Wound Assessment - Wound Care ResourceWound Location The location of the wound will also impact on determining a diagnosis and contribute to the plan(3). Below is a table showing locations

KimKaim 8/19/2016 Page1of31

Wound Assessment

[email protected]

www.woundcareresource.com

Assessment..................................................................................................................................................2History......................................................................................................................................................................2Examination............................................................................................................................................................3Measurethewound.............................................................................................................................................................4WoundLocation....................................................................................................................................................................6UsingTIMEtoassessthewound....................................................................................................................................7TisforTISSUE........................................................................................................................................................................7IisforINFECTION/INFLAMMATION.......................................................................................................................10MisforMOISTURE.............................................................................................................................................................13EisforEDGES.......................................................................................................................................................................15

Investigation........................................................................................................................................................16Diagnosis...............................................................................................................................................................16Implementation..................................................................................................................................................17Collaboration........................................................................................................................................................................18

Assessmenttoolsusedinwoundmanagement............................................................................18Thedigitalage.....................................................................................................................................................21

AppendixA–StudentAssessmentTool...........................................................................................22AppendixB–STARSkinTearClassification...................................................................................24AppendixC–PressureInjuryClassifications................................................................................26References.................................................................................................................................................29


Assessment Yearsago,clevererpeoplethanIcouldseepatternsemergingwhereifcertainthingsweredonetherewouldbebetterwoundhealingoutcomes.Theypulledalltheseideastogetherandwrappedmnemonicsaroundthemtomakethemeasiertoremember.TwomnemonicsthatworkwelltogetherareHEIDIandTIME.ThesestandforHistory,Examination,Investigation,DiagnosisandImplementation(HEIDI)andTissue,Inflammation,MoistureandEdges(TIME).TohelpremembertheseIhaveincludedadatacollectiontoolyoucanuse,seeAppendixA.NowwewillgointoALOTmoredetailabouteachofthese.

History ItisimportantthatyourassessmentconsiderstheWHOLEpatient,notjusttheHOLEinthepatient(1).Startbyconsideringwhatsystemicfactorsmightimpactonwoundhealingorimpactonyourplan.

o Systemic§ Diseaseprocesses§ Behavioral§ Social

ThisiscertainlyNOTcomprehensive,buttogiveyouanideaofwhatsomeofthesethingsmightlooklike:

Systemic Impactonabilitytoheal plan

Medical Poorcirculation–howwillthenutrientsgettotheskin,howwillwaste/oedemabetakenaway?Pooroxygenation–howmuchoxygenismakingittotheskin?Metabolic–whatimpactdoesdiabeteshaveonwoundhealing?Auto-immune–forreasonsnotyetfullyunderstoodthebodyattacksit’sownorgans,includingtheskinandsupportingstructures.

immunecompromised-willnotshowtypicalsignsofinfection,doyouwatchforothersignsoruseatopicalantimicrobialprophylactically?impairedsensation–cannotfeelifcompressionistootight.


Systemic Impactonabilitytoheal plan

Surgical/Iatrogenic

AlterationtolymphsystemsuchasinlymphnoderemovalforCancer–canleadtooedemaPreviousscartissue–suchasfromradiationorburns–structureisdifferenttonormalskinandslowertoheal,canbethesourceofmalignancyGatechanges–amputationwillchangegate,causingabnormalpressuresinotherareasofthefoot,potentialforfurtherulcerationinthosenewareas.

workingaroundsurgicalsites–applyingaVACaroundex-fixpinsmanagingexudatefromastomaorfistula

Nutrition Noteatingwell–oftenrelatedtoageVegetarian

expectdelay–higherproteinandcaloricintakeisrequiredforwoundhealing

Social Notmobile–pressurerelatedtissuedamage,poorcalfmusclepumpPoorhousingorincome–poorenvironmentalcontrolscanimpactonhealingSmoking–reducedoxygentoskin

onfeetallday–off-loading?Venousreturn?cost-cannotafforddressings

Medications CorticosteroidsAnti-inflammatoriesAnti-coagulents

Warfarin–wouldyoudebride?

Allergies AdhesivesIodineChlorhexadine

Theinformationwegetfromthepatient’shistorygivesusalistofitemsthatmayresultinimpairedhealingorthepotentialforskinbreakdown.Weneedtoplantomitigatetheimpactofasmanyaswecan;ieeducationonquittingsmoking,refertospecialist,orchoosingmoreaffordabledressingsaswellasanyhomesupporttheymighthaveorneed.

Examination Thisiswherewestarttogetourhandsonthepatient.So,continuingonfromabove,wenowneedtoassessregionalsymptomsthatwillneedtobemanagedtoimprovewoundhealing.

o Regionalexamples§ Circulation§ Infection§ Oedema


Regional Impactonabilitytoheal plan

Oedema oedemamakesitdifficultforadequatedistributionofnutrientstofeedtheskin

Canitbemanaged?

Pulses indicatesabilityofnutrientstogettothearea

Present?Notpresent?Doyouneedtocollaborate?

Atrophy,nohair,thinshineyskin

Oftenassociatedwithlackofpulses,mayindicatepoorarterialsupply,possibleclaudicationpain

RequirescollaborationwithVascularasaminimum–donotdebride

Haemosiderinstaining,varicoseveins,ankleflair,etc…

Oftenassociatedwithoedemaoraninvertedchampagnebottleappearance,mayindicatepoorvenousreturn

ReferraltoVeinspecialist,ABPIrequired,assessmentforcompressionsuitability

Drycrackedskin Lessresilient,increasesriskofinfection

non-soapcleaning,waterintake?,humidity(airconditioning),moisturize

Charcotdeformity Changestogate,potentialforulceration

Requirescollaborationwithpodiatryasaminimum

Contractures Maybeputtingconstantpressureontocertainareasorincreasingbuildupofmoistureincreases.

Redistributepressureasable.Managemoisture.Collaboratewithoccupationaltherapistand/orphysiotherapist

Again,notfullycomprehensivebutastart;seeifyoucancomeupwithmore!NOW!!Thisiswherewestarttolookatthewound(finally!).

Measure the wound Weneedtorecordthesizeandlocationofthewound.Serialsizemeasurementsneedtoberecordedastheyindicatewhetherornotawoundishealing;onesourcerecommendsthatawoundshouldbeatleast30%smaller(surfacearea)byweek4(2)tobeconsideredonahealingtrajectory.Measurementofthewoundcanbedoneinseveralways:

• Ruler• Acetate/Grid• Visitrak(planimetry)• Digitalphotoandwoundtracingsoftware(digitalplanimetry)• Specialisedphotographicdevice

Priortomeasuringthewound,cleanthewound.Ifplanningtodebride,conductmeasurementsafterdebriding.Positionthepatientinacomfortablepositionkeepingmindthatpositioning,bodycurvature,ortaperingofthelimbswillimpactontheaccuracyofthevarioustechniques(3).Alsoensurethatallmeasurementsaretakenofthewoundbase,correctidentificationofwoundmarginshasalargeimpactonwoundsizeaccuracy(4).


Whenusingaruler,measurementsaretakenofthegreatestwidestandthegreatestlengthperpendiculartothegreatestwidth(5).Thisisaquickmethodandworksbestwithregularlyshaped,smalltomediumsizedwoundsliketheoneinthephotoontheright(3,4).Multiplylengthxwidthtoconverttoanareameasurement.Inirregularlyshapedwounds,itismoreaccuratetotracethewoundontoacetateandmeasuretheareabyplacingthetracingongridpaperandaddingupthenumberofsquarescontainedwithinthemarginoftheoutlineofthewound.Whilethisisconsideredmoreaccurateforirregularlyshapedwounds,errorcomesintoplaywhentryingtodeterminehowtoincludepartiallycoveredsquares(3,4).Considerthewoundontherightandaskyourselfhowwouldyougomeasuringthiswound?Wouldyouusearuleroracetate?VisitrakisadevicethatwascreatedbySmithandNephewforwoundmeasurement.Ithadasterileacetatesheetwithdisposablebackingfortracingthewoundonto.Youthenlaidthetracingontothedeviceandre-traceditwiththedevice’sstylus.Whilethiswasverygoodforinfectioncontrolandcouldquicklyreportheight,width,areaandcircumference,therewerepotentialforerrorsinaccuracyrelatedtoretracingandalsothesizeofthedevicelimitedthesizeofthewoundyoucoulduseiton(4,5).ThereissoftwareavailableforpurchasesuchasMOWA,whichallowstheusertotakeaphotographwiththeircamera,tracethewoundedgesinthephoto,anditproduceswounddimensionsandrecommendstissuetypebasedoncolour.TherearealsofreeprogramssuchasImageJ,whichcanbeloadedontoacomputerandalsoallowstheusertotracethewoundedgesanditproducesthedimensions.Theaccuracyofbothofthesemethodswillbeaffectedbythecurvatureofthesurfaceandtheabilityoftheusertotracethewoundedgeaccurately.Anumberofspecializedphotographicdevicesareonthemarkettoday.TheSilhouetteStarisacamerawhichuseslasertechnologytomeasurewounddepthanddigitalplanimetry(wheretheusertracesthewoundedgeinthephoto)tomeasurearea.Themanufacturerclaimsahighdegreeofaccuracyandeaseofuse.YouneedtohaveacomputerortabletwiththeSilhouettesoftwareattachedtothecamera.WhiletheSilhouetteStardoeshaveamethodforcalculatingdepth,inallotherinstancestheuserwillneedtodothismanually.Also,evenwhenusingtheSilhouetteStar,underminingisnotdetectedand,again,willneedtobemeasuredmanuallywithasterileprobe.Thereareanumberofdevicesthatcanbeusedincludingcotton-tippedswabsandsterileplasticstickswithmeasurementgraduationsonthem.ThedepthgaugethatwassoldtoaccompanytheVisitraksystemwasathinplasticstickwithmeasurementgraduationsandafoamtip.Thiswasthinandflexibleenoughtomeasuremostundermining/sinuseswithoutfearofdamagingsurroundtissueorleavingfibresbehind.Youwillneedtoprobearoundthewoundtofindthegreatestdepthtorecord.Also,wherethereisasinusorundermining,youwillwanttorecordthegreatestdepthandalsothelocationatthewoundedge.Thisisdonebyimaginingaclockfaceoverthe


woundwith12o’clockbeingatthehead.Therefore,inthepictureontherightyouwoulddescribetheunderminingasbeingXcmextendingfrom6O’clockto9O’clock.

Wound Location Thelocationofthewoundwillalsoimpactondeterminingadiagnosisandcontributetotheplan(3).Belowisatableshowinglocationsandtheirlikelycorrelationstowoundtype.However,thisisjustaguideandnotadiagnosis.

Siteofwound&typeofulcerSite TypeofulcerLowerthirdoflegbelowknee VenousulcerBonyprominencese.g.heels,coccyx,sacrum,hips)

Pressureulcer

Topoffoot,bonyprominences ArterialulcersAnkles Venous,arterialorpressureulcerSoleoffoot&toes DiabeticfootulcersSunexposedareas Skincancers


Using TIME to assess the wound

T is for TISSUE Epithelial Granulating Slough Necrotic

Theimageaboveistryingtoconveythatifthewoundisgreaterthan50%granulatingandepithelial,considerprotectionasyouraim.Ifitfallstothesloughandnecroticsidethenconsiderdebridement.Tissuetypestendtobedescribedbycolour.Pinkisforepithelial,redforgranulating,yellowforsloughandblackforeschar.Alsoconsiderotherdescriptorsthatmaybehelpful,thesefouralonedonotalwaysgiveyouagoodpictureofwhat’shappeninginthewound.Thewoundinthephotoontherightcouldbedescribedas90%escharand10%granulationtissue.Butthatcouldalsopertaintoacrustydryscab,andthisisreallywet;it’sactuallycoagulatedbloodfromunderabloodblister.Somayberatherthansayingescharitcouldberecordedaswetescharorevenclottedbloodfirmlyadheredtothewoundbed.Photosareagreatwaytorecordawound,butevenwithaphotoagooddescriptioncanbeveryhelpful.Theepithelialandgranulatingtissuetypesareconsideredviable.Thesearealiveanddoingwell.Sloughandeschararenotviable,theydonothaveabloodsupplytosupporthealingandtheyarenotalive.Itisdeadmaterialanditneedstogo.Thepresenceofnon-viabletissueanddebris(foreignbodies/olddressingproduct/sutures)(6):

• providesafocusforinfection• prolongstheinflammatoryphase• mechanicallyobstructscontraction• impedesre-epithelialization• masksunderlyingfluidcollectionsor

abscesses• makesitdifficulttoevaluatewound depth

NonViable

Viable

Epithelial

Granulating

Slough

Necrotic

Debride

Protect


Debridementistheactofremovingdevitalizedtissuesfromthewoundbed.Theactofdebridingthewoundbednotonlyimprovesthetissueinthewoundbedbutitalsohasapositiveimpactoninflammation(restoresfunctionalextracellularmatrixproteins),moisture(reducesexudate)andedges(encouragesmigration)–theotherthreecomponentsofTIME.Anumberofthingsneedtobeconsideredbeforedebriding(7):

• Patientpreference-includingpaintolerance(plustheymightnotlikemaggots)• SkilloftheclinicianandScopeofPractice–Getotherswiththeexperienceandclinical

skillsinvolvedifneeded• Riskmanagement–isthereachanceyoucoulddomoreharmthangood,isthere

trainingyoucandotoimproveyourskills,andagain,istheresomeonewhocanassistyou?

• Environmentalfactors–thingslikelighting,posture,PPEandriskforcontaminationoftheenvironmentorfurthercontaminationofthewound

• Resources-makesureyouhaveeverythingyouneedbeforeyougetstarted.Insomeareasyoumaybelimitedinyouroptions.

• Contraindications-theseincludepropensitytobleed,presenceofunderlyingstructuresandlackofadequatebloodsupply.

Ifdebridementisrequiredyouneedtodeterminethebestmethod.MostoftenasNurseswemakeuseofautolyticandmechanicaldebridement(thevigoroususeofasurgispongeisconsideredmechanicaldebridement).Butyouneedtobesurethatdebridement–whateverthechosenmethod–issafe.WhennottoDebrideDebridementisnotalwaysthepreferredoptionforallwounds.Inthecaseofthenecroticheelortoeinthepatientwithpoorarterialflow.Iftheareaisdry,leaveit.Itwilleventuallymummifyandauto-amputate.Tryingtomoistenorremovethetissueisonlylikelytointroducenewwaysformicrobialinvasionthatthebodyisnotabletofight(8).Also,forthepalliativepatientwherecareissupportive,againifitisdryandnotcausinganypain,leaveit(9).Fungatingwoundsarechallenginginthattheyproducecopiousamountsofexudateandodourbutarehighlyvascular.Attemptstodebridemaycausecatastrophicbleeding,howeverleavingitcausesfurtherdamagetothesurroundingskinfrommacerationandstresstothepatientfromtheodour(10).CleaningwithsomethinglikeProntosanhelpstoreducethebioburden,whichinturnreducestheexudateandtheodour(11).


Table 1: Debridement methods Type Mechanisms of action Advantages Disadvantages Who/where

Autolytic

Uses the body’s own enzymes and moisture to rehydrate, soften and liquefy hard eschar and slough using occlusive or semi-occlusive dressings and/or antimicrobial products to create a balanced moist wound environment either by donating or absorbing moisture

Can be used for pre-debridement, when there is a small amount of non-viable tissue �Also suitable for wounds where other forms of debridement are inappropriate

Can be used for maintenance debridement

The process is slow, increasing potential for infection �and maceration

Can be done by both generalist and specialist

Biosurgical

Larvae of the green bottle fly are used to remove necrotic and devitalised tissue from the wound. Larvae are also able to ingest pathogenic organisms in the wound.

Highly selective and rapid

Costs are higher than autolytic debridement, but treatment is short once in place �Not suitable for all patients or wounds

Can be applied by generalist or specialist practitioner with training. Closed bag method reduces skill level required and can be left for 4-5 days

Hydrosurgical Removal of dead tissue using a high energy saline beam as a cutting implement

Short treatment time and selective. Capable of removing most if not all devitalised tissue from the �wound bed

Requires specialist equipment. There is potential for aerosol spread and it is associated with higher costs

Must be carried out by a specialist practitioner with relevant training. Can be used in a variety of settings

Mechanical

Traditional method involves using wet to dry gauze that dries and adheres to the top layer of the wound bed, which is �‘pulled’ away when the dressing is removed

Newer methods are more selective, faster and relatively pain-free �

Non-selective and traditional methods are potentially harmful Requires frequent dressing changes and can be very painful for the patient

Can be done by both generalist and specialist

Sharp

Removal of dead or devitalised tissue using a scalpel, scissors and/or forceps to just above the viable tissue level. This does not result in total debridement of all non-viable tissue and can be undertaken in conjunction with other therapies (eg autolysis)

Selective and quick. No analgesia is required normally

Clinicians need to be able to distinguish tissue types and understand anatomy as the procedure carries the risk of damage to blood vessels, nerves and tendons

Can be done at the patient’s bedside or in clinic by a skilled practitioner with specialist training

Surgical

Excision or wider resection of non-viable tissue, including the removal of healthy tissue from the wound margins, until a healthy bleeding wound bed is achieved

Selective and is best used on large areas where rapid removal is required

It can be painful for the patient and anaesthetic is normally required �It can be associated with higher costs

Must be performed in the operating theatre by a surgeon, podiatrist or specialist nurses following training

Ultrasonic

Devices deliver ultrasound either in direct contact with the wound bed or via an atomised solution (mist). Most devices include a built-in irrigation system and are supplied with a variety of probes for different wound types

Immediate and selective. It can be used for excisional debridement and/or maintenance debridement over several sessions

Availability issues due to higher costs and requirement for specialist equipment �Requires longer set up and clean up time (involving sterilisation of hand pieces) than sharp debridement.

Must be carried out by competent practitioner with specialist training in a variety of settings

TablecopiedfromDebridementMadeEasy(12)


I is for INFECTION / INFLAMMATION

Thisimageshowstheprogressionfromnormalinflammation(wherethewoundiscontaminatedwithopportunisticandtransientpathogens)tosystemicinfection.Beloweachphasearetheactionsyoucanconsiderforeachphase.Theyarecumulative:soforawoundthatappearscriticallycolonizedyouwouldwanttoclean,debrideanduseatopicalantimicrobial.Infectionistheoutcomeofthedynamicinteractionsthattakeplacebetweenahostandapotentialpathogenwherethehostdefensestrategiesaresuccessfullyevadedandthereisanegativeimpactonthehost(13).Complexinteractionsleadingtoinfectionarenotyetcompletelyunderstoodbuthavebeengroupedinto3broadareas:Contamination

• Allwoundswillhaveatransientcollectionofmicro-organisms.Whenthehost’sdefensesareadequateandtheconditionsarenotinfavourofthemicro-organism,theywillnotmultiplyandwoundhealingisnotdelayed.

Colonisation

• Microbialspeciesareabletosuccessfullygrowandreplicatebutdonotprogressfurthertodamagethehost.Woundhealingmaybedelayed.

Infection

• Thelevelofmicrobialgrowthandreplicationoverwhelmsthehost’sdefensesleadingtocellularinjuryandhostimmunologicalreactions.Woundmaydeteriorate.

Theimageshownabove,theinfectioncontinuumarrow,isamodifiedversionoftheonein“TheMicrobiologyofWounds”byPercival&Dowd(14).Theyexpandthisspreadfromcolonizationtoinfectioninto6stages:

Clean

Debride

TopicalAntimicrobial

SystemicMedications


Table 2: Stages of microbial invasion ContaminationorTransientStage

Thisiswherebacteriaareenteringanareaandassessingitssuitabilityforcolonization.Theymayhavecomefromsurroundingareasonthepatient(endogenous)orfromtheenvironmentorhealthcareworker(exogenous).Thesebacteriaarestillinafreefloatingor‘planktonic’stageandarevulnerabletoeradication.

ColonizationStage1—ReversibleAdhesion

Ifthebacteriadecidethatthisisasuitablelocationtogrowitwillstarttoattachitselftothehostcellsusingwhateveradhesionoptionsithas.Thisiscalledreversibleadhesionbecauseitisstillpossibletoremovethesebacteriawithlowlevelsofsheerforce(egsalinerinses)andtheyarealsostillverysusceptibletoantimicrobialagentsandhostdefenses.Astimegoesontheadhesionforcesbecomestrongerandthebacteriastarttoproduceextracellularsubstancestomaketheareamoresuitable,thusstartingthedevelopmentofthebiofilm.EarlycolonizingbacteriaaretypicallyStaphylococcusandbetahemolyticStreptococci.

ColonizationStage2—IrreversibleAdhesion

Atthispointthebiofilmisnowstartingtoaltertheconditionsinthewound,makingitmoredifficultforthehostdefensesandantibioticstogettothebacteriahidinginit.Itisstillpossibletoremovebutwithagreateramountofforcerequired.Thisnewbiofilmencouragesotherbacteriatojointhecommunity.Asthecommunitygrowsandnumbersofbacteriaincreasemicro-coloniesformandareasofthebiofilmbecomehypoxic,thuscreatingasuitableenvironmentforanaerobicbacteriaaswell.

CriticalColonizationStage—ClimaxCommunityor“Biofilm”

Fromaclinicalperspective,thisiswherethewoundissufficientlycolonizedtoexertit’seffectsonthewoundandpreventhealing.Fromamicrobiologicalpointofviewitisthecriticalmassofbacteriathathasformedaviablecolonybuthasnotyetobtainedhighenoughnumberstoinvadesurroundingtissues(causeinfection).Thereisnosetnumberasdifferentcombinationsofpathogensandhostdefensesmeanthisthresholdwillvary.

LocalInfectionStage

Oncethecolonyismature,growthwillcontinueexponentiallyandbacteriawillbeabletousethissafecolonyasastagingareatoinvadelocaltissues.Alocalwoundinfectionwillpresentclinicallywithredness(erythema),excessivepain,swelling,heatgeneration,woundbreakdownandincreasedlocaltemperature.Othermoresubtleclinicalsignsofinfectionhaveincludedalterationinexudate,friablegranulationtissuethatbleedseasily,malodor,anddiscoloredgranulationtissue.Reportedgranulationtissuediscolourationhasincludedyellow,green,orbluewhenbacteriasuchasPseudomonasaeruginosa,Streptococci,andBacteroidesfragilishavebeencultured.

SystemicInfectionStage

Ifthebiofilmisnotdisturbedwithappropriatewoundbedpreparationtechniques,appropriatedressingmanagementandtheuseoftopicalantimicrobialsthecolonywillcontinuetoproduceinvadingbacteriawhichcanleadtobacteriagettingintothebloodstream(bacteremia)leadingtosepsisorsepticemia(multiplicationofbacteriainthebloodandtoxinproduction),potentialorganfailure,andinextremecases,death.

Cleaning,debridingandappropriateuseofantimicrobialdressingsallhelptoreducebioburdenandreducetheestablishmentofabiofilm.Researchersarestillunclearhowlongittakesabiofilmtoform.Therearemanyvariablesincludingstrainofbacteriaandit’s


adhesionmethods,hostdefensesandtypeofmaterialbeingadheredto(ieskinvsimplant).Therearein-vitrostudies(controlledenvironment,inalab/notonalivesubject)thatindicateStaphylococcusaureuscancreateabiofilmwithin2-3hoursandotherstudiesonpigmodelsthathaveestablishedbiofilmswithin48hours(15,16).Thetheoriesbehindwhythesebacteriaformbiofilmsarealsovaried(17).Biofilmsmaybecreatedforprotectionfromhostdefenses,colonizationofanutrient-richareaand/orutilizationofthecooperativebenefitsofacommunity(17).Thebiofilmisknowntoenhancecommunalprotectionfromphagocytosisbypolymorphonuclearleukocytes(PMNs).Thismeansthatoncethehardierspecieshavestartedtoestablishabiofilmthemoresensitivespecieswillhaveasafeplacetoattachandgrow.Itmayevenmakethesesensitivespeciesappeartobe‘resistant’.Oncetheoxygenstartstobedepletedtheanaerobescanalsojointhecommunity.Thissynergybetweenaerobicandanaerobicbacteriahasbeendocumentedtoincreasetheseverityofaninfection(18,19).Thesitethebacteriachoosetocolonizemaybenutrientrich,butthebacteriastillneedtobeabletounlockthosenutrientsincludingglycoproteins,sugars,andproteins.Inordertodothisnumerousenzymesarerequired,rangingfromproteasestoglycosidases.Havingacommunityofbacteriawitharangeofdifferentenzymaticpropertiesmeansthatmorenutrientscanbe‘unlocked’whichwouldbenefitthecommunityasawhole(14).Bycreatingcommunitieswheredifferentbacteriainhabitnichemicro-habitatsbestsuitedfortheirsurvival,andwherethebacteriacooperatetomeettheircollectivemetabolicrequirements,thebiofilmismorelikelytosucceed.Ifwedonotremovethebiofilm,thenthewoundislesslikelytoheal(14,20).Howdoweknowit’sinfected?Identifyingthedifferencebetweeninflammationandinfectioncanbetricky.Generallyspeaking,erythema,warmth,exudateandpaincanbeassociatedwithboth.Inapersonwhoisimmunocompromisedorhasareducedimmuneresponseforanotherreason(suchasinthefeetofpeoplewithdiabetes)theremaybenolocalsignthatinfectionispresent;thefirstsignscouldberigorsorpainatregionallymphnodes(21,22).Chronicandacutewoundsarealsoassesseddifferentlybecauseinacutewoundswehavethewindowofthefirst48hourswherewehaveanexpectationofwhatthe‘normal’woundhealingwilllooklike.Weexpectthatfortheacutewound,after48hoursthereshouldbeareductioninerythema,warmth,exudateandpainandifthesedonotreduce,oriftheygetworse,theremaybealocalinfection.ForchronicwoundsSibbaldetal(23)recommendtwomnemonicstohelprememberwhattolookforandtoalsodifferentiatebetweensuperficialanddeepbacterialburden.Thedifferencebeingthatsuperficialbacterialburdenmayrespondtotopicalantimicrobialswhereasdeepinfectionsusuallyrequiretheuseofsystemicmedications.

Forsuperficialinfection,thinkofNERDS

Fordeepinfection,thinkofSTONES

NonhealingwoundsExudativewounds

Redandbleedinggranulationtissue(friable)Debris(yelloworblacknecrotictissue)

Smellorunpleasantodourfromthewound

SizeisbiggerTemperatureincreased

Os[probetoorexposedbone]Neworsatelliteareasofbreakdown

Exudate,erythema,edemaSmell


M is for MOISTURE

Animbalanceinmoistureresultsin:

• Desiccation-slowsepithelialcellmigration• Maceration–damagetowoundmargin

Theaimistorestoreepithelialcellmigrationthroughthemanagementofexudateanditsunderlyingcauses(24).Attheedgesofthewoundkeratinocytesproliferateandproducedaughtercellstomigrateintothewoundbed.Ifascabispresentproteaseshavetobreakdownandclearapathforthekeratinocytestoburrowunderneaththescab.Butinamoistenvironment,withoutascab,themigrationiseasierandhealingisaccelerated.Thisdiscoveryledtodevelopmentoftheconceptofmoistwoundhealing(25).Whilethisnewlayerofcellsisdelicate,mostmodernwounddressingsdonotremovethemwhenthedressingischanged.However,ifadressingisallowedtodryoutoradheretothewound,traumaticremovalofthedressingmayharmthedelicatenewepitheliallayer(26).Moistureinawoundcanbemodifieddirectlyorindirectly(27):

• Directo Theuseofabsorbentormoisture-balancingdressingso Theuseofcompressionand/orelevationtoeliminatefluidfromthewoundsiteo TheuseofTopicalNegativePressure(TNP)withdevisessuchastheVAC-

VacuumAssistedClosure• Indirect

o Controlofinfectionorbacterialloado Controlofoedemabysystemictherapysuchasthetreatmentofheartfailureo Useofimmunosuppressionorsteroidstocontrolinflammatoryexudatefrom

woundssuchaspyodermagangrenousum,vasculiticorrheumatoidulcersGeneralobservationsaboutdressings:

• DressingthatcontributetowoundmoistureincludeTenderWet,hydrogels,Honey,IodosorbPasteandother“Wet”dressings.

• Dressingsthatconservemoisture(stopiffromevaporatingawayand/orhandleasmallamountofexudate)includefilmsandhydrocolloids.

TooDry:Presenceofeschar,slower‘2-stage’healing

TooWet:Macerationandexcoriationdamagesperiwoundskinandslowshealing

Justright:Warm,moistwoundhealing

Absorb/ManageMoisture

Contribute/ConserveMoisture


• Moderateamountsofexudatecanbemanagedbyhydrofibres,alginates,foams,simpledressings(likemelolinifchangedfrequently)anddressingswhichcontaintheseitemsasoneofitscomponents.AnexampleofacombinationdressingistheAquacelSurgical,whichhasahydrofibreinterfaceandahydrocolloidadhesivebacking.

• Highamountsofexudateneedeithermuchmorefrequentchangesofsimplerdressings(suchascombine)oruseofhighabsorbencydressingssuchasZetuvitorDrymax.Alternativelyincontinenceaids(withtheelastictrimmedoff)canbesecuredtotheexudingarea.Productslikeblueys/pinkiesandimproperlysecuredincontinenceaidscanbetriphazardssoshouldnotbeusedonmobile,orpotentiallymobile,patients.

• Otheroptions.Therearesomedressingswhichwillallowtheexudatetopassthroughtoasecondarydressingssothattheprimarydressingdoesnothavetogetchangedasoftenasthecheapersecondarydressingbutstillprovidethebenefitsofthelongerweartimefortheprimarydressing(examplesaremepilextransfer,aquacel,tullegras,andsiliconeinterfacedressings).Exudatemanagementsystemsinvolvinghydrocolloidsealsandplasticbagsarealsoanoption.Topicalnegativepressuretherapycanalsobeconsidered.


E is for EDGES

Woundedgesthatare:• rolled• atadifferentleveltothewoundbed• undermined

donotallowforthemigrationofkeratinocytesacrossthewoundbed.Addressingtheunderlyingcauseshouldbetheanswer,butdebridementortheuseofadjunctivetherapiesmayneedtobeconsidered.Theaimistoencouragekeratinocytemigrationandwoundcontraction;thiswillbeseenasanadvancingwoundedgeandreductioninwoundbedsize(6).TheedgesreallyarethefinalindicatortoletyouknowthateverythingelseyoudidwithT,I,andMisworkingornot.Also,theedgescangiveusinformationtohelpdiagnosethetypeofwound.Belowisatableshowingedgecharacteristicsandtheirlikelycorrelationstowoundtype.However,thisisjustaguideandnotadiagnosisbyitself.

WoundedgecharacteristicsEdges TypeofwoundSloping VenousulcerPunchedout ArterialulcerRolled BasalcellcarcinomaRaised SquamouscellcarcinomaUndermining PressureulcerCalloused DiabeticfootulcerPurple Vasculitic

Theotherthingtorememberisthattheseedges,andtheperiwoundskin,needtobeprotectedduringthecourseofthewoundtreatment.Thingslikeexcessmoistureandincreasedbioburdenlevelscanaffecttheperiwoundskin.Theuseofadhesivescancausedamagefromtheirfrequentremovalormaytriggeranallergicresponse.Productsusedtodebridenecrotictissuecanbejustasreadytobreakdownthehealthytissuesocaremustbetaken.Theuseofmoisturizers/emollientsandanadequateintakeofwater,daily,helptogivetheskinresilience(28).Simpleperiwoundskinprotectioncanbeobtainedbyusingbarrierwipes,creamsorsprays(11).Insomecases,exudatemanagementbags,hydrocolloiddressingsandpastesneedtobeusedtoensureadequateprotection.Totryandsimplifyallofthisinformation,achartthatplotstissuetype,exudatelevelsandthepresences/absenceofinfectioncanbeusedtohelpsummarizeoptions.Butremember,everypersonisdifferent,everywoundisdifferent,sousethisasaguideonly.Andifawounddoes


notshowimprovementwithin2-4weeksofoptimumcare,doafullpatientre-assessmentandconsiderfurthercollaborationwithothers.

Investigation Dowehaveenoughinformationtounderstandtheunderlyingproblem(diagnosis)andcreateacomprehensivemanagementplan,ordoweneedmore?Examplesofinvestigationswecandoatthebesidearethingslikecheckingforthepresenceofpulsesandsensation.Getintothepractice(onhealthypatients)offindingbrachial,dorsalispedis,posteriortibialandpoplitealpulses.Wedon’ttendtousetheseoftensodon’tgetmuchpractice.Also,having,andknowinghowtouse,amonofilamentpenortuningforktodeterminesensationperceptionisveryuseful.Otherinvestigationsundertakenbythedoctorsincludepathologyandmedicalimaging.Youcanalwaysrecommendinvestigationsbedonewhendiscussingyourpatientwiththedoctor.Forexample,inawoundwithboneonview,itisreasonabletorecommendimagingforosteomyelitis.Inlegswithsignsofarterialorvenousdisease,itisreasonabletorecommendanABPI.Forthewoundbedthatisfriable,hasanoddorpearlytexture,especiallywherethepatienthasahistoryofskincancers,itisreasonabletorecommendabiopsy.Thedoctormayormaynotwishtoincludethisintheirplan,butatleastyouhavebroughtattentiontoapotentialproblem.RemembertouseyourSBARcommunicationskillswhenmakingtheserecommendations.

Diagnosis Weunderstandadiagnosistobetheidentificationofadiseaseormedicalconditionbyexaminationofthesigns,symptomsandanytestsperformed(29).Somediagnosesareobvious,likewhenthepatienthitstheirarmontherollatorandgetsaskintear.Thisisaskintear(withappropriateSTARcategory)secondarytotrauma.Wecanusuallyputadiagnosistotheacutewoundsandsomechronicwoundslikepressureinjuries.However,otherchronicwoundsthatarenothealingwithoptimumtreatmentmayeitherhavenodiagnosis,orthewrongone.Let’shaveanotherlookatthewomanwhohitherarmontherollator.Thewoundiscleaned,edgesre-apposed,anddressingwithcompressionapplied.Afterafewmonthsthewomanisseenagain,shestillhasasmallareathatappearstoheal,thengetsabitcrustyandstartsbleedingagain.Theareaisslightlyraisedcomparedtothesurroundingskin.Isthediagnosisofskintearstillappropriate?Orshouldtherebefurtherinvestigationstodeterminewhatishappeningatthecellularleveltostopthiswoundcompletelyhealing?Thisiswhereweneedtocollectasmuchinformationanddiscusstheneedforfurtherinvestigationsandpossiblyreferralwiththetreatingteam.Someexamplesofwounddiagnosesare:

• SkinTear(category1a,1b,2a,2bor3aspertheSTARclassificationsystem–seeAppendixB)

• PressureInjury(stageI,II,III,IV,mucosal,unstageable,orsuspecteddeeptissueinjuryaspertheNPUAPclassificationsystem–seeAppendixC)

• Surgical• DiabeticFootUlcer


• VenousUlcer• ArterialUlcer• MixedVenous/ArterialUlcer• Cancer(SCC,BCC,solarkeratosis,melanoma,andmanyothers)• Vasculitis• PyodermaGangrenosum• Toomanydermatologicalconditionstomention!

Theimportantthingtorememberisthatweneedtoknowwhatitistobeabletocreatethemostappropriatecareplan.Failuretocorrectlydiagnoseawoundtypemayresultinfailedmanagementandwastedresources.Interventionsbasedonaccuratediagnosisdeliversbenefitstopatients,healthcaresystemsandsociety(30).Let’slookatthepersonwithchestpainthatwesenthome.What’sgoingtohappen?Isthepaingoingtocomeback?Getworse?Thispatientislikelytore-presenttohospitaltimeandtimeagainwiththesamesymptoms,orworse.Theunderlyingcondition(whateveriscausingtheinfarct)isnotlikelytoimprovebyitselfandwillgenerallyfollowadeterioratingcourse.Sonowlet’slookatapersonwithaninfectedulcer.It’sbeenthereawhile,theantibioticsreducetherednessandswellingandthewoundappearstostarthealing,butithasdonethisbefore,andwilldoitagain.Why?Wehavenodiagnosissowedon’tknowwhy.Becausewehavenottreatedthecausewehavewastedtimeandresourcesandthepersonwiththewoundhastocontinuetolivewithitandbearthecosts,everyday.Whatifthediagnosisofthewoundisasquamouscellcarcinomaorperipheralvenousdisease?Weneedadiagnosistoensurethewoundisadequatelymanagedandallcontributoryfactorsareaddressed(29,31).Asoursocietycontinuestoage,andlifestylediseasescontinuetoincrease,theproblemofpressureinjuriesanddiabeticulcersisgrowing.Theseandothercommontypesofchronicwoundswillrequireaccurateandconcisediagnosisandappropriatetreatmentaspartofholisticcare(2).

Implementation Onceyouhavecollectedyourhistory,doneyourexamination,completedanyotherinvestigationsanddeterminedthewounddiagnosis,youwillbereadytoputtogetheryourcomprehensivewoundcareplan.Inallofthesepreviousstepsyouwillhaveidentifiedriskstohealingorotherthingsthatwillimpactonhealingoryourcareplan.Forexample:History • Smoking

• HeartFailurewithFluidoverload

• Lossof10kginthelast2months

• Educationtoquitsmoking• Thetreatingteamwillbemanagingthefluidoverload,buttheconditionwillimpactonanyplansforcompression:compressionshiftsthefluidfromthelegsbackintocirculation,whichwillexacerbatethefluidoverloadproblem.

• Refertodieticianfornutritionalsupportinlightoftheextrarequirementsneededforwoundhealing

Examination >50%sloughHighexudateOedemaVaricoseveins,ankleflair,haemosiderinstainingPalpabledorsalispedis,warmfeet.

• debride• Managemoisture,preventperiwoundmaceration• Manageoedema

Investigation ABPI:Leftleg1,Rightleg1.1Longdurationofulcer(6years)and‘lumpy’tissueinpartofthewoundbase

• Legswilltoleratecompressionbutthereisstilltheproblemoffluidshifts.

• DiscusswiththetreatingteamtheneedtoruleoutMarjolin’sulcerviabiospy.

Diagnosis ?VenousLegUlcer Discusswiththetreatingteamtheneedforadiagnosisandplanforcompression.


Collaboration Communication and collaboration inwound care is essential. Gottrup(32) refers to a studydoneinonehospitalinCopenhagenwheretheyfoundinthemajorityofcasesthat:

• Chronicwoundswerenothavingdiagnosticexaminations• Venouslegulcerswerenotreceivingcompressiontherapy• PatientswithfootulcerswerenotbeingassessedforDiabetesMellitus• Patientswithpressureulcerswerenothavingoff-loadingtreatment

Why?Didtheynothaveadiagnosisorwerethepeoplelookingafterthesepatientsmissingthenecessaryskills?Gottrupproposesthattoremedythisandprovideoptimumcareforthecomplexwoundcarepatient,careneedstobedeliveredbyteams,andnotindividuals.Whoare the collaborators thatmakeup these teams? Wementioned thepatient’s treatingteam,specialistsandalliedhealthabove. Whataboutthepatientandtheirfamily/carersorother support in thehome? Are they in anursinghome?For the complex, chronicwound,evidence tells us that we need a coordinated, multidisciplinary care team, includingparticipation fromat-home caregivers and thepatient, foroptimumresults. Specialist-leadadvancedcareisneededwhenthereisevidenceofischemia,inabilitytocomplywithwound-care regimens, suspected malignancy, and peripheral arterial disease(33). This is bestsupplemented with a member of the allied health care team (for example, occupationaltherapist,physicaltherapist,podiatrist,dietitian,socialworkerandsoon)(2).Howdoyouknowwhentorefer?Wheneveryouareindoubtregardingetiology,suspectedmalignancy,evidenceof ischemiaorwoundsthatdonotdemonstrateanadequateresponsetotreatment(33).Bygettingtherightpeopleinvolvedwecanallowforearlierdiagnosis,bettermanagement,andmayreducethecostoftreatingwounds(33).Withthelevelofcomplexityinthe patients we see, accurate wound diagnosis and development of successful treatmentsplanscanbequitechallenging(2).Butitcanbeequallyrewarding.

Assessment tools used in wound management Since1970wehaveknownthatastandardizedmethodformeasuringwoundhealingisneeded(34).Regularassessment,documentingprogressandassessingtheeffectivenessoftreatmentmaximizeshealingrates(35).Forchronicwounds,thosewoundswhichdonothealinatimelymanner,thebenefitsofusingastandardizedassessmenttoolcanbesignificant(36).Therearemanyfactors,systemic,regional,localandenvironmental,thatcanimpairwoundhealingandincreasetheriskofanacutewoundbecomingachronicwound(1).Thesystematicassessmentandcollectionofdataminimisesthisrisk(37).Whereassessmentsarenotperformedcorrectlythereistheriskofdelayedhealingandthepotentialforseriouscomplicationsassociatedwithlivingwithawoundforaprolongedperiodoftime(37).Notonlyarethererisksassociatedwithreducedskinbarrierfunction,suchasinfection,butthereisoftenpain,socialisolation,andpoorerqualityoflife(38,39).Delayedwoundhealingrequiresadditionalnursingandmedicalresources,highercostsofconsumablesinwoundcare,andpotentiallyhighercostsofhospitallengthsofstaytotreatcomplications(37).Theever-expandingmarketofdressingproductsonlyaddstoworsenthesituationwhenyoucombineapoorassessmentwithaninappropriateandexpensivedressingselection(34).Conversely,whereskilledcliniciansuseastandardizedframeworkwhichclearlyguidesNursesfromassessmentthroughtoimplementingandmonitoringwoundcareplansthatcorrectlyaddressthefactorsimpactingonwoundhealing,healingtimesarereduced,patientsufferingisreducedandtheoveralleconomicburdenisreduced(36-38).Byaddressingthesystemiccausesofwoundsandimpairedhealing,suchasreferralstovascularordermatologicalspecialists,


thereisalsothepotentialforreducingtheriskoffuturewoundsoccurringorreducingtheirduration(40,41).Theidealwoundassessmenttool(WAT)willleadcliniciansfromassessmentanddiagnosisthroughtosettingclearhealingobjectivesandwoundcareplans.Itwillbegroundedinresearchandevidence,andfasttouseforcliniciansofallknowledgelevels(42-45).AWMAhascreatedasetofstandardsforwoundmanagement(46)inwhichtheyincluderecommendationsforassessment,planninganddocumentation.TheirrecommendationsaresummarizedinTable1.TherecommendationsfromtheAWMAstandardsadheretothisidealandcanbegroupedasinitialassessment(patienthistoryandsystemicobservations),optionalassessment(regionalobservationsandinvestigationsrelevanttowoundlocationandaetiology),ongoingassessment(woundbedandlocalarea)andcareplanning(managementplan,collaboration,documentationandevaluation)(46).TheserecommendationsareverybroadandAWMAdoesnotprovidespecificsonhowthisshouldbedone.TheserecommendationswerethebasisforaliteraturereviewinvestigatinganumberofwoundassessmenttoolsandhowtheycomparedtotheAWMAstandard.Youcanreadthisreviewinfullonmywebsite(http://woundcareresource.com/downloads/litreview-wat.pdf).ThereviewshowsthatnosingletoolencompassedallrecommendationsfromtheAWMAstandards,howevertheGCUHWCPcoveredmoreitemsthanthecomparisontools.ThiswasstilllessthanhalfofAWMA’stotalrecommendations.Whileallthereviewarticlesagreedthatcomprehensivewoundassessmentisneeded,suchacomprehensivetoolasoutlinedbyAWMAwouldnotbepractical,andwouldnotbeusedbyNurses.ThiswasreflectedintheauditoftheGCUHWCPwhere(onaverage)halfoftheitemsonthetoolwerenotcompleted.NursesmainlyusedtheWCPonlyasameanstorecordwhatdressingswereappliedtothewound.Arguably,thegreaternumberofassessmentitemsmeansthegreatertheabilitytodetectvariation(47)butalsothemoretimeconsumingtoadministerandthereforemorecostly(48).Themoderncareenvironmentisonewherenursesfindtheyhavemoreresponsibilities,lesstimeandhighstaffturnoverrates;allofwhicharebarrierstoensuringconsistentuseofaWAT(38,45,49).However,itisimportanttorememberthatcorrectcompletionoftheWATshowingevidencebaseddecisionmakingprocesseswhichareclear,consistent,andcoherentwillreducetheriskofpoorpracticeand,subsequently,theriskoflitigation(50).


Table1Recommendationsforinclusioninawoundtool,modifiedfromAWMAstandardsInitialAssessment OngoingAssessment OptionalAssessment

whenindicatedCarePlanning

ReasonforPresentation

Woundtype/Aetiology Riskassessments(falls,skinintegrity)

Shortandlongtermgoals

HealthHistory Duration Vascularassessment ManagementPlantooptimizewoundhealingpotential

Age Location Sensoryassessment Individualandcarerpreference,abilityandwillingnesstoparticipate

Previouswoundhistoryandoutcome

Dimensions Nutritionalassessment Evidenceofinter-professionalcommunicationandcare

Medicationhistory Woundbedcharacteristics(tissuetypeandforeignbodies)

Psychologicalassessment

Comprehensiveandchronologicaldocumentation

Psychosocialimplicationsresultingfromwounding

Woundedgesappearance Medicalimaging Effectiveness

Nutritionalstatus Peri-woundappearance Pathology Increaseawarenessofhealthylifestylechoices

Sensitivitiesandallergies Exudate PromoteactivityandmobilityactivitiesRelevantdiagnosticsandinvestigations

Odour

Painassessment Inflammation/Infection Vitalsigns WoundPain Individual’sperceptionsofwoundhealinggoals


The digital age Collectionofinformationinthedigitalagehasallowedustoaccessthedataeasier,toquicklydeterminetrendsinhealing,ortousetheinformationforresearch(forexample,assessingindicatorsofpotentialvenuslegulcerrecurrence(51)).Theinternetprovidesuswithawealthofwoundmanagementinformation,someexcellent(WoundsInternational,WorldWideWounds)andsomewhichare,welllet’ssay,notpeerreviewed…WithinourhealthcaresettingsthemajorityofourWATsarestillpaper-basedandwecontinuetomeasurewithdisposablerulers.However,thedigitalageisencroachingonwoundcare.Inmyopinion,themostsignificantofthesehasbeentheintroductionofthedigitalcamera.Beingabletoquickly,easilyandaccuratelyrecordtheprogressofawoundthroughtheseimageshasbeenincrediblyhelpful,increasingobjectivityintemporalassessment.Woundmeasurementisalsoahotlydebatedtopicas,overtheyears,eachnewtechnologyhaspromisedtobecomethegoldstandardforwoundmeasurement(um,no,westilldon’thaveone).Theproblembeing,itisquickandeasytomeasureawoundwitharulerortraceitonaruledpieceofacetateandcountthesquares.Thesetoolsarecheapandeasytohavehandy.3Dcamerasandthesoftwaretorunthem,digitalplanimetrydevicesandtheirconsumables,allhavehighcostsandtaketimetolearn.Whilestudieshaveshownthattheaccuracyofthesemoreexpensivedevicesisgreaterthanthatofthestandardrulermeasurements(52),thequestionis–howaccuratedoyouneedthemeasurementtobe?Inter-raterandintra-raterreliabilityhasregularlybeenshowntobehighforsimplemeasurementssuchasthosewitharuler.Howevertherulermeasurementitselfhasbeenproventoconsistentlyover-estimatethewoundsize(53).Sodoesitmatterifthesizeisconsistentlyover-estimatedintheclinicalsetting?Itwillstillshowatrend,whichiswhatisrequiredtoassistinclinicaldecision-making.Butnowwecometothepointintimewhereeveryonehasacamera,andthesoftwarethatcanbeusedtocalculatethewoundsizeiseitherverycheap(MOWA)orfree(ImageJ).Whilesomeofthepitfallsofwoundphotographywillbementionedshortly,Ithinkthatitissafetosaythatwiththeaccuracyandnon-contactnatureoftakingthephoto(4),theminimalexpenserequired,thetech-savvynatureofnursesandspeedofmeasurement,thistypeofwoundmeasurementwillincreaseinclinicaluse.


Appendix A – Student Assessment Tool History

• What is the complaint?

• How long has it existed?

• What has been done about the complaint so far?

• Medical History

• Surgical History

• Medications

• Social History

• Ever Smoked

• Alcohol Intake

• Mobility

• Allergies

• Diet

Examination

• Systemic

• Regional

• Local Location

Size

o Tissue

o Inflammation

o Moisture

o Edges


Investigations

Diagnosis

Intervention

Cleansing

Emollient/Barrier

Primary Dressing

Secondary Dressing

Retention/Compression

Dressing change frequency

Review:


Appendix B –STAR Skin Tear Classification



Appendix C – Pressure Injury Classifications

Category/StageI:Non-blanchablerednessofintactskinIntactskinwithnon-blanchableerythemaofalocalizedareausuallyoverabonyprominence.Discolorationoftheskin,warmth,edema,hardnessorpainmayalsobepresent.Darklypigmentedskinmaynothavevisibleblanching.Furtherdescription:Theareamaybepainful,firm,soft,warmerorcoolerascomparedtoadjacenttissue.Category/StageImaybedifficulttodetectinindividualswithdarkskintones.Mayindicate“atrisk”persons.

Category/StageII:PartialthicknessskinlossorblisterPartialthicknesslossofdermispresentingasashallowopenulcerwitharedpinkwoundbed,withoutslough.Mayalsopresentasanintactoropen/rupturedserum-filledorsero-sanginousfilledblister.Furtherdescription:Presentsasashinyordryshallowulcerwithoutsloughorbruising.Thiscategory/stageshouldnotbeusedtodescribeskintears,tapeburns,incontinenceassociateddermatitis,macerationorexcoriation.


Category/StageIII:Fullthicknessskinloss(fatvisible)Fullthicknesstissueloss.Subcutaneousfatmaybevisiblebutbone,tendonormusclearenotexposed.Somesloughmaybepresent.Mayincludeunderminingandtunneling.Furtherdescription:ThedepthofaCategory/StageIIIpressureulcervariesbyanatomicallocation.Thebridgeofthenose,ear,occiputandmalleolusdonothave(adipose)subcutaneoustissueandCategory/StageIIIulcerscanbeshallow.Incontrast,areasofsignificantadipositycandevelopextremelydeepCategory/StageIIIpressureulcers.Bone/tendonisnotvisibleordirectlypalpable.

Category/StageIV:Fullthicknesstissueloss(muscle/bonevisible)Fullthicknesstissuelosswithexposedbone,tendonormuscle.Sloughorescharmaybepresent.Oftenincludeunderminingandtunneling.Furtherdescription:ThedepthofaCategory/StageIVpressureulcervariesbyanatomicallocation.Thebridgeofthenose,ear,occiputandmalleolusdonothave(adipose)subcutaneoustissueandtheseulcerscanbeshallow.Category/StageIVulcerscanextendintomuscleand/orsupportingstructures(e.g.,fascia,tendonorjointcapsule)makingosteomyelitisorosteitislikelytooccur.Exposedbone/muscleisvisibleordirectlypalpable.


Unstageable/Unclassified:Fullthicknessskinortissueloss–depthunknownFullthicknesstissuelossinwhichactualdepthoftheulceriscompletelyobscuredbyslough(yellow,tan,gray,greenorbrown)and/oreschar(tan,brownorblack)inthewoundbed.Furtherdescription:Untilenoughsloughand/orescharareremovedtoexposethebaseofthewound,thetruedepthcannotbedetermined;butitwillbeeitheraCategory/StageIIIorIV.Stable(dry,adherent,intactwithouterythemaorfluctuance)escharontheheelsservesas“thebody’snatural(biological)cover”andshouldnotberemoved.

SuspectedDeepTissueInjury-depthunknownPurpleormaroonlocalizedareaofdiscoloredintactskinorblood-filledblisterduetodamageofunderlyingsofttissuefrompressureand/orshear.Furtherdescription:Theareamaybeprecededbytissuethatispainful,firm,mushy,boggy,warmerorcoolerascomparedtoadjacenttissue.Deeptissueinjurymaybedifficulttodetectinindividualswithdarkskintones.Evolutionmayincludeathinblisteroveradarkwoundbed.Thewoundmayfurtherevolveandbecomecoveredbythineschar.Evolutionmayberapidexposingadditionallayersoftissueevenwithtreatment.InformationfromTheAustralianWoundManagementAssociation(AWMA)PanPacificGuidelineDevelopmentSteeringCommitteeandtheEuropeanPressureUlcerAdvisoryPanel/NationalPressureUlcerAdvisoryPanel.(54,55)


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Documents

Wound Assessment - Wound Care ResourceWound Location The location of the wound will also impact on determining a diagnosis and contribute to the plan(3). Below is a table showing locations