fi n- gernails short. It is important to develop a palpatory sense using different parts of your hands for different tests:
● The palms of the hands are best used to detect changes in soft tissue contours (induration, edema).
● The thumbs are useful in applying pressure to check for hardness or softness at different tissue depths.
● The fi nger pads are more sensitive to texture (fi brotic tis- sues) and fi ne discrimination.
● The back of the hands can get a sense of temperature, warmth or coolness. Follow-up with appropriate testing.
seen in the adjacent tissues, edema is likely to be present, and the periwound skin may be fragile. A patient diagnosed with a diabetic ulcer and insensitivity will often have an ulcer on the plantar surface of the foot. There may be areas of callus over bony prominence, bony deformities, and hyperkeratosis of the heel, which are related to polyneuropathy. Therefore, soft tis- sues adjacent to the area of wounding should be assessed for the attributes of location, sensation, circulation, texture, and color.
These fi ndings will be used to establish a treatment plan, and predict wound outcomes.
Observation and Palpation Techniques
Observation and palpation are classic components of physi- cal assessment of skin and wound attributes. They are used to determine alteration in soft tissue characteristics, including the skin, subcutaneous fascia, and muscles leading to a soft tissue or structural diagnosis.73 Proper lighting and positioning of the patient and tissue to be assessed will improve observation.
Effective palpation technique requires you to use light pres- sure and slow movements. Pressing too hard and trying to exam- ine the area too quickly can send confusing messages to your hands’ sensory receptors. It’s also helpful to reduce other sensory inputs in the environment (noise, traffi c, conversation). This will help you to concentrate and focus on the palpation examination.
Finally, you need a common language of easily understood terms with which to communicate your fi ndings. Paired descrip- tors, such as superfi cial-deep, moist-dry, warm-cold, painful- nonpainful, rough-smooth, hard-soft, and thick-thin, are useful to accurately describe fi ndings. The state of tissue changes can be reported as acute, subacute, chronic ( persistent), or absent.
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and lower extremities. This causes more prominent bony pro- tuberances on the hips, knees, ankles, and bony areas of the feet, which results in a higher risk of pressure ulcer formation.
Other changes of aging skin include loss of elasticity because of shrinkage of both collagen and elastin. There is a weakening of the juncture between the epidermis and dermis causing the skin layers to “slide” across each other and placing the person at risk for skin tears. Sebaceous glands and their secretions are diminished, which results in skin that is dry, often itchy, and eas- ily torn.74 Impaired circulation also contributes to changes in the skin; it is usually associated with aging, but can be due to a disease process, such as neuropathy associated with diabetes. This dis- ease impairs the secretion of sweat and sebaceous glands, which in turn contributes to the slow resurfacing of partial-thickness dermal ulcers. Loss of sweat changes the pH of the skin, making it more susceptible to infection and bacterial penetration.
To assess skin texture, use observation and palpation. Look for evidence of dryness, such as fl aking or scaling. To check skin turgor, gently pinch the tissues with thumb and forefi nger, and observe how they respond. For example, in older patients, loss of elasticity can be exhibited by the tissues’ slow return to nor- mal after pinching. Tenting of the skin when pinched can be an early indicator of dehydration. In older patients, it is best to check for general skin turgor on the forehead or sternal area.
Palpate by gently rubbing your fi ngers across the patient’s skin and feeling for sliding of the epidermis away from the dermis.
Skin inspection is an opportunity to spot suspicious signs of early melanoma. If a suspicious skin lesion is noted, ask the patient how long the area of skin has been discolored, whether it has changed shape or size in the past 6 weeks to 6 months, and whether it has been examined by a physician. The ABCD rule with a 90% positive value is a valid screening tool for early melanoma (Fig. 3.3).75
Scar Tissue
Inspection of the adjacent skin should include checking for scar tissue. If present, scar tissue should be assessed for smoothness, fl exibility, thickness, and toughness. Scar tissue that is mature has greater density and toughness and is less resilient than surround- ing skin. New scar tissue is thinner and more fl exible than mature scar tissue and is less resilient to stress. Wounding in an area of scarring will have less tensile strength when healed than will a new wound and will be more likely to break down (Fig. 3.4A).
New scar tissue is bright pink in appearance. As the scar tissue matures, it becomes nearly the same color as the peri- wound skin, except in individuals with darkly pigmented skin.
Hypopigmentation frequently follows injuries to dark skin.
Loss of skin color can create more anxiety for individuals than the wound itself. If the wounding disruption is less than full- thickness loss of the epidermis, repigmentation will usually CLINICAL WISDOM
Requirements for a Successful Palpatory Examination 1. Light pressure
2. Slow movement 3. Concentration
4. Standardized language to communicate fi ndings
They can also be graded on a scale of 0 to 3+; for example, pitting edema, discussed shortly, uses this grading scale.
The use of a grading scale is also helpful in reporting response to treatment intervention.
Assessment of Adjacent and Periwound Tissues
The tissues adjacent to and immediately surrounding a closed or open wound provide many clues to the patient’s over- all health status, the health of the integumentary system, the body’s ability to respond to the wound, and the precise phase of wound healing. The attributes of the adjacent tissues and peri- wound skin that you should assess, which are described in the following sections, include the following:
• Skin texture (e.g., dryness, thickness, turgor)
• Scar tissue
• Callus
• Maceration
• Edema
• Color
• Depth of tissue injury
• Temperature
• Hair distribution
• Toenails
• Blisters
• Sensation (pain, protective sensation, thermal sensation, and vibratory perception threshold [VPT])
Skin Texture
Smooth, fl exible skin has a feeling of fullness and resistance to tissue deformation that is called turgor. Turgor is a sign of skin health. In aging skin, atrophy and thinning of both the epithe- lial and the fatty layers commonly result in a loss of turgor. The areas most affected by loss of subcutaneous fat are the upper
RESEARCH WISDOM
ABCD Rule
While checking the skin, observe for ABCD signs of early melanoma:
A: asymmetry—uneven edges, lopsided in shape B: borders—irregular (scalloped, poorly defi ned)
C: color—black or shades of brown, red, white, occasionally blue
D: diameter—greater than 5 mm (larger than a pencil eraser)
FIGURE 3.3 Photo of melanoma.
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3 1 2
A
1
B
FIGURE 3.4 A: Wound with tunneling before insertion of a cotton-tipped applicator. Note: (1) Ulcer reoccurrence at site of old scar tissue, (2) Skin bridge between two open ulcers, (3) Surrounding skin has unblanchable erythema; wound edges rolled under demonstrate chronic infl ammatory phase, (4) Absence of proliferative phase. B: Same wound as in (A). The wound’s overall size is much larger than the surface open area. Tunneling is present. Note the bulge from the end of the cotton-tipped applicator. (Copyright © B.M. Bates-Jensen.)
occur over time. However, new skin covering deeper lesions and new lesions will appear pink.76 The scar area can even turn white. Hypopigmented areas are more susceptible to sunburn than are normally pigmented areas. For some individuals, burns and physical trauma can be followed by localized areas of hyperpigmentation. Like hypopigmentation, hyperpigmenta- tion causes anxiety in many individuals.
Observe for abnormal scarring characteristics. Hypertrophic scarring results from excessive collagen deposition, causing a very thick scar mass that remains within the area of the original wound. These scars are unattractive and disfi guring, and can cause itching or pain that interferes with functional mobility (Fig. 3.5).
Hypertropic scars are differentiated from keloids, which are also thickened but extend beyond the boundaries of the origi- nal wound (Fig. 3.6).77 Although keloids are found in people of all races, scarring is of special concern to African American individuals and some Asians because of the frequency of keloid formation in these populations. Frequency of occurrence is equal among men and women.
Keloids are similar to benign tumor growths in that they continue to grow long after the wound is closed and can reach a large size. Any attempt to cut or use dermabrasion to buff away a keloid will result in even more scarring.76 In keloids, the mechanism of collagen deposition is totally out of con- trol. Areas with keloids can be itchy, tender, or painful.78 New therapies are being used to control this phenomenon, but if a patient reports a previous keloid or a familial tendency to form keloids, special attention should be made to address this prob- lem at the time of initial assessment.
Hyperkeratotic scarring involves hypertrophy of the horny layer of the epidermis. It is commonly seen in diabetic patients and can be located in adjacent and periwound tissue (Fig. 3.7) (see Chapter 16).
Callus
Callus formation is a protective function of the skin to shear- ing forces of a prominent bone against an unyielding surface—
most often, a shoe. The most commonly encountered calluses are located on the plantar surface of the foot, along the medial
FIGURE 3.5 Hypertrophic scar. (Copyright © 2001, R. Scott Ward.)
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Maceration of Skin and Moisture Balance
Maceration is defi ned as “the softening of a tissue by soaking until the connective tissue fi bers are so dissolved that the tissue components can be teased apart.”74 Where it occurs, the stra- tum corneum takes on a soft, white, spongy texture (Fig. 3.9).
Softened tissue is easily traumatized by pressure and contrib- utes to the development of pressure ulcers.74
Determine the cause of the maceration. The source of mois- ture can be perspiration, soaking in a tub, wound exudate, or incontinence (urine or feces), as well as wound dressing products.
Macerated skin is thinner than adjacent skin. Palpate very gently to avoid trauma. Exposure to friction and shear should FIGURE 3.6 Keloid scar. (Copyright © 2001, R. Scott Ward.)
FIGURE 3.7 There is an absence of the epithelialization phase. Hyper- keratosis on heel ulcer of a 100-year-old woman. (Copyright © C. Sussman.)
side of the great toe, over the metatarsal heads, and around the heel margin (Fig. 3.8).
Untreated, callus buildup will continue, creating additional shear forces between the bony prominence and soft tissues, and resulting in breakdown of the interposing soft tissues.
Hemorrhage on a callus indicates probable trauma and perhaps ulceration beneath.
The location of the callus is a due to the underlying patho- logic condition.79 For example, neuropathy often leads to muscle imbalance and subsequent uneven weight distribution and high pressure and shear along the metatarsal heads, which results in callus formation in those areas. The presence of a callus indicates the need for further assessment of the foot. Chapter 12 contains illustrations and more information about callus management.
FIGURE 3.8 Callus on plantar surface of foot.
1
2
FIGURE 3.9 Intact skin with subcutaneous microvascular bleed- ing (unblanchable erythema), suggesting deeper trauma located over a bony surface. This wound would be classifi ed as a stage I pressure ulcer. (2) Note maceration of the periwound skin. (Copyright © B.M.
Bates-Jensen.)
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The presence of edema can be associated with the infl ammatory phase, the result of dependence of a limb, or an indication of circulatory impairment or congestive heart failure. One conse- quence of trauma is increased extracellular fl uid in the tissues that both blocks the lymphatic system and causes increased cap- illary permeability. The function of edema following injury is to block the spread of infection. The result is a swelling that is hard;
the application of pressure to the swollen area does not distort the tissues. The term brawny edema refers to this type of swell- ing and is associated with the infl ammatory phase. Traumatic edema is usually accompanied by pain, whereas swelling result- ing from lymphedema or systemic causes is usually painless.83
There are two types of edema: nonpitting and pitting.
Nonpitting edema is identifi ed by skin that is stretched and shiny, with hardness of the underlying tissues. Pitting edema is identifi ed by fi rmly pressing a fi nger down into the tissues and waiting 5 seconds. If the tissues fail to resume the previous position after pressure is released, and an indentation remains, pitting edema is present. Pitting edema is often observed with dependence of a limb and with tissue congestion associated with congestive heart failure, venous insuffi ciency, and lymphedema.
It is measured on a severity scale of 0–3+, where 0 = not present, 1+ = minimal, 2+ = moderate, and 3+ = severe (Fig. 3.10).
When examining for edema, look for body symmetry and review the patient’s medical history. Bilateral edema of the lower extremities can be a sign of a systemic problem, such as congestive heart failure, cirrhosis, malnutrition, or obesity. It may also be caused by dependence on or use of certain drugs.
Drug-induced edema is often pitting edema and can be caused by hormonal drugs, including corticosteroids, estrogens, pro- gesterones, and testosterone. Other drugs to consider include nonsteroidal anti-infl ammatory and antihypertensive drugs.
Symptoms usually resolve if the drug is withdrawn.83
Systemic edema can extend from the lower extremities into the abdomen, which is termed ascites. Unilateral edema of the lower extremity of sudden onset can be due to acute deep vein thrombophlebitis and is a medical red fl ag that requires imme- diate referral to a physician. Other causes of unilateral edema include chronic venous insuffi ciency, lymphedema, celluli- tis, abscess, osteomyelitis, Charcot joint, popliteal aneurysm, be avoided. Skin moisture barrier products can be used to
reduce the impact of moisture on the skin, but they need to be evaluated based on the needs of the patient.
Excessive sweating can be related to medication, infection, or the environment, and may not be controllable.81 Excessive sweating is a problem in skin folds, such as under the breasts.
Obese individuals have many skin folds that need to be examined because they are a common site of yeast infection.
Absorbant products to control the moisture need to be evalu- ated to meet the requirements of the individual. Moisture con- trol should include use of support surfaces and chair cushion coverings, because moisture and temperature affect tissue load tolerance. Moist skin has a higher coeffi cient of friction than dry skin; in that state, it has reduced tissue integrity. Cotton or air exchange covers for seat cushions are recommended because they can better dissipate moisture and heat on the surface, and promote better skin moisture balance.
As described, too much moisture can affect skin integrity.
Likewise, a dry or desiccated wound is out of balance and slows keratinocyte migration. A dry state can be benefi cial if the wound is located on the heel, has a dry eschar, and shows no signs of edema, erythema, or drainage; however, even these wounds should be monitored daily.41
Edema
Edema is “the presence of abnormally large amounts of fl uid in the intercellular tissue spaces of the body, usually referring to demonstrable amounts in the subcutaneous tissues. It may be localized, due to venous or lymphatic obstruction or increased vascular permeability, or systemic, due to heart failure or renal disease.”82 Edema is another example of moisture imbalance.
CLINICAL WISDOM
Good moisture balance of the skin can be achieved by choosing a dressing product that manages wound exudate and does not macerate the skin. Protect the periwound skin by applying petrolatum or a zinc oxide paste combined with petrolatum to make it less stiff and easier to apply with a tongue depressor. The zinc oxide does not need to be removed during dressing changes. To ease removal of zinc
oxide from the skin, apply petrolatum or oil.80 FIGURE 3.10 Pitting edema. (Copyright © Evonne Fowler, RN, CNS, CWOCN.)
CLINICAL WISDOM
Observation and Palpation of Calluses
Calluses often appear as thickened areas on the sole of the foot and are usually lighter in color (often yellow) than the adjacent areas. When palpated, the callus area will feel fi rm or hard to touch. There may also be some scaling or fl aking, roughness, or cracking of the callus. A cracked callus is a por- tal for infection. Buildup of callus around a wound signals an area of high pressure, and further examination is required.
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