Wound Assessment PDF

( Section 1 for skin disease ) wounds assessment  Wound assessment Cause: determine etiology Local wound characteristics: 1-Location 2-Size (length x width x depth) 3- Wound bed 4- Exudate (copious, moderate, mild, none) 5-Wound edge 6-Odor (absent, present) 7-pain (pe...

( Section 1 for skin disease ) wounds assessment  Wound assessment Cause: determine etiology Local wound characteristics: 1-Location 2-Size (length x width x depth) 3- Wound bed 4- Exudate (copious, moderate, mild, none) 5-Wound edge 6-Odor (absent, present) 7-pain (persistent, temporary ) 8-Condition of surrounding skin (peri wound area) 9-Clinical signs of infection 10-circulation to wound  1-Wound LOCATION Pressure: sacrum, heels, trochanter Venous: Inside the leg -Medial Arterial: Lateral of ankle and foot Diabetic: neuropathic areas Traumatic: anywhere  2-Wound SIZE (length x width x depth) wounds planimetry 1-Length x Width = wound surface area (cm2 ) 2-Depth 1-Techniques of wound surface area 1- simple ruler method (perpendicular method ) 2- planimetric methods: (a) manual (acetate tracing) (b) electronic (digital planimetry). 3- Digital imaging method (photographing)  Tracing wound Direct measurement 1-Simple ruler method:(perpendicular method ) The simple ruler method consists of multiplying the greatest length and width of the wound to determine the surface area. It is a low-cost method and easy to use. 2- planimetric methods (a) Manual tracing Method (acetate tracing ): In the manual method, a transparent film is placed on top of the wound and the margin of the wound is traced with a pen. The tracing is subsequently placed on a metric grid and wound area is determined by counting the number of squares in the grid covered by the traced area Takes curvature of the anatomy into account uncomfortable, increased risk of infection (b) Digital planimetry (electronic method) In digital planimetry, the margin of the wound is retraced onto a tablet computer that performs the same calculations. 3- Digital imaging: Step 1: Undress the wound. Step 2: Thoroughly cleanse the wound. Step 3: Photograph using the proper technique. Step 4: Upload the photograph and measure the wound area  2-Assessment of Wound Depth and Volume 1- Assessment of wound depth by using cotton tip applicator (swap measure technique) 2-Assessment of Wound Volume by Using Saline (Syringe method) 3-clock method 2- depth of wound (dead space types ) A- Tunneling A narrow opening or passage-way that can extend in any direction through soft tissue and result of abscess formation similar to sinus tract. measurement: By a sterile cotton tipped applicator into the tunnel Grasp the applicator at the margin Hold to ruler and measure using the Clock Method  B- Undermining Hidden shelf beneath wound margin , not visible from surface of skin May extend in one or many directions underneath the wound edge(s). measurement: Check for undermining at each "hour" of the clock Insert a sterile cotton tipped applicator into the undermining depth Use ranges for undermining areas using the face of the clock (ie. Undermining 1.5c.m from 12:00 to 3:00 and 2 c.m from 3:00 to 6:00 ) Undermining Wounds Undermining is caused by erosion under the wound edges, resulting in a large wound with a small opening what you see on the surface is not indicative of what lies below. Undermining is measured directly under the wound edge with a probe held almost parallel to the wound surface, stopping when resistance is felt. The distance from the probe tip to the point at which the probe is level with the wound edge represents the amount of undermining present. Undermining generally includes a wider area of tissue than tunneling. Tunneling generally occurs in one direction, whereas undermining may occur in one or more directions. Undermining occurs most often in patient with pressure wounds or neuropathic ulcers Clock terms can also be used to describe the location of undermining.  3- Wound BED 1-Viable Tissues (Granulation tissues, Epithelial tissues) 2-Non viable tissues (Necrotic, Slough ) 1-Viable Tissues A- granulation : Granulating tissue appears red (strawberry jam in color and appearance) B-Epithelial Tissue Epithelializing tissue appears pink or blue/mauve in color. This tissue should be kept warm (body temperature) and moist It is formed in the final stage of healing.  B: Nonviable tissues 1- slough : Slough is Yellow or white , soft tissue that adheres to the wound bed and composed of pus and bacteria or infection. 2- necrotic (eschar): a layer of dead tissue which can be brown or black in colour and is caused by inadequate blood  4-Wound EDGES A-Maceration Softening and breaking down of wound edge resulting from prolonged exposure to moisture and wound exudate, Frequently appears white. B-Dehydration low moisture impairing cellular development and migration needed for new tissue growth. c-Rolled edges Wound edge rolls downward and there is a premature closure of wound Epithelial tissue migrating down sides of the wound instead of across. Can present in wounds with inflammatory origin, and can result in poor healing outcomes if not addressed appropriately D-Undermining The destruction of tissue or ulceration extending under the wound edge so that the ulcer is larger at its base than at the skin surface  5-Wound DRAINAGE Type color consistency interpretation serous Clear , thin watery normal sanguineous Red , dark brown Slightly thickened normal serosanguinous Pink to light red watery normal purulent Yellow , green, brown Viscous , creamy infected Haemopurulent Reddish, milky Viscous infected pseudomonas Blue , black Viscous infected  6- Wound Oder 1-No odour 2-Slight malodour: 3-Moderate malodour 4-Strong malodour: 7- Peri-wound Skin Damaged or unhealthy periwound skin is a significant problem in chronic wounds The per wound area has been defined as the area of skin extending to 4cm beyond the wound edge.  Peri-wound Skin tissue examination 1-Callus ( hyperkeratosis) The presence of excessive stresses on epidermis may cause an increase in keratin production, leading to areas of skin that may be rough, thick, and yellow in color. Calluses tend to occur over bony prominences exposed to repeated pressure 2-Unbleachable erythema (pressure ulcer) 3-Excoriation abrasion of the superficial layers of the skin or linear erosion caused by itching due to contact with topical irritants, presence of pathogenic microorganisms, or removal of adherent dressings 4-Maceration 5-Edema  6- Peri-wound Skin Callus Excoriation  8-Signs of infected wound: pain swelling heat redness wound drainage or pus odor fever  9-Monofilament Testing for sensation Neuropathy Screening The test procedure is as follows: Use the monofilament to test sensation. Have patient close his or her eyes. Apply the filament perpendicular to the skin’s surface for approximately 2 seconds in duration. Using the monofilament , randomly test 10 sites on each foot Ask the patient to respond, “Yes,” when he or she feels the filament. Repeat the test up to 3 times on an area when the client does not indicate they feel the monofilament Record the number of positive results out of the number of sites tested, e.g. 6 / 10 indicates that the client felt the monofilament in six areas and only ten areas were tested Be aware that neuropathy usually starts in the first and third toes, It is likely that these areas will be the first to have negative results  10-Assessment circulation to wound Ankle/brachial index (ABI) Assessment of peripheral perfusion via ankle/brachial index (ABI) Patient supine and rest for about 10 to 30 minutes before the test starts. Check the blood pressure of the brachial artery in one of arms. Check the blood pressure in dorsalis pedis or posterior tibial artery in ankle area on the same side as the arm they just measured. Calculate ankle-brachial index by dividing higher systolic (top number) ankle blood pressure by higher systolic arm blood pressure.  Ankle brachial index with indication ABI ranges possible indication more than 1.2 falsely elevated.arterial disease , diabetes 1.19-0.95 Normal 0.94-0.75 mild arterial disease+ intermittent claudication 0.74-0.50 moderate arterial disease + rest pain less than 0.50 sever arterial disease Types of ulcer  chronic ulcers skin ulcer is an open wound that develops on the skin as a result of injury, poor circulation, or pressure.  1-Venous skin ulcers shallow, open sores that develop in the skin of the lower leg as a result of poor blood circulation. Causes Damage to the valves inside leg veins prevents blood from returning to the heart. Instead, blood collects in the lower legs, causing them to swell. This swelling puts pressure on the skin, which can cause ulcers  2-Arterial (ischemic) ulcers Arterial ulcers occur when the arteries fail to deliver enough oxygen-rich blood to the lower limbs. Without a steady supply of oxygen, the tissues die and an ulcer develops. Arterial ulcers can form on the outside of the ankle, feet, and toes  3-Neuropathic ulcers Neuropathic skin ulcers are a common complication of uncontrolled diabetes. elevated blood glucose levels can cause nerve damage, results in a reduced or total loss of feeling in the hands and feet(neuropathy). occurs in approximately 60–70 percent of people with diabetes. Neuropathic skin ulcers develop from smaller wounds, such as blisters or small cuts. A person with diabetes associated neuropathy not realize that they have an ulcer until leaking fluid or becomes infected, in which case notice an odor  4-Bedsores or pressure ulcers Decubitus ulcers, also called pressure sores or bedsores, occur as a result of constant pressure or friction on the skin. Skin tissues can withstand a maximum pressure of 30–32 millimeters mercury any increase in pressure beyond this range can lead to poor circulation, tissue death, and eventually ulcer formation. If left untreated, decubitus ulcers can cause damage to tendons, ligaments, and muscles tissue.  5-Buruli ulcer Buruli ulcer is a medical condition caused by the Mycobacterium ulcerous bacteria. An infection with this bacteria can form large ulcers on the arms and legs. If left untreated, Buruli ulcer can result in permanent physical damage and disability. Characteristic Arterial Ulcer Venous Ulcer Diabetic Ulcer Location Ankle, toes, and heels Medial region of the lower On soles over bony leg prominences Appearance Irregular margin, punched Irregular margin, sloping Overlying callus, out edges, little exudate edges, pink base, usually undermined, often exudative deep and infected Skin temperature Cold and dry Warm Warm and dry Pain Present, may be severe Mild-moderate, unless May be absent infected or with significant edema Arterial pulses Diminished or absent Present Present or absent Sensation Variable Present Loss of sensation, reflexes and vibration sense Skin changes Shiny and taut, edema Erythema, edema, Shiny, taut not common hyperpigmentation Arterial ulcer Venous ulcer Diabetic ulcer THANK YOU