Wound Assessment And Measurement

Amount of Erythema

Quantified by measuring how far the redness extends from the wound size; Pale skin: decreased blood size, newly formed scar tissue not yet regained new pigment; Blue skin: severe, prolonged ischemia; Hyperpigmentation: long standing venous insufficiency also known as Hemosiderin Staining

ABI

Ankle Brachial Index id the ratio of the systolic pressure in the ankle relative to the systolic pressure in the brachial artery in the arm. 1.0-1.4 normal/ <0.9 LEAD (Lower Extremity Arterial Disease)/ 0.5-0.8 Moderate Ischemia/ <0.4 Severe Ischemia

Wound odor

Assessed after the wound has been derided and rinsed; Described as either present or absent; Never to be used as sole indicator of wound status. (After wound is irrigated as some dressings can have a distinct odor)

Eschar

Black necrotic tissue; either soft or hard (dry or wet). (Eschar is typically soft if there is an underlying infection)

Erythema

Blanchable, Non-blanchable, Indicator of inflammation, If out of proportion to the size and extent of the wound, may indicate infection

Thickness

Chronic wounds tend to have thickened or rolled wound edges. (Callus are called Hyperkeratosis)

Color

Clear: Normal Pale yellow: Normal Red: Fresh blood Dark brown: Dried blood Ble- green: Probable pseudomonas infection ( Pseudomonas are gram negative bacteria- they are resistant to many antibiotics and can survive harsh conditions)

Wound Bed; Necrotic Tissue

Described by color, consistency, and percentage of wound bed it occupies. (The greater the depth, the more adherent the necrotic tissue)

Wound Size

Direct measurement; Wound tracings; Photographic measurements; Volumetric measurements; Total body surface area.

Wound Location

Document: Using anatomically correct terminology; Side and body surface of the lesion; If multiple wounds exist, document anatomical landmarks.

Epithelial appendages

Hair, nail, long standing ischemia will be unable to support hair growth and increases risk of fungal infection, pale and yellow; often seen with Arterial Disease.

Wound Characteristics

Location, size, tunneling/ Undermining, bed, edges, drainage, odor, peri- wound area

Wound Tracings

Materials: clean comfortable transparency, permanent fine- tipped pen;Tracing Sheets: wound contact layer, adhesive outer permanent layer; Improvised: CLEAN, plastic wrap folded in half; SHOULD be labeled with patients name, date, precise wound location, size, and characteristics.

Measuring Tunneling

Measured by inserting a probe into the passageway until resistance is felt; Tunnel depth is distance from the probe tip to the point at which the probe is level with the wound edge

Measuring Undermining

Measured by inserting a probe under the wound edge directly almost parallel the the wound surface until resistance is felt

Volumetric Measurement

Measuring either the amount of molding or saline required to fill the wound void; Provides a more complete illustration of wound size in three dimensions.

Amount

None: desiccated(means dry) wound bed Minimal and Moderate: Normal; however, wounds with drainage that is disproportionate to the amount of necrotic tissue may be infected.

Structure And Quality

Normal age related changes (makes skin fragile, thin, and translucent); Peri-wound hydration (anhydrous dry, scaly, and cracked; too much soft and maturated); Skin turgor (Lift the skin up between thumb and index; note if there is delay for skin to return to normal); Presence and location of any calluses; Scar formation; Presence of any deformity.

Wound Depth

Place a prob in the deepest part of the wound bed; the point the probe is level with the surrounding intact skin; Several depth measurements can be performed at standard wound locations.

Disadvantages for Photograph

Prone to errors; Camera distance and camera angle can influence resulting image size; Inconsistent lighting conditions may make wound assessment problematic; Costly and time-consuming (Use for information but not size).

Distinctness

Some superficial wounds present with indistinct edges; wound gradually transitions into intact skin; The deeper wounds have more distinct and well defined edges.

Photographic Measurement

Surface area determined by tracing photographic image; Advantages in comparison to wound tracing: Avoids contact with wounds, provides additional information about peri-wound and wound bed characteristics; Should include: Pt's name, date, precise wound location, measurement guide, results of direct wound measurement.

Wound Bed; Granulation Tissue

Temporary scaffolding of vascularized connective tissue that fills the wound void; Beefy red appearance indicating healthy granulation tissue and oxygen- rich capillaries; Pale or dusky

Consistency

Thin, watery: Normal Thick, creamery: possible infection

Disadvantages to Volumetric

Time consuming and painful for the patient (Molding); Inaccurate and problematic (Saline); Cannot be used on wounds that extend into body cavities/ fascial planes.

Wound Edges

Tissues at the perimeter of the wound; Characteristics: distinctness, thickness, epithelialization/ pigmentation (quality, color, pain, maceration, callus, rolled

Tunneling/ Undermining

Undermining: Occurs when the tissues under the wound edges become eroded, resulting in a large wound with a small opening. Tunneling/ Sinus Tracts: A channel that extends in any direction away from the wound bed. Can cross through fascia, muscle, and other underlying tissues. (tunneling can go to bone and if so Osteomyelitis may happen.

Size; Direct Measurement

Using the clock method: 12 o'clock head, 6 o'clock feet; On feet, 12 o'clock heel, 6 o'clock toes; Measure the longest length and the widest width perpendicular to the length; measuring in cm; Surface area= Length times Width (cm squared) (size is a major indicator of wound status, NEVER estimate the size of a wound).

Slough

Yellow or tan in color and has stringy or mutinous consistency.