wound Assessment
clock measurement
12:00-6:00 12:00 points to head and 6:00 to feet 3:00-9:00 is the width side to side. Measure the longest measurements
Wound assessment includes
A collection of data that characterizes the status of a wound and surrounding periwound skin.
Sinus Tract in wounds
A discharging blind-ended track that extends from the surface of the skin to an underlying area or abscess cavity.
Distribution/Arrangement Symmetric
pattern Being equal or the same in size, shape, and relative position
Pale pink in wounds indicates
poor blood flow anemia
Loosely adherent
pulls away from wound, but attached to wound base
Gray/blue
related to use of silver dressings
Epibole
rolled wound edges
Circinate
rounded in outline : characterized by or having the form of a flat coil of which the apex is the center. Partial circle
Distribution/Arrangement of lesion (confluent is?)
smaller into larger skin lesions that run together
Chronic diagnosis that contributed to wound healing
cardiovascular- CAD decreased circulating 02 Cardiac: Congestive heart failure- edema in lower extremities Peripheral Vascular disease-Inadequate vascular support Peripheral Arterial disease-Inadequate arterial support Respiratory: Pneumonia-Decreased 02 overall stress on body COPD- Decreased circulating 02. Exposure to shear/friction due to HOB elevation. Asthma- Steroid medication-impairs inflammatory phase of wound healing, slows healing Diabetes-abnormal glucose/ decrease sensation Cancer-radiation/chemo
Annular
circular shape to skin lesion with central clearing
Scar
connective tissue that fills a wound area Reflective of dermal damage.
amorphous
(adj.) shapeless, without definite form; of no particular type or character; without organization, unity, or cohesion
Crepitus
Accumulation of air or gas in tissues (Rice Krispies) feeling in the skin surrounding the wound. From gas bubbles from the bacteria fermenting carbs into carbon dioxide. Grating sound or sensation produced by friction between bone and cartilage or the fractured parts of a bone.
Distribution/Arrangement cleavage plane
Arranged along lines of skin tension.
fecal incontinence
Assess to determine the cause whether it is temporary, related to a problem or chronic. Determine the type: passive- person is unaware Urge-Inability to retain stool Seepage-after BM or around blockage Treatment: Medications, Bowel training regimen, moister barriers, diapers, modify diet, ensure adequate fluid intake and fecal pouches.
Sanquinous Exudate
Bloody (fresh bleeding). Seen in deep partial or full thickness wounds during angiogenesis. Small amount normal in the acute inflammatory phase.
Wound Edges/Margins- Types
Can be defined or undefined- Is there a clear differentiation where wound starts and ends.
Tunneling
Channel or pathway extends in any direction from the wound through subcutaneous tissue or muscle, resulting in dead space with potential for abscess formation. Measure and document depth and direction.
gyrate
Connecting Arcs to rotate or revolve quickly; to spiral
Firmly adherent
Does not pull away from base
Exudate?
Drainage is a liquid produced by the body in response to tissue damage. Healing wounds should be moist without measurable drainage.
Eschar
Dry, desiccated, no moisture necrotic tissue. Firm dry leathery, black at brown and flush with the level of the skin. (scab)
Fibrotic/Firm/Hyper-keratotic
Dry, tough, scaly appearance
non adherent
Easily separated from the wound base
Purple in wound beds indicates
Engorged swelling high levels of bacteria, trauma
Hyperemia
Extra blood in vessels in response to a period of blocked blood flow.
Morphology
Form or structure of an individual skin lesion
Purpose of wound assessment
Foundation for care plan Assists in determining the cause of the wound Essential for tracking progress or deterioration Most important skill of a wound expert.
Hypergranulation tissue
Granulation tissue forms above the surface of the surrounding epithelium. It delays epithelialization.
Brawy edema
Hardened, fibrotic, non-pitting edema, may be dusky in color.
Thick sometimes sticky (high viscosity) indicates?
High protein content due to infection or inflammatory process.
presence of sough and eschar?
Indicates full thickness tissue damage. They are the remnant of the collagen matrix of subcutaneous tissue.
Slough
Is hydrated moist necrotic tissue. Color varies. It is soft and thin, Fibrinous, stringy or mucinous.
Thin runny (low viscosity) indicates?
Low protein content due to venous or congestive cardiac disease or malnutrition.
linear measurement
LxWxD edge to edge straight line and the longest area. 1 cm has 10 mm, 1mm is = 0.1 cm
Yellow/Brown exudate
May be due to the presence of wound slough or material from an enteric or urinary fistula.
Green
May be indicative of a bacterial infection. (Pseudomonas aeruginosa)
Serpinginous lesions
Meandering/wandering following the track of a snake
Fluctuance
Moveable, compressible palpable fluid filled cavity (wave like motion.) Palpable fluid beneath the skin indicative of infection/pus
granulation tissue
New tissue that replaces dead tissue in healing wounds. Beefy red, irregular surface, puffy or mounded bubbly appearance.
Distribution/Arrangement assymetric
No pattern two halves are not equal
Ecchymosis
Non-blachable disoloration of variable size caused by vascular wall damage, trauma or vasculitis. (bruise)
Lesions- assessment
Number, size, color, location, sensation, duration, configuration, distribution and morphology
White color in wounds indicates
Poor blood flow, maceration, may be confused with bone or fascia. Cloudy milky white may indicate the presence of fibrin strands a response to inflammation or infection
Induaration
Process of the skin becoming hard. A hardened mass with defined edges. Red flag look for undermining, tunneling sinus tract or infection.
Shape of the wound is important for determining etiology and aggravating factors.
Round/elliptical= pressure Jagged edges= shear/friction Irregular shape= Irregular shape= vascular Linear= trauma or friction
Amounts of exudate
Scant- wound tissues moist , no measurable drainage.
Types of exudate (drainage)
Serous- Thin watery plasma. Moderate to heavy may indicate heavy bio-burden or chronicity due to sub clinical infection. (normal in the acute inflammatory phase)
Marginal
Sharp ill defined. in, at, or near the edge or margin; only barely good or important enough for the purpose
Peri wound tissue
Should be assessed within a minimum of 4 cm of wound edge.
Linear
Straight line
Parts of a wound
The Wound -Considered the open area only, diameter from edge to edge. Wound base -The bottom of the wound Wound depth -Deepest area in the wound bed. Verticle distance from the visible surface to the deepest area in the wound bed. Periwound -Tissue around the perimeter of the wound tunneling: -Channel or pathway that extends from the wound through subcutaneous tissue or muscle resulting in dead space with potential for abscess formation -Chances of bacteria, other things in there -Wound edges or wound margin The inside perimeter of a wound the rim.
purulent exudate
Thick, opaque, tan, yellow, green or brown color, never normal in wounds. Pus: indicates infection exp: cyst or access
Lipodermatosclerosis
Thickening and hardening of the skin and can be found in patients with chronic venous insufficiency.
Serosanguieous
Thin watery, pale red to pink (plasma with RBC's)
Infants skin is?
Thinner than adults, the dermis layer is only 60% of that of an adult and continues to develop after birth
Full thickness
Tissue damage involving total loss of epidermis and dermis and extending into the subcutaneous tissue and possibly into muscle or bone May be acute or chronic and heal by primary or secondary intention Exp: 3rd degree burn Bleeding and hemostasis do not occur with healing by secondary intention compromising the healing process.
Undermining
Tissue destruction underlying intact skin along the wound margins. Destruction of tissue or ulceration extending under the skin edges (margins) Wound is larger at its base then at skin surface. Erosion of tissue from underneath intact skin at wound edge Measure depth and direction starting at 12:00 o'clock
What is the purpose of measuring wounds?
To track and measure progression of healing from week to week. ( consistency is key) Start in the center of the wound and assess outward.
Tunneling vs undermining?
Tunneling involves a small portion of the wound edge whereas undermining involves a significant portion of the wound edge both are caused by shearing. Sagging wounds usually have undermining.
Distribution/Arrangement.
Unconnected; seperate; distinct. Linear (in a line), satellites (small lesions around a larger one) and diffuse scattered freely over an area. Should be clearly delineated. If there is more than one lesion over an area can be helpful in diagnosis and tx.
Frequency of wound assessment
Upon each dressing change/patient visit, and documented weekly at minimum.
Satellite lesions
Usually occurs w/ yeast infection; fungal infection; main lesion sends out "spores" to start a new lesion elsewhere
epithelial tissue
When wounds heal epithelial cells (tissue)regenerates across the wound Tissue that covers outside of the body. Deep pink to pearly pink. Light purple from edges in full thickness wounds. May form Islands
Causes of chronic wounds
Wound nature- related to underlying pathology (arterial insufficiency, rather than acute. Lack of bleeding may impair fibrin production and release of growth factors. Difference in healing- Initial inflammatory phase is often prolonged due to vascular insufficiency, necrosis and bacteria. There are Insufficient growth factors necessary to repair tissue, insufficient numbers because they break down quickly cellular senescence ( inability of cells to proliferate or respond to growth factor.) Host factors- Many factors such as malnutrition and smoking interfere with healing Denervation- Lack of adequate innervation
Large/copious exudate
Wound tissue is filled with fluid-Involves greater than 75%of bandage
Small/Minimal exudate
Wound tissue is very wet/moist, drainage is less of 25% bandage.
Moderate exudate
Wound tissues are wet, drainage involve 25-75% of bandage.
wound classification
Wounds are classified based on depth of tissue destruction and according to the cause Vascular change: Most common in lower extremity arterial insufficiency, ischemia, change in lymphatic system and venous insufficiency Neuropathic: occur with chronic disease diabetes and chronic alcoholism shear/friction especially over a boney prominence. Trauma: often result in contaminated wounds Surgery: Inflammation and infection:deteriorating wounds and fistulas Self inflicted: minor cuts to traumatic gun shots Hypergranulation/keloid formation: change character of wound and prevent healing.
Sinus tract
a tract between two epithelium-lined surfaces that is open at one end only
Color changes in peri wound
angry bright red- infection pink-may reflect inflammation or high bacteria level blue or pallor-poor blood flow white-moisture black- tissue death brown staining- on legs indicate venous insufficiency. Purple-trauma
Morphology
form or structure of an individual skin leasion
During adolescence
hair follicles activate and thickness of the dermis decreased about 20% this slows healing.
Iris or target
lesions that resemble iris of eye, concentric rings of lesions. Have a dark or blistered center. Bulls eye. Seen in Lymes disease
Zosterform
linear arrangement along a nerve route (herpes zoster)
Seropurulent
thin, watery, cloudy and yellow to tan in color
Partial thickness
tissue destruction through the epidermis and part of dermis (pink and painful) never any yellow tissue 2nd degree burn
Colors of non viable tissue
yellow, gray, green and black brown