Integumentary Tests and Measures

common areas to be measured in wound dimensions.

formula for surface area of the wound.

formula for volume of the wound.

is done at the initial assessment and is critical to calculate any change in wound size over time.

- appears pink or pearly white and wrinkles when touched

- occurs in final stage of healing

- appears red and moist

- occurs when healthy tissue is formed in remodeling phase

- appears yellow, brown, or gray

- is devitalised tissue made of dead cells or debris

- appears hard, dry, and black

- is dead tissue that prevents wound healing

- appears red, uneven, or granular

- occurs in the proliferative phase when tissue is overgrown

- clean, uninfected, no inflammation (classification of wounds)

- primarily closed

- do not enter respiratory, ailementary, genital, or urinary tracts

- clean-contaminated (classification of wounds)

- lack unusual contamination

- enter the respiratory, ailemtary, genital, or urinary tracts

- contaminated (classification of wounds)

- fresh, open wounds that result from insult to sterile techniques/ leakage from GIT into the wound

- incisions made that result in acute or lack of purulent inflammation

- dirty infected (classification of wounds)

- result from improperly cared traumatic wounds

- demonstrate devitalized tissue

- result from microorganisms presented in perforated viscera or the operative field

produces a moist environment that allows efficient migration of epidermal cells and prevents wound desiccation and further injury.

wound tissues dry.

- wound tissues moist

- no measurable exudates

- wound tissues wet

- moisture evenly distributed in wound

- drainage involved 25% of wound dressing

- wound tissues saturated

- drainage may or may nor be evenly distributed

- drainage involved greater than 25% to less than 75% of wound dressing

- wound tissues bathed in fluid

- drainage freely expressed, may or may not be evenly distributed in wound

- drainage involved greater than 75% of wound dressing

thin, bright red exudate.

thin, watery, pale red to pink exudate

thin, watery, clear exudate.

think or thick, opaque tan to yellow exudate.

thick, opaque yellow to green with offensive odor exudate.

- “generic” classification system identifies specific anatomic levels of the tissues involved, but does not report their condition or color

- used for wounds that are not categorized as pressure ulcers or neuropathic ulcers

often resolved by subcutaneous inflammatory processes.

heal by epithelialization.

a combination of fibroplasia or granulation tissue formation and contraction.

- described pressure ulcers using depth of anatomic tissue loss and the involvement of soft tissue layers and was redefined by adding two stages on deep tissue injury and unstageable

- can aid examination of the wound severity

intact skin with nonblanchable redness of a localized area usually over a bony prominence.

- the partial thickness loss of the dermis presents as a shallow open ulcer with a red-pink wound bed

- may also present as an intact or open/ruptured serum-filled blister

- full thickness tissue loss

- subcutaneous fat may be visible but bone, tendon, and muscle are not exposed

- slough may be present but does not obscure the depth of tissue loss

- may include undermining or tunneling

- full-thickness loss with exposed bone, tendon, or muscle

- slough or eschar may be present on some parts of the wound bed

- may include undermining or tunneling

full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.

- used to establish the presence of depth and infection in a wound

- developed for the diagnosis and treatment of the dysvascular foot

- assessment instrument in the evaluation of diabetic foot ulcers

skin intact (wagner scale).

superficial ulcer (wagner scale).

deep ulcer to tendon/bone (wagner scale).

ulcer has abscess or osteomyelitis (wagner scale).

gangrene on foot (wagner scale).

gangrene over major portion of foot (wagner scale).

- matrix of grades used for situations in which neuropathy is present and information is needed about infection, circulation, and the combination of infection and ischemia in order to assign risk and predict outcome

- each ulcer is given both a numeric grade and an alphabetic stage

- popular because of its simplicity and ease of use

- three colors are used - red, yellow, and black to describe the wound’s surface color, and each color corresponding to specific therapy needs

clean, healing, granulating.

signals possible infection, the need for cleaning or debridement, or the presence of necrotic tissue.

necrotic and needs cleaning and debridement.

- determine if the patient can detect pressure when the monofilament is placed against the skin and the force applied is sufficient to buckle the monofilament

- usually performed on the sole of the foot

no loss of protective sensation (Semmes Weinstein Monofilamen).

loss of protective sensation; no deformity or history of plantar ulceration (Semmes Weinstein Monofilament).

loss of protective sensation and deformity or abnormal blood flow without history of plantar ulcer (Semmes Weinstein Monofilament).

history of plantar ulcer (Semmes Weinstein Monofilament).

is a protective function of the skin to shearing forces of a prominent bone against an unyielding surface.

can be detected in lightly pigmented skin by applying pressure to the skin.

is one of the hallmarks of stage 1 pressure ulcers.

- type of hemorrhagic condition

- rupture of vessels around a wound that cause deposition of blood in the subcutaneous tissues

rust brown color skin.

- skin picking disorder

- is a partial thickness shearing of skin

callous-like tissue formation at wound edges that can extent around wound especially with diabetic ulcers

- candida infection resulting from excessive moisture

- rash is identified by the yeast buds on the periwound

- white or yellow

- redness along the wound walls

thickening and hardening of soft tissues of the body, is the result of inflammatory processes caused by various triggering factors.

- occurs with moisture for too long, it may feel soft, wet, soggy to the touch

- associated with improper wound care

- skin appears dry and cracked

- skin flakes, peel, and scaly

form as part of the body’s healing process, it builds tissue to repair damaged skin and close gaps due to an injury.

- also known as dry skin

- may cause discomfort

- is linked to decrease in the oils on the surface of the skin, usually triggered by environmental factors

- occurs when fluid builds up in your tissues

- will cause parts of the body to increase in size

is assessed to rule out signs of inflammation.

standardized, evidence based assessment tool commonly used in health care to assess and document a patient’s risk for developing pressure injuries.

has been the first pressure sore risk evaluation scale to be created.

- primary aim of this tool is to assist you to asses risk of a patient/client developing a pressure ulcer

- consists of seven items: weight, height, visual assessment of the skin, sex/age, continence, mobility, appetite, and special risk factors

indicated for the positioning of a scar to avoid deformation or to maintain or increase the stretch on a scar.

is custom fit to a patient and matches the patient’s anatomic shape.

has a fixed shape and maintains a position through immobilization of the splinted part.

apply a force, or a stretch, to a body part or allow resistance to movement for exercise.

are basically static splints that are remolded to a newly achieved position of a body part.

provided decreased plantar pressure by increasing weight bearing over the entire lower leg.

externally applied device used to modify the structural and functional characteristics of the neuromuscular and skeletal system.

- is the process of identifying characteristics known to be associated with nutritional problems

- pinpoint individuals who are malnourished or at nutritional risk

- refers to pulse points that are the furthest from the trunk

- are assessed to identify the presence of arterial vascular disease and to detect abnormalities

is a non invasive vascular test that uses sound waves to show blood moving through vessels.

- most widely used

- gives us a phasic flow pattern

- used in measuring skin perfusion pressure

- uses a low energy laser probe secured in the bladder of a blood pressure cuff

- uses a computed to change sound waves into different colors

- shows the speed and direction of blood flow

- can provide more detail of blood flow than standard color doppler

- cannot show the direction of blood flow

- shows blood flow information on a graph

- shows how much of a blood vessel is blocked

uses standard ultrasound to take images of blood vessels and organs.

- noninvasive test to check for peripheral arterial disease

- compares the blood pressure in the arm to the bloop pressure in the ankle

- a noninvasive clinically approved method to obtain skin oxygen levels

- measurements have shown to be predictive healing of ulcers and amputation wounds

- measures venous refill time

- measure the light reflected from the skin as it changes colors with filing of microvasculature

not able to prevent urine and stool from leaking.

diaper rash, irritant dermatitis, moisture lesions, or perineal dermatitis.

happens in long standing incontinence.

- uses the level assistance an individual needs to grade functional status from total independence to total assitance

- lists six self care activities.

specifically measures the degree of assistance required by an individual on 10 items of mobility and self care ADL/

- index of four instrumental activities combined with six personal daily life activities

- ability to perform each activity is scored using a three point scaled: independent, partly dependent, and dependent