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