Wound Examination

Question 1

What are some wound specific questions to ask?

Answer 1

• when/how did wound begin?
• have any tests been performed?
• are you on any medication for your wound?
• any wound related pain?
• what has been/is currently being done on the wound?
• is your wound improving?

Question 2

What are the two systems that should be screened in those with wounds?

Answer 2

• GI
• genitourinary/reproductive

Question 3

What should be asked when screening the GI system?

Answer 3

• nutrition intake
• supplementation
• continence
• BMI

Question 4

What should be asked when screening the urogenital system?

Answer 4

• incontinence
• poorly controlled diabetes
• UTI’s

Question 5

What are some tests for the Cardio/pulm review?

Answer 5

• HR
• BP
• RR
• Edema
• pulse ox

Question 6

What are some tests for the MSK review?

Answer 6

• structure
• posture
• ROM
• strength

Question 7

What are some tests for the neuromuscular review?

Answer 7

• mobility
• transfers
• gait
• balance

Question 8

What are some tests for the integ review?

Answer 8

• breif screen of skin
• skin integrity
• skin color/formation
• nail and hair growth

Question 9

What are some tests for BF?

Answer 9

• pulses
• ABI
• Rubor of dependency
• capillary refill
• venous filling time
• transcutaneous oxygen monitoring
• toe pressures
• doppler studies

Question 10

When examining a wound what are the 12 things to exam?

Answer 10

• location
• pulses
• periwound temp
• periwound characteristics
• odor
• color
• shape (circle/oval, round, irregular)
• size
• depth
• drainage
• wound edges
• signs of infection

Question 11

What is a fistula?

Answer 11

• a tunnel that connects with a body cavity or organ

Question 12

What types of tissue can be found in the wound bed?

Answer 12

• granulation tissue
• necrotic tissue (black eschar, slough) adherent or non-adherent
• other structures (bone, tendon, capsule)

Question 13

How do colors describe the wound bed?

Answer 13

Red:
- ready to heal appearance with definite boarders
- graduation tissue is present and revascularization

Yellow:
- pus, debris, fibrin, slough, and yellow exudate present which may require cleansing and minor debridement to promote healing
- may require use of topical antimicrobial if wound is unusually contaminated

Black:
- necrotic tissue/eschar may be present
- may include pus, fibrin, and other cellular components that inhibit granulation tissue

Question 14

What is the difference in yellow slough and fibrin?

Answer 14

Slough:
- produced by autolysis
- soft and mushy
- product of inflammatory phase
- snot like consistency

Fibrin:
- yellow but more fibrous in appearance
- can be mistaken as connective tissue

Question 15

What type of drainage can come out of a wound?

Answer 15

• serous: yellow
• sanguineous: bloody
• serosanguinous: yellow w/ blood tinge
• purulent: milky, pus-like, white, green, yellow

Question 16

What is normal drainage for a wound?

Answer 16

• serous
• sanguineous (normal in response to trauma)
• serosanguineous

Question 17

What drainage wound indicate a possible infection for a wound?

Answer 17

• purulent
• seropurulent

Question 18

What is the interpretation for the color of drainage?

Answer 18

• clear/pale yellow: normal
• red: fresh blood
• dark brown: dried blood
• blue-green: probable pseudomonas infection

Question 19

How can wound edges be described?

Answer 19

• distinctness
• attachment to base of wound
• thickened/rolled (epiboly, hyperkeratotic - callus)
• evidence of epithelialization, maceration, scarring, pigment changes

Question 20

How wound you document skin temperature?

Answer 20

• increased, decreased, or normal

Question 21

What are some different colors of skin?

Answer 21

• normal
• erythema (blanchable vs Non blanchable)
• pale or cyanotic
• hyperpigmentation

Question 22

How would you test for pitting edema?

Answer 22

• firmly press thumb or index finger into area for 5 seconds

Question 23

How would you interpret a test for pitting edema?

Answer 23

1+: barely perceptible depression (<2mm)
2+: easily identifiable depression, rebounds <15 sec (2-4mm)
3+: depression rebounds 15-30 sec (5-7mm)
4+: depression last >30 sec (>7mm)

Question 24

What are different odors for wounds?

Answer 24

Sickly sweet: pseudomonas
Ammonia-like: proteus infection
Musky: typical malignant tissue

Question 25

What are some signs of infection?

Answer 25

• erythema disproportionate to size of wound
• poorly defined erythema boarder
• fever
• warmth disproportionate to size of wound
• could have induration

Question 26

What are the three phases of healing?

Answer 26

• inflammatory
• proliferation
• maturation & remodeling

Question 27

What goes in the objective section of a wound examination?

Answer 27

Systems review:
- integ
- cardio pulm (vitals)
- MSK
- neuromuscular
- cognition

Wound exam:
- all 12 aspects of the wound examined
- any special tests performed

Question 28

What goes in the assessment section of a wound examination?

Answer 28

• interpretation of individuals tests and measures
• integration of the test and measure data with other info collected during history
• determination of: diagnosis amenable to PT management and prognosis (including goals)
• development of POC

Question 29

What are positive indicators of a good prognosis?

Answer 29

• A1c, ABI, previous healing, and compliance with compression (ALL good levels)
• 20-40% decrease in wound surface area w/in 2-4 weeks

Question 30

What are negative indicators of a bad prognosis?

Answer 30

• A1c, smoking, ABI (ALL bad levels)
• no decrease in size or signs of improvement w/in 2 weeks

Question 31

What are some good intervention’s for wound healing?

Answer 31

• education
• debridement
• dressing selection and modification
• biophysical agents
• mobility training
• referrals

Question 32

What is the role of the PTA in wound care?

Answer 32

• allowed to follow POC and treatment
• can conduct objective tests and measure goals
• can measure wounds
• describe wounds (color, drainage, odor, wound bed, periwound, etc.)
• circumferential measurements