Wound Assessment


Article Author:
Sean Nagle
Abdul Waheed


Article Editor:
Steven Wilbraham


Editors In Chief:
Mark Dreyer
Dustin Constant
Melanie Violand


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
5/13/2019 2:15:10 PM

Introduction

A wound is damaged or disruption to the skin and, before treatment, the exact cause, location, and type of wound must be assessed to provide appropriate treatment.[1][2][3] Each clinician will have widely differing and distinct opinions and understanding of wound care depending on their prior experience. The reason for this because of the widely differing and distinct types of wounds, each with their etiology. An ostomy nurse will have a completely different approach to wound care that will require an orthopedic surgeon who deals with trauma and both will be far different from a dermatologist who treats burn victims. Nevertheless, each of these healthcare providers is performing wound care. How do professionals then approach wound assessment when the causes are so diverse? Below are some basic questions to ask during a wound assessment to best classify and treat a wound presenting in a clinical setting.

Function

Clinicians perform wound assessment as a means for determining the appropriate treatment for an extremely diverse grouping of disease processes. Just as hypertension is not treated the same as diabetes, each of the underlying etiologies of the given wound must be identified and treated as if it were its own disease, not a blanket classification of "wound."[4][5]

The initial assessment should begin with the following:

  • How: How was the wound created and, if chronic, why is it still open? (underlying etiology)
  • Where: Where on the body is it located? Is it in an area which is difficult to offload, or to keep clean? Is it in an area of high skin tension? Is it near any vital structures such as a major artery?
  • When: How long has this wound been present? (eg., chronic or acute)
  • What: What anatomy does it extend? (e.g., epidermis, dermis, subcutaneous tissue, fascia, muscle, tendon, bone, arteries, nerves)
  • What: What comorbidities or social factors does the patient have which might affect which might affect their ability to heal the wound?
  • Is it life threatening?

All of these factors significantly affect the treatment plan moving forward. While there are many excellent biologics, skin grafts, and other options available, without the appropriate understanding of the nature of the wound the chances of healing decline significantly.

Issues of Concern

While some wounds are simple, the majority of wounds many clinicians encounter are caused by or complicated by some other issue.[6][7][8][9] These are a few of the possible complications from different wound types:

  • A chronic wound will have a different makeup than that of an acute wound, requiring conversion for healing.
  • An underlying infection will prevent wound healing even if the infection is subacute.
  • A damaged or constricted arterial supply will prevent appropriate blood flow to the wound.
  • A damaged venous supply will cause venous stasis.
  • Physical pressure on chronic ulceration will cause repeated damage, preventing healing.

Clinical Significance

 Each of the potential underlying causes must be addressed for the wound to heal. Before determining the underlying cause, it is important to determine what type of wound the patient has. These subclassifications can be acute or chronic.[3][4][10]

Types of Wounds

Acute

Clinicians assess acute wounds by the method of injury and damage to the soft tissues and bony structures. In crush or high impact injuries, there is an area of demarcation which is not fully recognized until sometimes as much as a week or 2 later. For this reason, it is important to determine the method of injury and to keep in mind that the wound seen is not necessarily the entirety of the wound which will be present in a week. In these cases, the patient and their family should be educated on this progression to prevent frustration and misunderstanding.

For all acute types of wounds, it is important to determine the length of time since injury (days or hours), the involvement of neurovascular supply, muscle, tendon, ligament, and bony involvement, and the likelihood of contaminants in the wound. Also of importance is when the patient had their last tetanus shot. CLinicians should start antibiotics if the wound is severely contaminated or if it is longer than 3 hours since the injury. All underlying tissue should be repaired if possible, and the wound should be irrigated to remove contaminants and bacteria.

In cases of open fracture the most used classification is Gustillo-Anderson:

  • Type 1: Clean wound, less than one cm with minimal soft tissue damage, adequate soft tissue coverage of bone, and no periosteal stripping
  • Type 2: Wound with moderate contamination, greater than one cm with moderate soft tissue damage, adequate soft tissue coverage of bone, and no periosteal stripping
  • Type 3A: Wound with significant contamination, with significant soft tissue damage, adequate soft tissue coverage of bone, and periosteal stripping is present
  • Type 3B: Wound with significant contamination, with significant soft tissue damage, unable to cover bone with soft tissue (requiring graft), and periosteal stripping
  • Type 3C: Similar to type A or B, however with Arterial damage requiring repair

Chronic

If a wound becomes arrested in progression through the normal stages of inflammation and wound healing and remains open, then this becomes a chronic wound. While there is no consensus as to when a wound becomes chronic, a study by Sheehan et. al determined that in diabetic wounds, the degree of healing at 4 weeks is a strong predictor of 12 week healing, suggesting that those wounds which have not healed approximately 50% in 4 weeks are likely to have an arrested healing process, and therefore are chronic.[11][12]

In the chronic setting, the main goal is to identify why the wound is not healing and to fix this obstacle or obstacles.

There are a limited number of reasons a wound becomes chronic; however, once these reasons are rectified, the wound resumes its natural course of healing.

  1. Arterial: Is there enough blood flow? Generally speaking, an ABI of less than 50 mm Hg, or an absolute toe pressure less than 30 mm Hg (or less than 50 mm Hg for persons with diabetes) indicates critical limb ischemia and predicts failure of wounds to heal.
  2. Venous: Pressure-induced changes in blood vessel wall permeability then lead to leakage of fibrin and other plasma components into the perivascular space. Accumulation of fibrin has direct and negative effects on wound healing as it down-regulates collagen synthesis.
  3. Infection: Underlying infectious processes including cellulitic and osteomyelitis processes will inhibit wound healing. Culturing for aerobic, anaerobic, and fungal pathogens is recommended.
  4. Pressure: Increased pressure to the area of concern will destroy new tissue growth and prevent proper perfusion of blood to the wound site. These areas need to be offloaded to avoid pressure in the area.
  5. Oncologic: Always biopsy areas of concern in nonhealing wounds, as this can be an atypical presentation of some types of malignancies.
  6. Systemic: There are multiple systemic diseases which inhibit wound healing, with diabetes being the most common culprit. It has been determined that uncontrolled blood glucose levels suppresses the body’s normal inflammatory response, as well as causing microvascular disease which limits healing.
  7. Nutrition: While serum albumin has not been found to be a good predictor of wound healing, there is some evidence that protein malnutrition, as well as insufficient levels of certain vitamins and minerals, will limit the body’s ability to heal chronic wounds.  
  8. Pharmacological: Hydroxyurea has been reported in multiple instances to cause nonhealing ulcerations.
  9. Self-inflicted/psychosocial: There are instances where a patient is causing the ulceration, either on purpose or as a result of noncompliance. This is often the hardest factor to spot and overcome, but must always be a consideration.

Once the underlying issues are determined, then the assessment of the actual wound is performed.

What type of tissue is present in the wound? Is it healthy normal tissue? Is it granular, necrotic, fibrotic? In red, granular tissue the treatment is generally to keep it clean and moist and to offload to allow healing to take place. If the wet necrotic tissue is present, this should be resected immediately to remove a potential nidus for infection, if dry and there is a compromised vascular supply the patient may need revascularization before debridement, or the debridement will just cause an increase in the wound size. For fibrotic tissue, debridement must be performed to create a healing wound environment. This can be performed with scalpel or curette, or with enzymatic debridement.

Is the wound wet or dry? A simple rule of thumb is that if it is wet, dry it, if it is dry, wet it. The idea with this is to keep the wound at an optimal moisture level for healing. Hydrogels are useful for keeping a relatively dry wound moist, while moisture absorbing materials such as alginates are useful for drying out the weeping ulcer. Some wounds, such as venous stasis ulcerations, are so wet that they require daily dressing changes just to keep the surrounding skin from becoming overly wet.

Is the surrounding tissue healthy, friable, or macerated? Friable skin (fragile and thin) especially is a challenge as any adhesive may tear the skin, increasing the size of the wound. Macerated skin is found when the moisture from the wound is not well controlled. The excess moisture softens the skin till it begins to break down, therefore increasing the wound size.

Finally, is the wound infected? Cellulitic appearing skin appears more erythematous and edematous than the surrounding tissue, with an increase in temperature to the area in question. There is often purulent discharge and, depending on the offending organism, may have a strong odor. The presence of a strong odor, especially in venous stasis wounds, is not indicative of infection unless it is either noticeably worsened from normal, or combined with other signs of infection; as heavy drainage will have a distinct odor by itself. In the case of lower extremity erythema and edema, especially where it is seen bilaterally, this may simply be vasculitis and not an infection. A simple test is to elevate the leg for three to five minutes. If the erythema resolves significantly during that period, it is likely that it is vasculitis, not an infection. However, if there is an open wound and/or other reasons to be suspicious for infection, always err on the side of caution.

Imaging in these cases is vital, as the depth and extent of the infection will change the type of treatment. On plain film x-ray, it is possible to see the destruction of bone, which indicative of osteomyelitis (bone infection). Generally speaking, bone with visible destruction from infection needs to be resected and treated with 6 weeks antibiotics to clear the infection fully. Other signs to look for are focal areas of decreased density which can indicate an abscess formation which will need to be incised and drained, or soft tissue erythema which is diffuse areas of decreased density which indicates gas in the tissue and is seen in severe infections including clostridium perfringens, which is often seen in gas gangrene and is a medical emergency which requires immediate excision and irrigation of infected tissues.

If the infection is suspected be sure to take deep cultures of the wound (just swabbing the rim will likely culture a wide variety of organisms.) If the purulent discharge is present, this is a good source for culture. If sepsis or bacteremia is suspected and the patient is to be given antibiotic therapy, make sure to take the blood cultures before antibiotic therapy is given.

For local treatment of infected wounds, irrigation and debridement are warranted, and if there is a concern for abscess, incision and drainage are necessary to remove any nidus of infection.

While there are many factors to consider when approaching a wound, understanding the nature of the wound and underlying factors causing the wound in question will lead to successful evaluation and treatment of the wound.

Other Issues

This review is not exhaustive, but it provides a basic understanding of the common types of wounds, as well as the underlying concerns for each. The takeaway is the need for appropriate assessment of wounds. Too often, wounds are not treated properly because of a lack of understanding of the underlying disease process.

Enhancing Healthcare Team Outcomes

When wounds fail to heal, a thorough assessment is necessary. Most chronic wounds are complex and best managed by a multidisciplinary team that includes a wound care nurse, general and vascular surgeon, hyperbaric specialist, infectious disease consultant, dietitian, and physical therapist. The key is to first find out the cause of wound breakdown. Without resolving the primary cause, wounds cannot heal. There are hundreds of wound care dressings and solutions and for the most part, all work in a similar way with the same efficacy. The second point is to ensure that the wound is clean, has ample blood supply and is regularly debrided. Other factors that play a role in wound healing include patient nutritional status, comorbidities, state of the immune system, age, the degree of ambulation, presence of foreign body and infection. It is important to have a team of wound experts regularly assess the wound and the patient in order to successfully heal the wound.[11][13][14]

Nursing Actions and Interventions

Generally, ongoing nursing and clinician assessments and monitoring of wounds are similar:

  • Identify the location of the wound
  • Determine the cause of the wound
  • Determine the stage of the wound
    • Stage I: Superficial involving only the epidermal layer
    • Stage II: Partial-thickness affects the epidermis, and may extend into the dermis
    • Stage III: Full-thickness extends through the dermis and into the adipose tissues
    • Stage IV: Full-thickness extends through the dermis, and adipose exposing muscle or bone
  • Evaluate and measure the depth, length, and width of the wound
  • Measure the amount of undermining and tunneling
  • Evaluate the wound bed
  • Assess for presents, type, and amount of exudate:
    • Serous, serosanguineous, sanguineous, or purulent
    • Minimal, light, moderate, or heavy
  • Access surrounding skin tissue
  • Assess wound margins for tunneling, rolled, undermining, fibrotic changes, and if unattached
  • Evaluate for signs and symptoms of infect - warm, pain, odor, delayed healing
  • Assess pain

Document finding and report unexpected findings to the healthcare team.

Nursing Monitoring

 Wound checks are typically once per shift but the clinician may vary this protocol based on concerns raised by the healthcare team.


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Wound Assessment - References

References

Subrata SA,Phuphaibul R,Kanogsunthornrat N,Siripitayakunkit A, ADIE - nursing interventions of diabetic foot ulcer: An integrative review of the literature. Current diabetes reviews. 2019 Mar 7;     [PubMed]
Jiao C,Su K,Xie W,Ye Z, Burn image segmentation based on Mask Regions with Convolutional Neural Network deep learning framework: more accurate and more convenient. Burns     [PubMed]
Jenkins DA,Mohamed S,Taylor JK,Peek N,van der Veer SN, Potential prognostic factors for delayed healing of common, non-traumatic skin ulcers: A scoping review. International wound journal. 2019 Feb 28;     [PubMed]
Bonifant H,Holloway S, A review of the effects of ageing on skin integrity and wound healing. British journal of community nursing. 2019 Mar 1;     [PubMed]
Lim E,Mordiffi Z,Chew HSJ,Lopez V, Using the Braden subscales to assess risk of pressure injuries in adult patients: A retrospective case-control study. International wound journal. 2019 Feb 7;     [PubMed]
Walker CA,Rahman A,Gipson-Jones TL,Harris CM, Hospitalists' Needs Assessment and Perceived Barriers in Wound Care Management: A Quality Improvement Project. Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society. 2019 Mar/Apr;     [PubMed]
Computer-Assisted Wound Assessment and Care Education Program in Registered Nurses: Use of an Interactive Online Program by 418 Registered Nurses. Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society. 2019 Mar/Apr;     [PubMed]
Haesler E,Swanson T,Ousey K,Carville K, Clinical indicators of wound infection and biofilm: reaching international consensus. Journal of wound care. 2019 Mar 2;     [PubMed]
Bates-Jensen BM,McCreath HE,Harputlu D,Patlan A, Reliability of the Bates-Jensen Wound Assessment Tool (BWAT) for Pressure Injury Assessment: The Pressure Ulcer Detection Study. Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society. 2019 Mar 3;     [PubMed]
Barry R,Modarresi M,Duran R,Denning D,Wilson S,Thompson E,Sanabria J, The Impact of Obesity on Outcomes in Geriatric Blunt Trauma. The American surgeon. 2019 Feb 1;     [PubMed]
Dowsett C, T.I.M.E. to improve patient outcomes: use of a clinical decision support tool to optimise wound care. British journal of community nursing. 2019 Mar 1;     [PubMed]
Wiegand C,Abel M,Hipler UC,Elsner P,Zieger M,Kurz J,Wendel HP,Stoppelkamp S, Hemostatic wound dressings: Predicting their effects by in vitro tests. Journal of biomaterials applications. 2019 Feb 21;     [PubMed]
Olivieri B,Yates TE,Vianna S,Adenikinju O,Beasley RE,Houseworth J, On the Cutting Edge: Wound Care for the Endovascular Specialist. Seminars in interventional radiology. 2018 Dec;     [PubMed]
Joyce P,Moore ZE,Christie J, Organisation of health services for preventing and treating pressure ulcers. The Cochrane database of systematic reviews. 2018 Dec 9;     [PubMed]

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