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Clinical Wound Assessment - A Pocket Guide

Developed by

•ProfessorFinnGottrup,Denmark •Dr.RobertKirsner,US

•Dr.SylvieMeaume,France

•Dr.ChristianMünter,Germany

•ProfessorGarySibbald,Canada

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“The comprehensive wound assessment follows the patient assessment. The wound assessment will define the status of the wound and begin to identify impediments to the healing process”.(1)

Hess,C.T.andKirsner,R.S.,2003

The authors and Coloplast A/S hope that this pocket guide will help you in clinical practice. Barriers consisting of local and systemic factors may delay or impede healing. Through the assessment it is essential to identify these factors to facilitate faster wound healing whenever possible.

The pocket guide information is intended as a general guideline; please consult wound care guidelines applicable in your area.

If you have any questions or comments about the pocket guide, please send an email to dkbme@coloplast.com

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List of contents

Evidence-based wound management ........................... 4

Pathwaytoclinicalcareandclinicalevidence ................ 5

Fasterwoundhealing ..................................................... 6

Patientassessment ........................................................ 7

Wound assessment ....................................................... 8

Characteristics of different wound types ........................ 9

Clinical pictures of different wound types .....................10

Indications of when to use silver dressing .....................11

Clinical signs .................................................................12

Criteria for an ideal dressing .........................................13

Biatain® Foam Dressings ............................................14

Contreet® Antimicrobial Foam and

Hydrocolloid Dressings .............................15

Clinical research on Contreet Dressings .....................16

Searching for evidence-based information ....................18

Wound care mini-glossary ............................................19

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Evidence-based wound management

Evidence-based medicine and ultimately practice with focus on wound care requires the highest level of evidence.FurtherelaborationfromDavidSackett(2000)(2) defines evidence-based wound management as the integration of best research evidence with clinical expertise and patient values.

The approach for integrating evidence-based wound management into practice is:

• Clinicalresearch(clinicalresearchstudies)• Outcomesresearch(everydaypracticeresearch)• Health-economicanalysis(cost-effectiveness)

A pathway to clinical care and clinical evidence for patients with chronic wounds is presented on page 5.

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Pathway to clinical care and clinical evidence

Dressings are part of a holistic wound management plan with individualized patient goals. One goal may be to facilitate faster wound healing by providing the optimal environment for healing to proceed. However, it is necessary to look at the whole patient, underlying disease processes and patient-centered concerns before looking at the wound itself.(3)

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Faster wound healing by reducing the barriers of healing

Wound bed preparation extends the existing practice of using a holistic approach to evaluate and remove all barriers to healing, so that wound repair can progress normally. The overall goal of management is to achieve a stable wound that has healthy granulation tissue and one that is characterized by a well-vascularized wound bed. This would involve the removal of factors that delay healing.(4)

Various factors may delay or impede healing. Local factors occur directly within the wound, whereas systemic factors occur throughout the body.(1)

Local Factors Systemic Factors

Primary• Bloodsupply(tissueperfusion)• Tissueoxygentension

Pivotal• Haemodynamicconditions(perfusion,

hypovolemia, hypoxia, pain, etc)

Secondary• Tissuedamage• Mechanicalstressofthetissue• Hypothermia• Pain• Radiation• Infection• Surgicaltechnique• Suturetechniqueandmaterials• Others (vasculitis, immunological, etc)

Important• Age• Smoking• Medication• Diseases• Nutritionalstatus• Anaemia• Alcoholism• Radiation• Others(immunological,etc)

ModifiedfromGottrup,F.etal.,1995 (5)

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Patient assessment

Wound healing is determined by the general health of the patient. The assessment of the patient as a whole is critical for the planning and evaluation of care and should include:

• Medicalhistory• Causeoftissuedamage• Medication/Allergies • Otherdiseasessuchas: - Diabetes - Vascular disease - Immune compromise• Inadequatenutrition• Lifestyle/Environment - Obesity - Tobacco/Alcohol abuse• Impairedmobility• Inadequatesocialnetwork,caregiversupport• Psychologicalproblems

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Wound assessment

Wound assessment is not an exact science, but requires the skills and assessment of trained professionals. The following need to be assessed and carefully recorded at each dressing change:

• Cause:determineetiology• Localwoundcharacteristics: - Location - Size (length x width x depth) - Wound bed (black, yellow, red, pink, undermined) - Exudate (copious, moderate, mild, none) - Wound edge (callus and scale, maceration,

erythema, edema) - Odor (absent, present)• Patientconcerns:pain(persistent,temporary)• Conditionofsurroundingskin(normal,edema,

warmth, erythema) • Clinicalsignsofcriticalcolonization/localinfectionand

infection (please see pages 11-12)

Assessment of the wound is a prerequisite to the selection of an appropriate dressing.

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Characteristics of different wound types(6)

Arterial Venous Diabetic Pressure

Location

Usually distal

Above malleolus

Pressureareas on foot

Pressureareas

Size

Small Small to Large

Usually small but may be large

Small to Large

Shape

Round Irregular Round Roundbutmay be irregular if large

Depth

Usually relatively shallow

Shallow Shallow to deep*

Shallow to deep*

Base

Pale Variable; frequentely exudative

Variable; frequentely necrotic if infected

Variable

Margins

Smooth Irregular Usually smooth

Variable

Surrounding Skin

Pale Pigmented Frequentely callused

Variable

* may have tracking and/or undermining

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Venous leg ulcer

Arterial leg ulcer

Pressure ulcer

Diabetic foot ulcer

Clinical pictures of different wound types

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Indications of when to use silver dressings

* (7): A 20%-40% reduction of wound area in 2 to 4 weeks is likely to be a reliable predictive indicator of healing: the efficacy of this fact has been demonstrated specifically for venous leg ulcers.

**AdaptedfromHess,C.T.andKirsner,R.S.,Ostomy/WoundManagement2003.Enoch,S.andHarding,K.,Wounds2003.

Pleaserememberthatdiabeticfootulcersdonotalwayspresentwiththeclassicalsignsoflocalinfection.Furtherreading:InternationalConsensusontheDiabeticFoot(2003)bytheInternationalWorkingGroupontheDiabeticFoot.

Disclaimer:Thesearegeneralguidelines.Pleasechecklocaltreatmentrecommendationsapplicabletoyourcountryorhealthcareinstitution.

Contamination/Colonization

Critical colonization/ Local infection

Infection

Likely signs Likely signs Likely signs

No local pain New or increased pain at wound site

Severe or increased pain at wound and surrounding tissue

No fever No fever Fever,systemicsymptoms

Normal smell May have odor Foulorexcessiveodor

Healthy granulation Abnormal/absent granulation

Abnormal granulation or necrotic tissue

Minimal exudate Excessive or increased serous exudate

Excessive and purulentexudate

Normal wound margin Possibletunnelingor pocketing

Tunneling, pocketing, maceration, edema, erythema, warmth

Healing wound* Static wound Increased wound size

TreatmentSelect a wound dressing that provides moist wound healing. Topical antimicro-bial (e.g. sustained silver release) dressings may be used if risk of infection is a concern. Always conduct a thorough assessment, as it will determine the treatment.

TreatmentTopical antimicrobial (e.g. sustained silver release) dressings are appropriate. Always conduct a thorough assessment, as it will determine the treatment.

TreatmentSystemic antibiotics are appropriate. Topical antimicrobial (e.g. sus-tained silver release) dressings may give added benefit together with sys-temic coverage. Always conduct a thorough assessment, as it will determine the treatment.

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Contamination/ colonization

Critical colonization/local infection

Infection

Clinical signs

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Criteria for an ideal dressing An ideal dressing must provide:

Exudate Management• Beabletohandlevaryingamountsofexudate

Secure Application• Remainsecurelyinplaceduringactivities

Easy Removal• Beeasytouseandremovewithouttraumatizingthe

wound or surrounding tissue

Increased Wear-time• Requireaminimalnumberofdressingchanges–

to diminish disturbance of the healing process and decrease the nursing time required

Cost-effective Solution• Lowernursinganddressingcosts

Comfort• Promotegoodqualityoflifeforthepatient

ModifiedfromKarlsmarketal.,BritishJournalofNursing,2004 (8)

Characteristics of the ideal silver dressing must:• Combineantimicrobialeffectandcapacitytoabsorb

exudate(9)

• Deliversilverinaneffective,sustainedrelease (9)

• Be supported by clinical documentation in randomized, controlled trials

• Beeasytouseandcomfortableforthepatient(9)

• Becost-effective (9)

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Biatain® Dressing - Minimize maceration and leakage

Biatain Dressings have proven fluid handling capacities(10) leading to less risk of maceration & leakage.

Clinical evidence has shown:

• Lower incidence of leakage and better absorption capacity(11)

• Lessneedforasecondaryabsorbentdressing (11)

• Lessneedforspecialtreatmentofthesurroundingskin (11)

• Significantly longer wear time compared to the hydrocellular dressing, thereby having an impact on the total cost per treatment(11)

• Clinicallytestedonpatientswithdiabeticfootulcers (11)

Biatain is indicated for moderately to highly exuding leg ulcers, pressure ulcers and non-infected diabetic foot ulcers. It may also be used for superficial burns, superficial partial thickness burns, donor sites, postoperative wounds, and skin abrasions.*

Biatain® Dressing Contreet® Dressing

*PleaseseepackageinsertforcompleteInstructionsforUse

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Contreet® Dressing - Minimize maceration and leakage as well as provide effective, sustained silver release

Contreet Foam combines the fluid handling capacities of Biatain® with effective sustained silver release. This unique combination provides an efficient way to get healing started.(12)

Clinical evidence has shown:

• ContreetFoam reduces the ulcer area by 45-56% within 4 weeks(12,13,14,15)

• ContreetFoam has been shown to aid in wound bed preparation(12,13)

• ContreetFoam provides exudate management(12,13,14,15)

• Odorisdramaticallyreducedoreliminatedafterjust one week of Contreet Foam treatment(12,13)

• ContreetFoam is a cost-effective treatment(16)

• Clinicallytestedonpatientswithdiabeticfootulcers (14)

Contreet Foam Dressings are indicated for treatment of moderately to highly exuding leg ulcers, pressure ulcers, diabetic foot ulcers, partial thickness burns, donor sites, postoperative wounds, and skin abrasions. It can be used to progress wounds with delayed healing due to bacteria/fungi, or wounds where the risk of infection exists.*

Excellent fluid handling foam = Biatain Dressing + Silver = Contreet Dressing

*PleaseseepackageinsertforcompleteInstructionsforUse

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Clinical research on Contreet®*

Author Title Published

Jørgensen,B.etal. The silver-releasing foam dressing, Contreet Foam,promotes faster healing of critically colonized venous leg ulcers: a randomized, controlled trial.

InternationalWoundJournal2005, Vol. 2 (1): 64-73.

Rayman,G.etal. Sustained silver-releasing dressing in the treatment of diabetic foot ulcers.

BritishJournalofNursing2005, Vol. 14 (2): 109-114.

Karlsmark,T.etal. Clinical performance of a new silver dressing, ContreetFoam,forchronicexuding venous leg ulcers.

JournalofWoundCare2003, Vol. 12 (9): 351-354.

Lansdown,A.B.G.etal. Contreet Foamand Contreet Hydrocolloid: an insight into two new silver-containing dressings.

JournalofWoundCare2003, Vol. 12 (6): 205-210.

SibbaldR.G.etal. WoundBedPreparation properties of a foam dressing and a silver- containing foam dressing.

Posterpresentedatthe2nd World Union of Wound Healing Societies’ meeting in Paris,France,July2004.

Mosti,G.etal. Preparingthewoundbedfor skin grafting with a silver hydrocolloid compared to a standard hydrocolloid.

Posterpresentedatthe2nd World Union of Wound Healing Societies' meeting in Paris,France,July2004.

Voyatzoglou, D. et al. Clinical evalution of an anti-bacterial silver-contain-ing foam dressing in the treatment of neuropathic/neuroischemic diabetic foot ulcers.

Posterpresentedatthe2nd World Union of Wound Healing Societies' meeting in Paris,France,July2004.

Gottrup,F.etal. Evaluation of clinical results from 4 studies on two new antibacterial silver-containing dressings.

Posterpresentedatthe13thEWMAConference,Pisa,Italy, May 2003.

Falanga,V. Topical antimicrobials: Can they affect outcomes? The use of a new silver dressing.

Outcomes in Wound Healing, Symposium proceeding,ETRS2001.

*ForfurtherdocumentationpleasecontactColoplastA/S

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Outcomes research on Contreet®*

Author Title Published

Price,P.andtheContreet StudyGroup

Health-related quality of life aspects after treatment with a foam dressing and a silver-con-taining foam dressing in chronic leg ulcers.

Posterpresentedatthe2ndWorldUnion of Wound Healing Societies' meetinginParis,France,July2004.

Russell,L.etal. TheCONTOPmultinationalstudy:preliminarydatafromtheUKarm.

WoundsUK2005, Vol. 1 (1): 44-54.

Münter,K.C.etal. TheCONTOPstudy:Alargescale,comparative, random-ised study in patients treated with a sustained silver releasing foam dressing

Posterpresentedatthe15thEWMA Conference, Stuttgart, Germany,September2005.

Health economic analysis on Contreet*Scanlon, E. et al. Cost-effective faster wound heal-

ing with a sustained silver-releasing foam dressing in delayed healing leg ulcers - a health-economic analysis.

InternationalWoundJournal,2005. Vol. 2 (2): 150-160.

Scanlon, E. et al. Cost-effectiveness of a silver-containing hydro-activated foam dressinginGermanyandtheUK.

Posterpresentedatthe2ndWorldUnion of Wound Healing Societies' meetinginParis,France,July2004.

In vitro documentation on Contreet*Lansdown,A.B.G.etal. ContreetFoamandContreet

Hydrocolloid: an insight into two new silver-containing dressings.

Posterpresentedatthe13thJournalofWoundCare2003,Vol.12 (6): 205-210.

Dolmer, M. et al. In vitro silver release profiles for various antimicrobial dressings.

Posterpresentedatthe2ndWorldUnion of Wound Healing Societies' meetinginParis,France,July2004.

Larsen,K.and Dolmer, M.

Antimicrobial activity of Contreet FoamDressingonmicroorgan-isms commonly found in chronic wounds.

Posterpresentedatthe13thConferenceoftheEWMA,Pisa,Italy, May 2003.

Kolte,M.I.etal. Exudate management of silver containing dressings.

Posterpresentedatthe12thConference of the European Wound Management Association, Spain, May 2002.

Ip,M,LaiLui,S.,Roon,V.K.M.,Lung,I.,andBurd, A.

Antimicrobial activities of silver dressings: An in-vitro comparison.

JournalofMedicalMicrobiology55,55-59, 2006.

*ForfurtherdocumentationpleasecontactColoplastA/S

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Searching for evidence-based information

• Askthequestion:Whatinformationareyou looking for?

• Whereareyougoingtosearchandwhich key words do you choose?

• Howareyougoingtodetermineiftheresultsare valid and relevant?

• Doesthisnewinformationansweryouroriginal question?

• Applytheinformationtoclinicalpractice

• Evaluatethefinaloutcomeonpatientcare

WithinspirationfromRyan,S.etal.,Ostomy/WoundManagement,2003 (17)

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Wound care mini-glossary

Bacteria A single cell organism that can damage healthy cells

Bacterial load The total microbial numbers in the skin and/or wounds with normal commensals and potential pathogens

Colonization The presence of replicating bacteria that adhere to the wound bed but do not cause cellular damage to the host

Contamination The presence of non-replicating microorganisms within a wound

Cost-effectiveness (Health-economic analysis)

A comparative analysis of two or more alternatives in terms of their costs and clinical outcomes.

Critical colonization/ local infection

An increasing bacterial load in a wound is intermediate between the category of colonization and infection. Will not heal but may not display classical signs of infection.

Evidence-based wound management

The integration of best research evidence with clinical expertise and patient values

Granulation tissue The pink to red, moist, fragile tissue that fills in an open wound bed during the proliferative phase of healing. Capillary buds on its surface give it the characteristic bumpy or granular appearance.

Infection Classical signs in the presence of replicat-ing micro-organisms within a wound with a subsequent host response that leads to a delay in healing

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References1. Hess,C.T.andKirsner,R.S.,Orchestratingwoundhealing:Assessing

and preparing the wound bed. Advances in Skin & Wound Care 2003, Vol. 16 (5): 246-257.

2. Sackett, D.L., The fall of ”clinical research” and the rise of ”clinical-practice research”. Clinical and Investigative Medicine 2000, Vol. 23(6): 379-381. Erratum in: Clinical and Investigative Medicine 2001, Vol. 24 (1): 4.

3. Sibbald,R.G.,etal.,Preparingthewoundbed2003:Focusoninfectionand inflammation. Ostomy/Wound Management 2003, Vol. 49 (11): 24-51.

4. Enoch,S.andHarding,K.,WoundBedPreparation:Thesciencebehindthe removal of barriers to healing. Wounds: A Compendium of Clinical ResearchandPractice2003,Vol.15(7):213-229.

5. Gottrup,F.,Settingstandardsforthemanagementofsurgicalwounds.In:Cherry,G.W.,Leaper,D.J.,Lawrence,J.C.,Milwalleds.Proceedingsof the 4th European Conference on Advances in Wound Management. Macmillan Magazines, London, 1995: 10-14.

6. Holloway,G.A.,Arterialulcers:Assessment,classificationand management.In:Krasner,D.L.,etal.,ChronicWoundCare: AClinicalSourcebookforHealthcareProfessionals,ThirdEdition, HMPCommunicationsInc,2001:495-503.

7. Flanagan,M.,Improvingaccuracyofwoundmeasurementinclinical practice. Ostomy/Wound Management 2003, Vol. 49 (10): 28-40.

8. Karlsmark,T.etal.,Hydrocapillarydressingtomanageexudateinvenouslegulcers.BritishJournalofNursing2004,Vol.13(6supp):29-35.

9. White,R.J.,Anhistoricaloverviewoftheuseofsilverinwound management.BritishJournalofNursing2001,Vol.10(supp):3-8.

10. Thomas, S. et al., An in-vitro comparison of the physical characteristics of hydrocolloids, hydrogels, foams and alginate/CMC fibrous dressings, www.dressings.org. Technical publication, 2005.

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11. Andersen,K.E.etal.,Arandomized,controlledstudytocomparethe effectiveness of two foam dressings in the management of lower leg ulcers. Ostomy/Wound Management 2002, Vol. 48(8): 34-41.

12. Jørgensen,B.etal.,Thesilver-releasingfoamdressing,Contreet® Foam,promotesfasterwoundhealingofcriticallycolonizedvenouslegulcers:arandomized,controlledtrial.InternationalWoundJournal2005,Vol. 2 (1): 64-73.

13. Karlsmark,T.etal.,Clinicalperformanceofanewsilverdressing,ContreetFoam,forchronicexudingvenouslegulcers. JournalofWoundCare2003,Vol.12(9):351-354.

14. Rayman,G.etal.,Sustainedsilver-releasingdressinginthetreatmentof diabeticfootulcers.BritishJournalofNursing2005,Vol.14(2):109-114.

15. Russell,Letal.,TheCONTOPmultinationalstudy:preliminarydatafromtheUKarm.WoundsUK2005,Vol.1(1):44-54.

16. Scanlon, E. et al., Cost-effective faster wound healing with a sustained silver-releasing foam dressing in delayed healing leg ulcers – a health- economicanalysis.InternationalWoundJournal2005,Vol.2(2):150-160.

17. Ryan,S.etal.,Searchingforevidence-basedmedicineinwoundcare: An introduction. Ostomy/Wound Management 2003, Vol. 49 (11): 67-75.

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Selection of wound care products

Biatain FoamNon-Adhesive

Size Product Code

4" x 4" 3410

4" x 8" 3412

6" x 6" 3413

8" x 8" 3416

2" round 3465

3" round 3467

Biatain FoamAdhesive

Size Product Code

5" x 5" 3420

7" x 7" 3423

4" x 4" 3430

Biatain HeelandSacralFoamAdhesive

Size Product Code

9" x 9" Sacral 3485

71/2" x 8" Heel 3488

Biatain® Dressings

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Contreet Hydrocolloid

Contreet HeelandSacralFoamAdhesive

Contreet FoamAdhesive

Contreet FoamCavity

Contreet FoamNon-Adhesive

Contreet® Dressings

Size Product Code

4" x 4" 9622

6" x 6" 9625

Size Product Code

2" x 3" 9628

Size Product Code

5" x 5" 9632

7" x 7" 9635

Size Product Code

9" x 9" Sacral 9641

71/2" x 8" Heel 9643

Size Product Code

4" x 4" 9610

6" x 6" 9613

“…Evidence-based wound management is the integration of best research evidence with clinical expertise and patient values”(2)

Modified from Sackett, D.L., 2000

The passion of Elise SørensenThe story of Coloplast begins in 1954 when nurse Elise Sørensen invented the world’s first disposable ostomy bag out of compassion for her 32-year-old sister Thora.

Since Coloplast was established in 1957, the spirit of Elise Sørensen has been in the company.

Coloplast is driven by a passion to do things better. Our empathy and ability to respond to patient needs are based on a continuous dialogue with patients and health care professionals.

In Coloplast we are determined to help wound care professionals heal wounds faster – thus improving patients’ everyday life.

Coloplast Corp.Minneapolis, MN 55411800.533.0464usmedweb@coloplast.comwww.us.coloplast.comwww.sweenstore.com

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