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HK ENTERSTOMALTHERAPIST ASSOCIATION

CONTEMPORARY WOUND COURSE 2013

WOUND ASSESSMENT & DOCUMENTATION

APN Lam Ming ChuNTEC FM & GOPC

26th Jan 2013

Wound care management

•Not only treat the wound, treat

the patient as a whole.

Phases of Wound Healing

� The entire wound healing process is a complex series of events that begins at the moment of injury and can

continue for months to years.

� Usually follow well-defined process

• Inflammation (3 - 4 days)

• Proliferation (2 days – 3 weeks)

• Remodeling (3 weeks to 1 year)

Factors that impede healing

�Systemic factor

�Systemic diseases(e.g. diabetic, cardiac, renal and

respiratory)

�Insufficient oxygen & perfusion

�Malnutrition

�Medication (corticosteroids, chemotherapy,

immunosuppressant)

�Age

�Local factors:

�Infection

�Foreign body

�Pressure

Wound assessment

• Purpose

• Examine the severity of the wound

• Determine the status of wound healing

• Establish a baseline for the wound

• Assess and plan the wound management

• Facilitate the continuity of care

General Assessment

�Age / sex

�Physical including: level of mobility, degree of dependence, nutritional status, the presence or absence of concurrent illness, medication, treatment

(RT / chemotherapy)

�Social background: martial stage, family support,

financial support

�Education level: illiterate / primary/ secondary / tertiary

�Personal habit: Smoking, drinking, soft drug abuser

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General Assessment

�Systemic disease processes / medication / treatment that adversely affect metabolism, perfusion and are

likely to delay wound healing.

�Psychological status.

�Healing is dependent on the delivery of adequate supplies of nutrients and oxygen to the injured area

for cell metabolism and effective waste product removal.

�Investigation: e.g. blood test / ABI

General Assessment

• Skin assessment

• All patients require a routine and systemic skin

assessment, which includes daily evaluation of the integrity, temperature, texture and presence of lesion on

the skin.

Wound Assessment

• Etiology / type of skin damage

• Duration of wound

• Wound condition

Wound Classification System

• Classification by depth of tissue injury

• Classification of Burn Depth

• Pressure ulcer staging system (National Pressure Ulcer Advisory Panel)

• Wagner staging for grading severity of dysvascular ulcer

Classification of tissue injuryThickness of skin

loss

Definition Clinical example /

healing process

Superficial wound epidermis Sunburn, stage 1 pressure

sore / heal by inflammation

Partial-thickness skin loss Extends through the epidermis

but not through the dermis

Skin tear, abrasion, tape

damage, blister / heal by

epithelialization

Full-thickness skin loss Epidermis, dermis and

subcutaneous fat and deeper

structure

Donor sites, venous ulcer,

surgical wound / heal by

granulation tissue formation

and contraction

Subcutaneous tissue

wound

Extend into or beyond

subcutaneous

Surgical wound, arterial

wound / heal by granulation

tissue formational and

contraction

Classification Burn Depth

Thickness of skin

involved

Definition Clinical example

Superficial

(1st degree burn)

epidermis Sunburn

Partial-thickness

(2nd degree burn)- i) Superficial- ii) Deep

i) Involve epidermis

and upper layers of dermis

ii) Destruction of

epidermis and most of dermis

i) Blister

ii) Blister but most appear slightly moist to dry and are dark

red to pale in color

Full-thickness

(3rd degree burn)

Destroy all layer of the

skin

Dry and leathery and

firm

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Pressure ulcer staging system (NPUAP 2007)

Suspected deep tissues injury Purple or maroon localized area of discolor

intact skin or blood. Filled-blister due to

damage of underlying soft tissue from

pressure and or shear.

Stage Ⅰ Non-blanchable redness of intact skin

over bony prominence

Stage Ⅱ Partial thickness loss of dermis

presenting s a shallow open ulcer with red pink wound bed, without slough

Pressure sore – Staging system

StageⅢ Subcutaneous tissue / fat exposed (slough

/ undermining / tunneling but not obscure

the depth of tissue loss)

StageⅣ Full thickness tissue loss with exposed

bone / tendon / muscle / fascia

Unstageable Full thickness skin loss, the base is

cover by slough / eschar

DM foot ulcer – Wagner grading system

Grade 0 Intact skin, may have body deformity.

Grade 1 Superficial skin loss, not involving subcutaneous

tissue.

Grade 2 Full thickness skin loss, involving subcutaneous

tissue, may expose bone, tendon and joint.

Grade 3 Presence of deep ulcer with abscess, osteomyelitis

or joint abscess.

Grade 4 Gangrene localized to the forefoot or heel.

Grade 5 Extensive gangrene

Wound Assessment

�Wound Type

�Site

�Size

�Wound bed (tissue status)

�Exudate

�Periwound skin

�Odor

�Pain

Wound Type

�Wound type

�Arterial ulcer

�Burn / scald

�Cancerous

�Diabetic foot ulcer (Neuropathic)

�Skin tear

�Surgical

�Pressure ulcer

�Traumatic

�Venous leg ulcer

�Fistula

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Wound location

• Description: head, face, chest, abdominal, sacral, lower limbs, upper limbs

• Body chart

Wound Size

�Two-dimensional measurement techniques

�Wound photography

�Wound tracings

�Linear measurement – paper or plastic ruler (does not acknowledge wound depth)

Wound SizeThree –dimensional measurement

• Length x Width x Depth

• Length = from head to toe

• Width = cross section

• Depth = deepest

w

L

Undermining

Pt’s head

Pt’s toes

DHead

4.5x4.2 x 1 cm and

undermining4cm deepest at 5 o’clock

Tissue Status

�Classification of tissue injury

�Pressure Ulcer Staging system (National Pressure Ulcer Advisory Panel 2007)

�Wagner grading system for Diabetic foot ulcer

�Wound base tissue

Wound Base Tissue

Wound base Description Color %

Granulating tissue - Inflammation /

proliferative phase- Pale pink to beefy red

25%

50%75%100%

Slough - Non-viable tissue,

yellowish- Loose / hard

Necrotic tissue - Dead tissue

- Dry eschar

Exudate

• Color & texture:

• serous / haemoserous / purulent (pus) /greenish

• abnormal drainage e.g. bile, urine, fecal matter, ascites

etc.

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Exudate�Amount depend on wound status and dressing used:

Description Amount

Minimal 5 ml / 24hrs(inner dressing soaked through < 2 cm)

Moderate 5 – 10 ml ml/24hrs (inner dressing soaked through > 2 cm not to outer dressing)

Excessive >10 ml / 24hrs(inner dressing soaked through >2 cm and

also to outer dressing)

Periwound skin

Intact

Erythema

Maceration

Periwound skin

Edema

Hyperpigmentation

Scaling

Cellulites

Odor

• Foul smell e.g. infected wound / fungated wound

• Some occlusive dressing may have a smell on removal & disappear when dressing discard

Pain

• Visual Analogue Scale (VAS)

• Descriptive pain intensity scale

No pain Mild pain moderate pain Severe Pain

Wound documentation

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Documentation

�Past history / allergy history:

�Social background:

�Occupation:

�Education level:

�Smoker / non-smoker / drinker / non-drinker

�ADL: dependent / partial dependent / dependent

�Mobility: walked unaided / with stick/ frame/ one assistance

�Wound occurred:

�Wound type : Surgical / Burn & scald / Skin tear / Traumatic

/ Leg ulcer / Pressure sore / Cancerous / Other: Dog

bite

�Investigation: e.g. blood test, ABI

Documentation

�Wound condition

�Site:

�Size : (L) x (W) x (D) cm

�Exudate : minimal / moderate / excessive

�Wound bed : pink / red / yellow / black (%)

�Periwound skin : intact / maceration / erythema /

hyperpigmentation / hypo pigmentation / oedema / scaling

/ cellulites

�Odor : nil / mild / offense

�Pain (VAS) :

Treatment

�Cleansing lotion : NS / Hibitane / Betadine

�Primary dressing : Medipore / Jelonet / melolin/ Mesalt/ Hydrocolloid / Foam / Alginate

�Secondary dressing : gauze / combine

�Outer dressing : bandage / surgifix

�Frequency of dressing : QD / Alt day / Q 2-3 days / Q 3-4 days / Q 1W

Treatment

�Other:

�Wound care

�Diet advices : high protein / vit C / low purine / low

salt / fluid restriction, DM diet with even CHO distribution

�Skin care : apply moisturizer / emollient daily

�Minimize edema by elevating the legs / put on

tubigrip

�Improve venous return by putting on pressure garment / calf cuff exercise

Documentation

�Past history / allergy history:

�DM, HT, End stage renal failure on HD three days/ week

�No allergy history

�Social background : lived with wife with good family support

�Financial support : Pension self

�Occupation : retired GS

�Education level : F.3

�Non-somker / non-drinker

�ADL: independent

�Mobility: walk unaided

�Investigation: HbA1c 8% on 31/12/12, afrebrile

Documentation

�Wound occurred :scald by hot pack few days ago and treated by A/B

�Wound type : scald

�Site: left heel

�Size : 7x5.3cm

�Exudate : moderate

�Wound bed : 100% necrotic

�Periwound skin : maceration and erythema and edema

�Odor : mild

�Pain (VAS) : 5, treatment: oral analgesic

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Treatment

�Cleansing lotion: NS

�Primary dressing: Bactigras (antimicrobial agent)

�Secondary dressing : gauze

�Outer dressing: bandage

�Frequency of dressing : QD

�Other:

�Wound condition and care plan explained, Mr. X and his wife

showed understand

�Elevated the heel by pillow and avoid pressure

�Nutrition: DM diet with even CHO distribution

�Skin care educated

Follow up documentation

�Push Tool 3.0

�Other wound assessment form

�puBWAT

Reference� Baranoski, S & Ayrllo, EA (2008). Wound Care Essentials Practice Principles 2nd ed., Lippincott,

U.S.A.

� Barnard, AR & Allison, K (2009). The classification and principles of management of wounds in

trauma. Trauma. 11: 163-176

� Benhow, M (2007). Patient assessment and wounds. Journal of Community Nursing. Sutton,

Vol. 21, lss. 7, p.18.20.22 (3 pp.)

� Murphy F (2006). Assessment and management of patients with surgical cavity wounds.

Nursing Standard. Vol 20, lss. 45, p57-8, 60, 62.

� Push Tool Version 3.0 : 9/15/98, National Pressure Ulcer Advisory Panel.

� Saunders, K. & Rowley, J. (2006). Implementing a wound assessment and management system. Australia Nursing Journal : May, 13, 10: 31-33

� Sussman. C & Jensen, B.B., (2007). Wound Care – A Collaborative Practice Manual for Health Professional , 3rd ed., Chap 1 – 5, Lippincott, U.S.A.

� White R (2008) Delayed wound healing: in whom, what, when and why?

Primary Health Care, 18, 2, 40-46.

� Wiebelhaus, P. & Hansen, SL. (2001). Nursing management: July; 32, 7, 31-35.