Wound Assessment

Wound Management: General Principles The goal of wound management is primarily restoration of function, which requires minimizing risk of infection and repair of injured tissue with a minimum of cosmetic deformity.

Wound Assessment: Time of injury After 3 hours, the bacterial count in a wound increases dramatically. Wounds may be closed primarily up to 18 hours after injury; clean well and use clinical judgment. Wounds up to 24 hours old on the face may be closed after good cleaning. The blood supply in this area is much better and the risk of infection therefore much less. The risk of infection may be reduced in wounds by use of tape closures

Wound Assessment Wounds Requiring Debridement A. Provide Basic General Wound Care I. Assess and treat patient for systemic illness (History, Focused Exam, Vital Signs) II. Assess for diabetes and maintain Hb<7 III. Evaluate nutritional status and correct deficiencies IV. Identify and treat infection V. Upgrade Tetanus (and if indicated rabies) VI. Assess and correct local hypoxia/ischemia VII. Provide appropriate edema reduction measures

Wound Assessment Wounds Requiring Debridement

• VIII. Provide method for off-loading any weight bearing wound site • IX. Educate patient and/or care taker about appropriate wound care • X. Facilitate provision of appropriate off-site wound care • XI. Ensure patient has primary care assignment, and refer to appropriate specialist as indicated

Wound Assessment B. Assess Peri-wound Area 1. Do neurovascular examination 2. Evaluate and document the following findings in the periwound area: • Edema, localized swelling • Erythema, cyanosis, pallor, discoloration • Induration • Tenderness • Temperature-warmth/coolness • Eschar • Necrosis-wet. Dry • Rashes

Wound Assessment C. Assess the Wound Area 1. Evaluate following findings: • Callous, Hypertrophic skin, Maceration, Necrosis, Tracts, fissures, Undermining Invagination/Evagination ,Re-epithelialization 2. Evaluated wound base: • Clot/bleeding ,Granulation tissue, Fibrous tissue,Vital structures (tendon, nerve, muscle, blood vessels, bone, peritoneum, fascial sheaths, joint capsule, cartilage, ect.), Foreign Bodies (glass, suture, clips),Odor,Pus, drainage, discharge, Tunneling, cavities, fistulas

Wound Assessment 3. Measure and Record Wound Size: • Length, Width, Depth, Location of tracts, tunneling, Length and diameter of tracts, Acquire Photographs and Wound Tracings at least weekly

Wound Assessment

Principles of wound management 1. Determine wound aetiology. 2. Identify and where possible eliminate or control factors impairing healing. 3. Determine realistic and achievable long and short term objectives. 4. Regularly monitor responses to management regime and reassess as necessary. 6. Ensure optimal outcome achievement 7. Based on assessment plan wound management regime in collaboration with client; should be individually tailored a/c to the person, health, social, economic, psychological status, and wound characteristics

Healing Impairment: Intrinsic factors • Increasing age, Diabetes, Liver failure, Rheumatoid arthritis, Anaemia, Inflammatory bowel, disease, Autoimmune disorders, Reduced vascularity, NSAIDS/SAIDS, Cytotoxics, radiotherapy, Poor nutrition, Obesity, Reduced sensation, Poor mobility

Healing Impairment: Extrinsic factors

• Moisture (eg incontinence), High bacterial load /Infection, Wound desiccation(dryness), Cooling of wounds below 37oC, Pressure, shear and friction, Foreign bodies

Old dressing: Assessment Assessment of the old wound dressing is often overlooked. The old dressing reveals vital information in: • determining the appropriateness of the dressing products chosen and the wound characteristics. • provide information on the amount, colour and consistency of wound exudate. • If dressings are leaking or adhered to the wound the dressing regime or frequency of dressing changes may need to be altered.

Tools in wound assessment Assess wound at every change of dressing to know expected outcomes • Regular and systematic documentation of wound characteristics . • Wound assessment chart a useful tool to ensure that all wound characteristics are assessed and documented • Photographs are an excellent wound • documentation tool. Photographs may be used in • addition to or in place of an assessment chart and • provides a degree of detail that cannot be obtained by written description or drawings.

Wound Characteristics: Assessment

• Wound size • Tissue types: devitalised or necrotic tissue Necrotic: Black, hardened dead tissue. It may be moist or dry. Sloughy: Yellow, devitalised tissue. Granulating: Red, healthy tissue. Epithelialising: Pink tissue evident as epithelium covers the wound.

Wound Characteristics: Assessment Exudate: Following descriptions used to identify exudate types: Serous: clear fluid, straw coloured Haemoserous: slightly blood stained serous fluid Sanguineous: heavily blood stained or frank blood Purulent: containing pus Odour: Offensive odour indicates presence of high levels of bacteria. Presence of necrotic tissue produces a putrid smell which is the result of anaerobic bacteria.

Wound Characteristics: Assessment Surrounding skin: Assess following: Maceration: Soft, white, moist skin due to exposure to excessive moisture Erythema: Redness which may or may not blanch when pressed. Erythema may indicate infection or pressure. Non blanchable erythema is a heralding sign of tissue destruction. Contact dermatitis: may result from sensitivity to a dressing product, prolonged use of adhesive dressings or or tapes, or prolonged exposure of the skin to wound exudate.

Wound Characteristics: Assessment Callous: Indicates pressure. commonly occurs on the foot. Callous can also mask a wound.