This document discusses integumentary integrity and wound assessment. It includes scales to assess risk of pressure sores, such as the Norton scale and Braden scale. Adaptive devices are designed for people with disabilities, while assistive devices can be used by anyone. Associated drawbacks of devices include skin breakdown. Wound assessment involves measuring the wound, reviewing skin characteristics, and checking for infection. Goals in wound care are supporting healing, preventing ulcers, and treating existing ulcers or wounds. Proper positioning and frequent repositioning are important to prevent skin issues.

1. INTEGUMENTARY INTEGRITY
TESTS AND MEASURES
DR. QURATULAIN MUGHAL
IIRS
BATCH IV
DOCTOR OF PHYSICAL THERAPY
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2. CONTENT
Including:
A. Activities, positioning, and postures that produce or relieve trauma
to the skin.
B. Assistive, adaptive, orthotic, protective, supportive, or prosthetic
devices and equipment that may produce or relieve trauma to the skin.
C. Skin characteristics, including blistering, continuity of skin color,
dermatitis, hair growth, mobility, nail growth, sensation, temperature,
texture and turgor.
D. Activities, positioning, and postures that aggravate the wound or scar
or that produce or relieve trauma.
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3. NORTON PRESSURE SORE RISK
ASSESSMENT SCALE
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4. BRADEN SCALE
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9. ADAPTIVE DEVICES ASSISTIVE DEVICES
• Adaptive devices is
designed only to enable
individuals with
disabilities to function
more fully.
• Assistive includes items
that may be utilized by
persons without
disabilities as well.
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10. ASSOCIATED DRAWBACKS
• Poor patient compliance.
• Discomfort.
• Difficulty with transfers.
• Difficulty in donning and doffing.
• Increased energy expenditure with ambulation.
• Decreased pulmonary capacity.
• Muscle atrophy.
• Nerve compression.
• Skin breakdown.
• Local pain
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11. Stages of Pressure Ulcer
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14. Assessment
• Review of systems
• Skin diseases
• Previous bruising
• General skin condition
• Skin lesions
• Usual healing of sores
• Skin color distribution
• Skin turgor
• Presence of edema
• Characteristics of any skin lesions
• Wound length, width, and depth
• Clinical signs of infection
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15. Wound Measurement
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1. Linear measurement—a ruler is used to measure the width
and length of a wound. This does not measure wound depth
and is not well-suited to an irregular wound.
2. Planimetry—graph paper is used to duplicate the shape of a
wound. This can allow a large, irregular wound to be drawn to
scale and is best used for a flat wound. Be sure to indicate the
scale used (e.g., 1 cm = 1 inch).
3. Stereophotogrammetry—a special video camera downloads
to a computer. This method allows color images and is
noninvasive. It also gives some indication of wound depth.
4. Wound photography—photos of the wound illustrate the
color of the wound bed and its edges, as well as giving an
indication of the condition of surrounding skin.
5. Wound tracing—transparent paper may be laid over the
wound and the edges lightly traced. This is effective for flat,
irregular wounds.
6. Wound culture: confirm or rule out presences of
infection

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17. Risks
• For Impaired Skin Integrity: applies to pressure ulcers and
wounds extending through the epidermis but not
through the dermis.
• Impaired Skin Integrity: altered epiderms and/or dermis
• Impaired Tissue Integrity: applies to pressure ulcers and
wounds extending into SC tissues, muscles, or bones.
• For Infection: with severe skin impairment, pt is
immunosuppressed
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18. Goals in Planning
• Supporting wound healing : maintain moist wound
healing, nutrition and fluid, preventing infection and
positioning
• Preventing pressure ulcer
• Treating pressure ulcer :RYB (Protect (cover) red,
cleanse yellow, and debride black)
• Dressing wound
• Cleaning wound
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19. Types of Wound Dressings
• Transparent film
• Impregnated no adherent
• Hydrocolloids
• Clear absorbent acrylic
• Hydrogel
• Polyurethane foam
• Alginate
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20. BED POSITIONING
• Be changed frequently.
• Keep the person’s head
in line with his body,
neither too flexed nor
too extended.
• Prevent friction or
compression between
body parts by the use
of pillows or other
position devices.
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