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BURNS AND WOUNDS

481

timeters, rather than inches, are morc universally used

in the literature.

•

Multiple wounds can be documented relative to each

other if the wounds are numbered-for example, "Wound

#1: left lower extremity, 3 cm proximal to the medial malleolus. Wound #2: 2 cm proximal to wound # 1."

Depth can be measured by placing a sterile cotton-tip applicator

perpendicular to the wound bed. The applicator is then grasped or

marked at the point of the wound edge and measured. If the wound

has varying depths, this measurement is repeated.

Undermining or tunneling describes a continuation of the wound

underneath intact skin and is evaluated by taking a sterile cotton-tip

applicator and placing it underneath the skin parallel to the wound

bed and grasping or marking the applicator at the point of the wound

edge. Assessment of undermining should be done all around the

wound. It can be documented using the clock orientation (e.g.,

"Undermining: 2 cm at 12 o'clock, 5 cm at 4 o'clock").

Color

The color of the wound should be documented, because it is an indicator of the general condition and vascularity of the wound. Pink indicates recently epithelized tissue. Red indicates healing, possibly

granulating tissue. Yellow indicates infection, necrotic material being

sloughed off from the wound, or both. Black indicates eschar.

It is important to doclimem the percentage of each color in the

wound bed-an increase in the amount of pink and red tissue, a

decrease in the amoum of yellow and black tissue, or both are indicative of progress. An increase in the amount of black (necrotic) ti sue is indicative of regression.

Drainage

Wound drainage is described by type, amount, and odor. Drainage

can be (I) serous (clear, thin; this drainage may be present in a

healthy, healing wound), (2) serosanguineous (containing blood; this

drainage may also be present in a healthy, healing wound), (3) purulent (thick, white, pus-like; this drainage may be indicative of infection and should be cultured), or (4) green (usually indicative of Pseudomollas infection and should also be cultured). The amount of

drainage is generally documented as absent, scant, minimal, moder-

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AClITE CARE HANDBOOK FOR PHYSICAL TI-IERAPISTS

ate, large, or copious. (Note: there is no consistent objective measurement that correlates to these descriptions.) A large amount of drainage can indicate infection, whereas a reduction in the amount of

drainage can indicate that an infection is resolving. The presence and

degree of odor can be documented as absent, mild, or foul. Foul odors

can be indicative of an infection.

Wound Culture

A wound culture is a sampling of micro-organisms from the wound

bed that is subsequently grown in a nurrient medium for the purpose

of identifying the type and number of organisms present. A wound

culture is indicated if there are clinical signs of infection, such as

purulent drainage, large amounts of drainage, increased local or systemic temperature, inflammation, abnormal granulation tissue, local erythema, edema, cellulitis, increased pain, foul odor, and delayed

healing.o, Results of aerobic and nonaerobic cultures can determine

whether antibiotic therapy is indicatedo, Methods of culturing

include tissue biopsy, needle aspiration, and swab cultures. Physical

therapists may administer swab cultures. Otherwise, wound cultures

arc performed by the nurse or physician, depending on the protocol

of the institution.

All wounds are contaminated, which does not necessarily mean

they are infected. Contamination is the presence of bacteria on the

wound surface. Colonization is the presence and multiplication of

surface microbes without infection. Infectioll is the invasion and multiplication of micro-organisms in body tissues, resulting in local cellular injury.63.65.66

Clinical Tip

Unless specifically prescribed otherwise, cultures should be

taken after debridement of thick eschar and necrotic material and wound cleansing; otherwise, the culture will

reAect the growth of the micro-organisms of the external

wound environment rather than the internal environment.

Surrounding Areas

The area surrounding the wound should also be evaluated and compared

to noninvolved areas. Skin color, the absence of hair, shiny or Aaky skin,

the presence of reddened or darkened areas, edema, or changes in the

nailbeds should all be examined and documented accordingly.

BURNS AND WOUNDS

483

Clinical Tip

Increased localized temperature can indicate local infection; decreased temperature can indicate decreased blood supply.

WOImd Stagillg alld Classification

Superficial wOllllds involve only the epidermis. Partial-thicklless

woullds further involve the superficial layers of the dermis; full-thickness wounds continue through to muscle and potentially to bone.

This terminology should be used to describe and classify wounds that

are not pressure ulcers. Pressure ulcers have their own classification

system because of their unique characteristic of developing from the

"inside out." Pressure ulcers are traditionally described by a fourstage system, presented in Table 7-12.

Woulld Clea1lsing a1ld Debride",e1lt

It is beyond the scope of this chapter co discuss in derail the methods

of wound cleansing and debridement. Instead, general descriptions

and indications of each are provided. Wound cleansing and debridement can be performed by physical therapists, nurses, or physicians, Table 7-12. Four-Stage Pressure Ulcer Classification