Section 3 - Wound Assessment

Sinus tract

*discharging* blind-ended track that extends from the surface of the skin to an underlying area or abscess cavity (think of volcano)

Pain

*fifth vital sign*

Ecchymosis

*non-blanchable discoloration of variable size may be caused by vascular wall damage, trauma, or vasculitis*

Include in assessment and documentation of skin lesions

*number, size, color, location, sensation, duration, configuration, distribution, morphology*

Induration

*red flag to look for undermining, tunneling, sinus tract or infection*

*Wong-Baker Faces Pain Rating Scale*

*use for non-verbal, cognitively impaired patient, non-English speaking, or children*

Eschar (necrotic tissue)

1. dry, desiccated (no moisture) 2. firm, dry, leather 3. BLACK TO BROWN 4. flush with level of skin 5. as it is moistened, turns to slough

Important sociological factors

1. economic status and resources 2. health care patterns (compliance, hx of non-adherence)

Hypergranulation tissue (tissue types seen in wounds)

1. forms above the surface of the surrounding epithelium 2. delays epithelialization

Presence of slough or eschar indicates

1. full thickness tissue damage 2. slough and eschar are the remnant of the collagen matrix of subcutaneous tissue

Stage 3 pressure ulcer

1. full thickness tissue loss 2. subcutaneous fat may be visible but bone, tendon or muscle is not exposed 3. slough may be present but does not obscure the depth of tissue loss 4. may include undermining and tunneling 5. bone/tendon *is not visible* or directly palpable

Stage 4 pressure ulcer

1. full thickness tissue loss with exposed bone, tendon, or muscle 2. slough or eschar may be present on some parts of the wound bed 3. often include undermining and tunneling 4. can extend into muscle and/or supporting structure 5. exposed bone/tendon *is visible* or directly palpable 6. osteomyelitis possible

Slough (necrotic tissue)

1. hydrated, moist 2. color varies - YELLOW, GRAY, TAN, BROWN 3. soft and thin, fibrinous, stringy, or mucinous

Perform wound assessment by...

1. inspection 2. palpation 3. listening 4. smell

Linear measurements

1. length x width x depth 2. greatest length x greatest width method

*Pressure Ulcer Scale for Healing (PUSH) Tool*

1. monitor pressure ulcer healing over time 2. monitors three parameters: size (length x width), exudate amount, and tissue type

Cons of tracing technique

1. more time and steps required 2. for best results, same person should do it each time

Tissue types seen in wounds

1. necrotic tissue 2. epithelial tissue 3. granulation tissue 4. hypergranulation tissue 5. muscle 6. tendon 7. fascia 8. bone

Necrotic tissue (tissue types seen in wounds)

1. non-viable, dead or dying tissue 2. caused by injury or ischemia 3. either called eschar or slough

Two wound classifications

1. partial thickness 2. full thickness

Stage 2 pressure ulcer

1. partial thickness, loss of dermis presenting as a shallow open ulcer with a RED/PINK wound bed *without slough* 2. *three P's - pink, partial, painful* 3. may also present as an intact or open/ruptured *serum-filled* blister

Pros of tracing technique

1. permanent two-dimensional records 2. length and width can be taken directly from the tracing 3. overlay comparisons can reveal subtle changes in healing

Cons of linear measurement

1. poor descriptor of measurement 2. *does not include peri-wound assessment*

Primary lesions

1. present at initial onset of problem 2. caused directly by the disease process

Mucosal pressure ulcers (MPrU)

1. pressure ulcers found on mucous membranes 2. don't stage 3. don't classify as full or partial thickness

Unstageable pressure ulcer

1. temporary stage 2. full thickness tissue loss in which the base of the ulcer is *covered by slough or eschar* in the wound bed 3. unable to visualize true depth of tissue destruction 4. until enough slough or eschar is removed to expose the base of the wound, the true depth cannot be determined and can't be staged 5. *stable eschar on the heels should not be removed*

High viscosity exudate

1. thick, sticky 2. infection/inflammatory process 3. necrotic material 4. enteric fistula 5. residue from dressing (ie: Duoderm) 6. high protein content

Low viscosity exudate

1. thin, runny 2. low protein content 3. urinary, lymphatic, or joint space fistula

Partial thickness wound

1. tissue destruction *through the epidermis and part of the dermis only* 2. PINK and PAINFUL 3. never any yellow tissue 4. no slough or granulation tissue

Full thickness wound

1. tissue destruction *through the epidermis, dermis and INTO the subcutaneous, possibly extending down to bone or muscle* 2. slough and granulation tissue can be present

Percent of diabetic foot ulcers that occur due to improperly fitting shoes

50%

Scale (secondary lesion)

peeling sheets of scale (ie: cradle cap)

Pros of photography

permanent documentation, relatively easy

Pink/red (significance of exudate color)

presence of RBCs, indicating *capillary damage*

Yellow/brown (significance of exudate color)

presence of wound slough or material from an enteric or urinary fistula

Round, elliptical (shape of wound)

pressure

Loosely adherent tissue

pulls away from wound, but attached to wound base

Jagged edges (shape of wound)

shear or friction

*Episodic pain, cyclic* (cause of pain)

recurrent dressing changes, open to air, medication burning, cleansing pain, turning/repositioning

*Configuration*

refers to the shape or outline of the lesions

Gray/blue (significance of exudate color)

related to the use of silver-containing dressing

Crust (secondary lesion)

result of the drying of plasma or exudate on the skin

*Epibole*

rolled/curled under wound edges

*Annular* (configuration)

round or circular with central clearing

Wound pain assessment - PQRST

P = provokes Q = quality R = radiates S = severity T = time

Sanguinos (type of exudate)

bloody, fresh bleeding (deep partial and full thickness wounds during angiogenesis)

Wound base

bottom of wound

Cons of photography

bulky equipment, cost, make sure the angle, distance and lighting are the same each time or measurements will be inaccurate, risk management concerns

Patch (primary lesion)

change in the color of skin, circular, flat discoloration, larger than 1 cm

Macule (primary lesion)

change in the color of skin, circular, flat discoloration, less than 1 cm (ie: freckle)

Tunneling

channel or pathway extends in any direction from the wound *through subcutaneous tissue or muscle* resulting in dead space (potential abscess formation), causes are shearing and overpacking

Pustule (primary lesion)

circular, collection of leukocytes, free fluid filled, varies in size

Nodule (primary lesion)

circular, elevated, solid, greater than 1cm (ie: cyst)

Bulla (primary lesion)

circular, free fluid filled, greater than 1cm

Vesicle (primary lesion)

circular, free fluid filled, up to 1cm

*Distribution*

clinical arrangement of lesions

*Coagulum*

clot on mucous membrane is soft

*Mixed category pain* (type of pain)

complex mixture of nociceptive and neuropathic factors, may be caused by an acute injury and secondary effects

Fissure (secondary lesion)

crack or split in skin

*Neuropathic pain* (type of pain)

damage or malfunction nerve fibers, "burning" or "electric shock" feeling

*Incidental pain, noncyclic* (cause of pain)

debridement, major trauma

Pressure sore cannot be accurately staged until?

deepest viable tissue layer is visible

*Zosteriform* (configuration)

dermatomal corresponding to nerve root distribution

Firmly adherent tissue

does not pull away from wound base

Fibrotic/firm/hyperkeratotic

dry, tough, scaly appearance

Non-adherent tissue

easily separated from wound base

Pros of linear measurement

easy, inexpensive, most widely used

Tracing technique

two-dimensional outline of the wound

*Continuous pain, chronic* (cause of pain)

underlying cause, infection irritation, disease process

Macerated/soft

too much moisture, WHITE fragile appearance, usually due to *inappropriate topical dressing* or increased wound drainage

Photography

1. *"Picture is worth a thousand words"* 2. must have informed consent from patient 3. *always make sure the angle, distance and lighting are the same each time or measurements will be inaccurate*

Suspected deep tissue injury

1. *PURPLE or MAROON* 2. localized area of discolored *intact skin* or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear 3. area may be preced by tissue that is painful, firm, mushy, *boggy*, *warmer*, or cooler as compared to adjacent tissue

Stage 1 pressure ulcer

1. *intact skin with NON-BLANCHABLE REDNESS* 2. usually over a bony prominence 3. may be painful, firm, soft, warmer or cooler as compared to adjacent tissue

Granulation tissue (tissue types seen in wounds)

1. BEEFY DEP RED, irregular surgace, puffy or mounded bubbly appearance 2. new tissues that replaces the dead tissue in healing wounds 3. grows from the base of a wound

Tendon (tissue types seen in wounds)

1. GLEAMING YELLOW OR WHITE 2. shiny when healthy (if exposed, use Hydrogel to keep moist) 3. attaches muscle to bone

Bone (tissue types seen in wounds)

1. MILKY WHITE, shiny, smooth

Muscle (tissue types seen in wounds)

1. PINK TO DARK RED, firm, striated 2. highly vascularized

Color of wound

1. Red - healthy, good blood flow 2. Pale pink - poor blood flow/ischemia, anemia 3. Purple - engorged, swelling, high levels of bacteria, trauma 4. Black or brown - non-viable, necrotic tissue 5. Yellow - non-viable, necrotic tissue 6. Gray - non-viable, necrotic tissue 7. Green - infection, non-viable tissue (ie: Pseudomonas) 8. White - poor blood flow/ischemia, maceration

Fascia (tissue types seen in wounds)

1. WHITE, shiny, thin to thick 2. covers muscles 3. infections slide/glide along fascial plane

Epithelial tissue (tissue types seen in wounds)

1. compose the outermost layer of skin 2. regenerate across the wound surfacefrom the edges to close the wound 3. DEEP PINK TO PEARLY PINK 4. epithelial islands in superficial wounds 5. epithelial bridging 6. LIGHT PURPLE from edges in full thickness wounds

*Scar*

1. connective tissue reflective of dermal damage 2. new scars are PINK and thick 3. over time become WHITE and atrophic

Attached or unattached wound edges?

Are the edges flush with wound bed or is there a shelf or undermining noted?

Wheal (primary lesion)

firm, edematous plaque, infiltration of dermis, may last a few hours (ie: TB test, mosquito bite)

*Morphology*

form or structure of an individual skin lesion

*Mushy* (sDTI)

having the consistency of mush, soft - yielding readily to pressure or weight

Linear (shape of wound)

trauma or friction

Only difference between eschar and slough

hydration

Wound edges/margin

inside perimeter of a wound, rim of wound

Patients who are at high risk for breakdown

inspect skin daily

Defined or undefined wound edges?

is there a clear differentiation where wound starts and ends

Excoriation (secondary lesion)

linear erosion (caused by scratching)

Exudate/drainage

liquid produced by the body in response to tissue damage (type, color, consistency, amount)

*Nociceptive, acute pain* (type of pain)

localized, contact, noncyclic or cyclic, time limited, originates from tissue damage

Ulcer (secondary lesion)

loss of epidermis and dermis and sometimes underlying subcutaneous tissue

Denuded (secondary lesion)

loss of epidermis, caused by exposure to urine, feces, body fluids, wound exudate or friction (redness on bottoms)

Erosion (secondary lesion)

loss of epidermis, superficial (part or all)

Atropy (secondary lesion)

loss of substance, thinning

Green (significance of exudate color)

may be indicative of bacterial infection (ie: *Pseudomonas aeruginosa*)

Cloudy/milky (significance of exudate color)

may indicate the presence of fibrin strands or infection

Secondary lesions

may result from primary lesions or may be caused by external forces (ie: scratching, trauma, infection and healing process)

Undermining and tunneling (linear measurement)

measure and document *depth* and *direction*

Clear/amber (significance of exudate color)

often considered normal

Plaque (primary lesion)

superficial, elevated, solid, flat topped lesion greater than 1 cm (ie: psoriasis)

Papule (primary lesion)

superficial, solid, less than 1 cm, color varies (ie: pimple, insect bite)

Purulent (type of exudate)

thick, opaque, tan, yellow, green or brown color, *never* normal in a wound

Lichenification (secondary lesion)

thickening of the epidermis seen with exaggeration of normal skin lines (due to chronic rubbing or scratching)

Scar (secondary lesion)

thickening, permanent fibrotic changes, secondary pigment characteristics

Serous (type of exudate)

thin, clear, watery plasma (seen in partial thickness wounds, venous ulcerations)

Serosanguineous (type of exudate)

thin, water, pale red to pink plasma with RBCs

Seropurulent (type of exudate)

thin, watery, cloudy, yellow to tan

Peri-wound

tissue around the outside perimeter of the wound, minimum of 4cm

Undermining

tissue destruction underlying intact skin along the wound margins, wound is larger at its base than at the skin surface, causes are shearing

Irregular shape (shape of wound)

vascular

Wound depth

vertical distance from visible surface to the *deepest* area in wound bed, most *subjective* measurement

Skin assessment frequency

weekly

Boggy (sDTI)

wet, spongy, *soft*

None (amount of exudate)

wound tissue *dry* (ie: scab)

Scant (amount of exudate)

wound tissues *moist, no measurable drainage*

Large/copious (amount of exudate)

wound tissues filled with fluid, involves *greater than 75% of bandage*

Small/minimal (amount of exudate)

wound tissues very moist/wet, *drainage less than 25% of bandage*

Moderate (amount of exudate)

wound tissues went, drainage involves *25-75% bandage*