Week 3 | Wound Assessment (17171-SP)

Photo of wound on a foot.

Content Outline

  • Patient Assessment  
    • Onset and duration of wound 
    • Treatment History 
    • Co-morbid conditions; past medical and surgical history 
    • Factors affecting healing 
    • Pertinent family history 
    • Current medications, allergies 
    • Recent lab values/culture results 
    • Nutritional and hydration status 
    • Functional status 
    • Incontinence 
    • Psychosocial issues
    • Knowledge base ​
  • Focused Wound Assessment  
    • Anatomic Location 
    • Wound Measurement (in cm.)
      • Length
      • Width
      • Depth
      • Surface area
      • Wound shape
    • Wound Classification

a. Partial thickness/Full thickness

Partial thickness: Confined to the skin layers; skin damage that does not penetrate below the dermis and may be limited to the epidermal layers only. 
 
Full Thickness: Tissue damage involving total loss of the epidermis and dermis extending into the subcutaneous tissue and possibly into muscle or bone.
 
b. Staging System for Pressure Injuries
 
c. Classification systems for specific types of wounds
  • Wound Base (% tissue type, color, consistency, adherence) 

​a. Viable tissue (%): granulation, clean, non-granulating, epithelial.

  • Granulation tissue: Pink/red, moist tissue composed of new blood vessels, connective tissue, fibroblasts, and inflammatory cells, which fills an open full-thickness wound when it starts to heal. Typically, appears deep pink to red with an irregular, “berry-like” surface. 
  • Clean, nongranulating: Absence of granulation tissue; wound surface appears smooth and red as opposed to cobblestone or berry-like.  
  • Epithelialization: Regeneration of the epidermis across a wound surface. Pink, fragile-looking layer of new cells, may appear as islands.

b. Non-viable tissue (%): eschar, slough = full thickness damage

  • Slough: Soft moist avascular (devitalized) tissue; may be white, yellow, tan, or gray, may be loose or firmly adherent.  
  • Eschar: Black or brown necrotic, devitalized tissue; tissue can be loose or firmly adherent, hard or soft, dry or wet.

c. Tissue quality  

  • Wound Edges/Margins (degree of attachment to the wound base, distinctness, thickness). Record location using the face of a clock and extent in cm.  
    • Undermining: Tissue destruction extending under intact skin along the periphery of a wound; commonly seen in shear injuries. 
    • Tunneling: Course or path of tissue destruction occurring in any direction from the wound surface or edge of the wound; results in dead space. 
    • Non-proliferative wound edges/Epibole: Edges of top layers of epidermis have rolled down to cover the lower edge of epidermis, including basement membrane, so epithelial cells cannot migrate from wound edges. Presents clinically as a sealed edge of mature epithelium. Wound edge may present clinically as hard/thickened and/or discolored ( e.g.yellowish, gray, white). Also known as closed wound edges. 
  • Presence and Character of Exudate  
    • Color
    • Odor 
    • Consistency 
    • Volume: Wound dry-no exudate, Moist wound- small, Wet/saturated- moderate, Saturated, wound bathing in fluid- large. 
  • Presence or absence of symptoms of infection
    • Local signs 
      • Erythema 
      • Increased amount and/or change in character of exudate
      • Odor 
      • Increased local warmth
      • Edema or induration
      • Pain or tenderness
    • Systemic signs
      • Fever
      • Chills
      • Leukocytosis
      • Elevated glucose in patient with diabetes
      • Pain in a neuropathic extremity
    • Criteria for Critical Colonization and Infection
      • Critical Colonization: NERDS 
      • Deep tissue infection: STONES
  • Condition of the periwound skin 
    • ​Erythema 
    • Induration: Firmness to palpation 
    • Maceration: Tissue bathed in fluid, need to focus on exudate management 
    • Pigmentation 
    • Edema 
    • Hyperkeratic rim/callus
  • Pain assessment (at rest and during dressing changes)
  • Mnemonic:

    Little--Location
    Snails--Size
    Can--Classification
    Be--Base
    Eaten---Edges
    Easily---Exudate
    If---Infection 
    Prepared--Periwound
    Properly--Pain

Key elements of wound management documentation

  • Reason for consultation
  • Brief medical history
  • Wound history
  • ​Factors impacting healing
    • Tissue perfusion and oxygenation

    • Poor nutritional status

    • Infection

    • Diabetes

    • Medications: Corticosteroids

    • Age

    • Stress

    • Immunosuppression

  • Focused wound assessment
  • Short and Long Term Goals
  • Treatment recommendations 
  • Plan for follow-up

Case Studies

Summary

Objectives for Learning Outcomes

At the end of this course work the learner will be able to:

  1. Identify the essential elements of a focused wound assessment.
  2. Describe the types of tissue that may be visualized in the wound.
  3. Describe a structured approach for wound management that begins with a comprehensive assessment.

Additional Information

Format: 
Video
Course summary
Available: 
06/27/2017
Expires: 
10/17/2018

Renee Anderson, MSN, RN, CWON
Certified Wound and Ostomy Care Nurse; Co‐Director, Wound Management Education Program, University of Washington School of Nursing , Seattle; Clinical Faculty, Biobehavioral Nursing & Health Systems University of Washington School of Nursing; President, Rainier Clinical Consultants, Inc., Seattle, WA

 

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