Wound Care

Course Modules
Course Introduction
1. Five Assessments for the
Wound Patient
2. Assessment of the Patient
3. Risk Assessment Tools
4. Assessment of Adjacent
and Periwound Skin
5. Assessment of the Wound
6. Wound Classification by
Etiology
7. Other Classification
Systems
8. Tools to Document Wound
Healing Status
9. Reassessment of the
Wound
10. Resources and References
Author:
Wound Care
Carrie Sussman, PT, DPT
Contact hours: 3.5
Pharmacotherapy hours: 3.5
Expiration date: August 1, 2014
Course price: $29
Course Summary
Covers the five steps of assessment: patients health status, risk factors, adjacent
and periwound skin, wound attributes, and classification by etiology. Risk
assessment tools, re-assessment, and a case study conclude the course.
Criteria for Successful Completion
80% or higher on the post test, a completed evaluation form, and payment where
required. No partial credit will be awarded.
Conflict of Interest/Commercial Support
Accreditation Information
Objectives: When you finish this course you will be able to:
List five important assessments for the wound patient.
Explain wound healing by primary and secondary intention.
Identify the elements of interest in assessment of the patient who has a
wound.
Discuss risk assessment especially as to pressure, diabetic foot, and venous
ulcers, as well as chronic non-healing risk.
Describe assessment of adjacent and periwound skin, its elements and its
importance.
Teach the steps of assessing the wound in terms of size, location, duration,
and tissue attributes.
Tell how to classify wounds by etiology, according to wound characteristics
(stages, depth, color).
Explain the PUSH and BWAT tools for documenting wound healing status.
Spell out what to look for on a reassessment.
Five Assessments for the Wound Patient
The assessment of a wound involves the gathering and evaluation of data to
determine factors that may impair healing and to prepare an appropriate plan of
care. This course reviews the phases of wound healing and look at the five steps of
wound assessment that are essential for health professionals who address wound
care. The five steps are:
The course concludes by presenting two validated tools to document assessment
findings of wound status and to track wound healing progress.
Wound Healing by Primary and Secondary
Intention
Wounds heal by primary and secondary intention. This understanding is fundamental
in recognizing the status of the wound you are assessing.
Wound healing of superficial or partial-thickness injury to the skin (epidermis and
dermis) occurs by primary intention, meaning that the wound heals by repair and
resurfaces without leaving a scar. Inflammation is usually short and resurfacing is
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Assessment of patients health status and related issues 1.
Assessment of risk factors 2.
Assessment of adjacent and periwound skin attributes 3.
Assessment of wound attributes 4.
Assessment of wound classification by etiology to determine wound
severity
5.
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rapid, within 2 to 3 weeks. Secondary intention healing occurs when a wound is
deeper than the dermis and extends into the subcutaneous tissues. These
regenerated tissues are not identical to the original skin, muscle, blood vessels, or
nerves: they are scar tissue.
Regeneration normally occurs in an orderly way, going through predictable phases
that manifest as a cascade of overlapping events beginning with coagulation
(clotting) in the wound bed to stop bleeding. The cells of repair are quickly brought
to the area of injury by increased blood flow, and so begins the inflammatory phase
of healing.
During the inflammatory phase the surrounding wound becomes edematous,
erythematous, painful, and warm. In the wound bed the cells begin the process of
laying down the scaffolding for new vascularization, collagen deposition, and control
of infectioncomponents of the proliferative phase. As the scaffolding is
revascularized it become red and bleeds easily. The cells pile upon one another and
look like beads or granules, which is why the tissue is referred to as granulation
tissue (Figure 1, ac).
When the open wound has filled to the level of the surrounding skin, healing has
reached the late proliferative phase and begins to change so that the edges of
the wound are drawn together (contraction). The epidermal cells are then able to
cross over from the wound edges and meet their kind on the surface of the wound,
and the wound closes This is the epithelialization phase.
Figure 1: Pressure Ulcer in Proliferative Stages of Healing
Figure 1-a. Note granulating wound bed, flattening out of wound
edges on one side, bulge of hypergranulating tissue and glistening of
the wound, indicating some minimal amount of wound exudate.
Copyright 2012 Sussman Physical Therapy, Inc. Used with
permission.
Figure 1-b. Same wound in later stage of proliferation. Note
epithelialization along the wound edges and undermining at top right
next to granulation tissue. Periwound tissue shows hemosiderosis.
Copyright 2012 Sussman Physical Therapy Inc. Used with
permission.
Figure 1-c. Same wound now continuing to contract and epithelialize.
Granulation tissue is reducing. Undermining is reduced but still
present above the granulating wound. Periwound tissue shows
hemosiderosis. Copyright 2012 Sussman Physical Therapy, Inc.
Used with permission.
As the wound closes, changes occur that modify the scar tissue; this is called the
remodeling phase. The skin thickens and a scar is formed. Remodeling may take 6
months to 2 years. Scar tissue will never be as strong as the original, unscarred
tissue.
In chronic wounds, the phases of wound healing have not progressed in the usual
predictable and timely manner and the result is a wound that remains open longer
maybe indefinitely. The chronic wound needs help to heal.
Phases of Wound Healing
Source: Mikael Hggstrm. Wikimedia Commons. (http://en.wikipedia.org/wiki/File:Wound_healing_phases.png)
Assessment of the Patient
Assessment of the whole patientnot just the woundprovides information about
factors that contribute to or inhibit wound healing. A systems review of the medical
record can identify the presence of such factors. For example, a patient at the end
of life may experience skin failure. As the largest organ in the body, the skin can fail
just as the heart, lungs, or kidneys do. In this section we discuss the systems to
review.
General Health Status
The patients medical history may indicate the presence of conditions that contribute
to the development of skin breakdown (e.g., peripheral neuropathy related to
chronic alcoholism or chemotherapy). Diabetes is often mentioned as an inhibitor of
wound healing; the longer the time since the onset of diabetes the more likely it is
that the patient will have a stocking-glove (feet and hands) neuropathy that
influences the ability to manage dressing changes and orthotics successfully. History
of a stroke due to vascular insufficiency suggests the need for testing peripheral
vascular patency. A patient with a history of spinal cord injury may have had several
surgeries or incurred ulcers on the sitting surface. Recurrent history of leg ulcers is
suggestive of venous disease, and their management history should be reviewed.
Assessment of the patients current health status focuses on the ability to support
wound healing in the context of the patients viability. Is the patient at the end of
life? Mobility status, confined to bed or chair, assistive devices used, and self-care
functional abilities are determined by questioning the patient or caregiver as well as
by observation. Additional questions address lifestyle behaviors that affect health
such as smoking, drug, and alcohol use. Each of these factors has been shown to
affect the potential for wound healing.
Comorbidities
Comorbidities affect the plan of care for wound management. Chronic obstructive
pulmonary disease (COPD) and heart disease reduce blood flow and oxygen to the
tissues. Paralysis, peripheral neuropathy, or morbid obesity can limit mobility, and
immobility is a risk factor for skin breakdown. Diabetic patients have changes in
sensation as well as circulation. Peripheral vascular diseasearterial or venous
insufficiencymay be part of the etiology of lower-extremity wounds.
Are any of the comorbidities modifiable? Would that change the prognosis for the
wound? Immune suppression, such as is common in patients with diabetes or
human immunodeficiency virus (HIV), impairs the inflammatory response.
Age
Physiology changes with aging. Wound healing in elders may be slowed up to 4%
compared to younger populations. All body systems are affected. Aging produces
changes including:
Reduced skin turgor
Decreased flexibility
Change in structure (e.g., the attachment between the epidermis and dermis)
Thinning, as adipose tissue diminishes and slides more easily
Capillaries and venules decrease in number, are subjected to bending and
folding with shear and friction
The skin thus becomes fragile and subject to bruising and tearing. Sebaceous glands
also decrease in number and size, especially in females, and the result is dry, flaky
skin. Tissue turnover slows, notably including the epidermal cells needed to
resurface a wound.
Neural transmission slows with age due to a decline in neurotransmitters (dopamine,
serotonin, gabapentin) and pain reaction time increases; response to pressure, for
example, may be delayed, allowing irreversible tissue ischemia to occur. Visual
changes also occur, making it difficult for the patient to monitor a wound and
provide suitable wound care. Changes in neural transmission also affect balance
from visual and other sensory receptors.
Psychosocial and Mental Status
Individuals who have wounds are impacted psychologically as well as physically. The
body-mind connection has been demonstrated in multiple studies on healing.
Patients who have negative feelings about an outcome following surgery, for
example, are likely to have longer recovery times, likely to have more adverse
complications like infection, and likely to have more pain than those who have a
more optimistic outlook. Caregivers of people with Alzheimers or other dementias
have slower healing times for simple skin wounds than do those who are less
stressed.
By the time adults reach the eighth to tenth decades of life, there may be changes
in mental status due to cerebral atrophy, small strokes, or vascular insufficiency.
Individuals with a history of chronic pain may have cerebral atrophy. Altered mental
status limits the ability to choose a balanced diet or even to self-feed and is an
identified risk factor for developing pressure ulcers. Dementia makes it difficult for
the patient to accept and adhere to the prescribed wound treatment.
Mental status can be assessed by talking to the patient or caregiver to determine
the patients cognitive abilities (learning, memory, comprehension), response to
having a wound, and ability to provide self-care. Knowledge about how the patient
has responded to healthcare procedures in the past is useful in care planning. If the
patients level of cognition is still unclear, consider using the Mini Mental Status
Examination.
Pharmacotherapy
Medications, their use and overuse, can be major healthcare challenges. In
assessing for wound care, it is important to consider all four components of the
pharmacokinetics of a drug: absorption, distribution, metabolism, and elimination
(ADME). Each of these components is affected by aging.
Absorption remains constant but a decrease in gastric acid affects the speed at
which capsules and coatings are broken down. Use of antacids increases the
problem. Distribution may be affected by altered blood flow dynamics resulting
from anatomic and physiologic changes. Metabolism of the drug, which is usually
through the liver, is affected by decreased liver mass, decreased liver enzymes, and
decreased hepatic blood flow. The overall result may be that the drug remains active
for a longer period of time, thus increasing the risk for adverse effects. Elimination
routing is usually through the kidneys but there may be altered kidney function in
elders, including decreased kidney tissue mass and kidney blood flow. Delayed
elimination may extend the half-life of many medications (e.g., insulin, Valium) used
by wound patients.
Several classifications of drugs affect wound healing. Wound patients who have
comorbidities may be taking anticoagulation or anti-inflammatory agents. These
medications interfere with platelet activation, a key component of the wound healing
cascade. Anticoagulation agents include aspirin or other salicylates, Plavix
(clopidogrel), and Coumadin (warfarin). Supplements are also commonly taken and
they affect the ADME of pharmaceutical agents like Coumadin. Reaction of wound
healing is not known.
Even a baby aspirin can cause maximal inhibition of the platelet function and
hemostasis needed for wound healing to begin. Platelet function is restored within
12 hours of administration of these drugs. Nonsteroidal anti-inflammatory drugs
(NSAIDs) taken early in the inflammatory phase blunt the coagulation response
needed to start hemostasis. The consequence may be delayed wound healing or
delayed progression to the second phase of wound healing. Anticoagulation effects
are seen as subcutaneous bruising that occurs with mild trauma.
Steroids are another class of medications prescribed for a diverse set of medical
conditions. Steroids delay all phases of wound healing. They also cause depletion of
Vitamin A, interfere with collagen synthesis, and decrease antibody protection and
immune system function. Application of topical vitamin A and systemic vitamin A
supplementation are effective in counteracting steroid effects. Vitamin A also
stimulates both humeral and cell-mediated immune mechanisms. It is important not
to overuse this drug and trigger hypervitaminosis. Follow recommended doses.
Topical antibiotics are not recommended because of the potential for developing
resistance in microorganisms, rendering systemic antibiotics ineffective and
increasing skin sensitization. One exception is topical doxycycline, a member of the
tetracycline family, which inhibits metalloproteinases and may improve healing,
especially of diabetic foot ulcers.
Growth factorsincluding platelet-derived growth factor, macrophage growth factor,
fibroblast growth factor, and transforming growth factor, just to mention a feware
produced by various systems within the wound itself and play an important role in
all phases of healing. Platelet-derived growth factor (PDGF) is available
commercially by prescription as a topical gel containing 0.01% recombinant human
plateletderived growth factor and is approved by the Federal Drug Administration
(FDA) for treatment of diabetic foot ulcers. It has been shown that patients using
the gel healed faster, with greater reduction in ulcer size, than those who used the
placebo.
Analgesics are used to treat pain symptoms related to the wound or to
comorbidities. Analgesics other than NSAIDs generally have no negative effect on
wound healing. Management of pain is important because there is evidence that
pain impairs wound healing (discussed later in this course).
Pentoxifylline/oxpentifylline (Trental) is used to promote blood flow to ischemic
tissues and thus improve wound healing. It is also used to treat peripheral vascular
disease and intermittent claudication.
Nutrition and Hydration
Undernutrition, formerly called malnutrition, is defined in the 2009 guidelines of
the National Pressure Ulcer Advisory Panel (NPUAP) and European Advisory Panel
(EPUAP) as nutritional deficiency or an excess imbalance of energy protein and
other nutrients essential for support of bodily functions. Unintended weight loss is a
signal of nutritional problems. Warning signs for pending unintended weight loss
include complaints of mouth pain, poorly fitting dental devices, coughing or choking
while eating or drinking, and eating less than half the meal or snack served. Medical
status affects eating and thus weight loss or gain.
Undernutrition appears in the frail elderly and those who are morbidly obese.
Albumin levels are the recognized test for this condition. A laboratory test for
albumin levels defines the status of protein. Albumin levels are affected by many
factors. Among them:
Acute infection
Chronic inflammation
Alcohol abuse
Burns
Congestive heart failure
Dementia
Diabetes mellitus
Insufficient calories and protein are comorbidities for impaired wound healing.
Laboratory tests measure recent nutrition and protein levels. Normal values for
albumin are 3.5 to 5.5 grams/decaliter.
Dehydration also contributes to poor wound healing because there may not be
enough blood volume to bring necessary oxygen and nutrients to the tissues. Even
patients who are anemic but well hydrated have been shown to heal. Extra fluids
may be needed. The blood volume needs to be sufficient to carry oxygen and
nutrients to the healing tissues. Sources of dehydration include the low-air-loss and
Clinitron beds that are used for wound patients.
A registered dietitian should be consulted for a nutritional assessment. Referral for a
nutritional assessment by a dietitian should be considered for all patients with
wounds, but especially for those who are unable to take food by mouth or who
experience unintended weight loss.
A decision tree about nutrition in pressure ulcer treatment can be found in the
NPUAP Prevention and Treatment of Pressure Ulcers, Clinical Practice Guideline
(NPUAP, 2009).
Risk Assessment Tools
Understanding risk is a key element in prevention as well as treatment. This section
looks at risk assessment parameters for three wound etiologiespressure ulcers,
diabetic foot ulcers, and venous ulcersand for chronic wounds in general.
Pressure Ulcer Risk
The Braden Scale is the most commonly used risk assessment tool for pressure
ulcers. It has been shown to have high validity and reliability. The Braden Scale
assesses six risk factors:
Mobility
Activity
Moisture
Sensation
Nutrition
Shear
Scores range from 6 to 23, with a score from 15 to 18 indicating some risk; 13 to 14
moderate risk; 10 to 12 high risk; and 9 very high risk. See Resources at the end
of this course to download a version of the Braden Scale. Perform the risk
assessment on admission and repeat it if there is a change in the patients condition.
This scale is valid for use with individuals of all skin tones.
Diabetic Foot Ulcer Risk
One of the most devastating outcomes for a patient who has diabetes is to develop
foot ulcers that fail to heal (Figure 2).
Figure 2: Neuropathic Foot Ulcer
Neuropathic foot ulcer on heel of patient with diabetes mellitus. Periwound callus
buildup shows rolled wound edges; hemorrhagic area has not yet declared.
Wound is moist, granulating, with scant serous drainage. Copyright 2012
Sussman Physical Therapy, Inc. Used with permission.
The goal of wound care in this patient is to prevent the potential loss of the foot. To
address this issue, the National Diabetes Education Program (NDEP)a coalition of
the National Institutes of Health (NIH), the Centers for Disease Control and
Prevention (CDC), and over 200 organizationshas produced a publication entitled
Feet Can Last a Lifetime. It includes tools for diabetic foot screening that can be
used by healthcare professionals as well as tools that can be applied by the patient
or caregiver. The program is available online and the entire screening kit is available
free (see Resources). Categories of defined diabetic foot ulcer risk are presented in
the table below. A screening form appears later in the course.
Risk Categorization
Risk category defined Management guidelines
Low-risk patients
None of the five high-risk
characteristics below.
Perform an annual comprehensive foot exam.
Assess/recommend appropriate footwear.
Provide patient education for preventive self-care.
Perform visual foot inspection at providers discretion.
High-risk patients
One or more of the
following:
Loss of protective
sensation
Absent pedal pulses
Foot deformity
History of foot ulcer
Prior amputation
Perform an annual comprehensive foot exam.
Perform visual foot inspection at every visit.
Demonstrate preventive self-care of the feet.
Refer to specialists and an educator as indicated.
(Always refer to a specialist if Charcot foot is
suspected.)
Assess/prescribe appropriate footwear.
Certify Medicare patients for therapeutic shoe
benefits.
>Place a High-Risk Feet sticker on the medical record.
Source: Feet Can Last a Lifetime, NDEP, 2009.
The most common risk factor for foot ulcer is loss of protective sensation in the feet.
This is measured during a foot screening examination, described later in the section
on Sensation.
Another risk factor arises from musculoskeletal deformities that can lead to the
development of wounds in neuropathic feet. All bony prominences are areas of risk.
Some common foot deformities and their areas of risk are shown in Figure 3, ad.
Figure 3: Musculoskeletal Deformities in Neuropathic Feet (drawings from
LEAP)
Figure 3-b. Claw toes: Areas of risk, the tops of the toes,
metatarsal heads, and tips of the toes that come in
contact with the shoe.
Figure 3-d. Plantar view, Charcot joint: Areas of risk, the
head of the first and fifth metatarsal joints.
Figure 3-a. Hammer toes: Area of
risk, the tops of the toes.
Figure 3-c. Bunions (Hallux
valgus): Area of risk, the
protruding joint.
Venous Ulcer Risk
No formal risk assessment plan exists for venous ulcers; however, characteristics
found in the research literature are presented here as a guide. Takahashi and
colleagues (2010) studied more than 12,000 medical records and found that 581
had diagnosis of venous ulceration. The risk factor most highly associated with
venous ulceration was venous insufficiency. This was followed by presence or history
of pressure ulcers, older age, female gender, previous hospitalization, diabetes,
renal insufficiency, peripheral vascular disease, congestive heart failure, depression,
degenerative arthritis, peripheral neuropathy, hypothyroidism, and falls.
Chronic Non-Healing Risk
Wound assessment needs to include the risk of non-healing and the need for
specialized care. The methodology proposed by Sibbald and colleagues (2000) can
be easily adapted to assess for non-healing. It looks at:
Ability of the wound to heal: blood supply measurements (an ankle-
brachial index of 0.50.8 delays healing), comorbidities, medications,
mobility
Causes of tissue damage: pressure (internal or external), vascular issues,
iatrogenic wound care, interventions (compression, offloading, dressings), lab
values (e.g., HB1C, albumen, hematocrit, hemoglobin, red and white blood
cell counts)
Wound status: history and attributes, phase of repair
Bioburden: necrotic tissue, infection
Wound healing rate (Is the wound on the trajectory of healing or
nonhealing?) Rate of healing per unit of time: 30% to 50% reduction in
surface area size during first 2 to 4 weeks predicts healing.
Other factors that affect healing outcomes include:
Large size (extent): Takes longer to heal
Long duration: Less likely to heal
Assessment of Adjacent and Periwound Skin
Tissue assessment begins by looking at the adjacent and periwound skin for ten
attributes, as follows.
1. Skin texture
Skin texture is assessed by observation and palpation to determine alterations in its
characteristics. Proper lighting and positioning are required, as well as a quiet
environment to avoid distractions and permit concentration. Use light pressure and
slowly palpate the skin surface. Language that you can use to report your findings
might include: moist or dry, warm or cold, rough or smooth, thick or thin.
Skin that is thin, fragile, shiny, and hairless is an indication of decreased vascular
supply. Loss of sweating function may cause cracking of the skin and fissures that
can become infected.
Callus (hyperkeratosis) is commonly encountered on the soles and heels of feet
where there are areas of pressure, uneven weight distribution, and friction. Calluses
appear as thick, rough, yellow skin patches and are the result of excessive skin
buildup, a protective skin function in response to high pressure over bony
prominences. Corns, also a thickening of the epidermis, may be found on the tops
or between the toes.
Callus buildup creates additional shearing forces between bone and skin and should
be reduced on a regular schedule to prevent skin breakdown under the callus. Callus
buildup is particularly risky for patients with peripheral neuropathy. An example of
such skin breakdown is seen in Figure 4.
Figure 4: Diabetic Foot Ulcer Surrounded by Callus
Periwound callus buildup shows rolled wound edges.
Source: Courtesy of WOCN.
Lipodermatosclerosis (LDS, or liposclerosis) refers to a thickening in the tissues
underneath the skin. It can be easily detected by feeling the leg for woody hard
changes as opposed to normal suppleness of the tissues. Excess lymph fluid in the
tissues causes change in the texture of the tissues. Large protein molecules lodge in
the lymph channels and cause tissue fibrosis. This is particularly obvious in patients
who have varicose veins that have become hard and uncompressible, or in those
with lymphedema.
2. Scar
Wounds that heal by secondary intention close by scar formation. Check the skin for
signs of scarring, which indicates an earlier full-thickness (or greater) wound. Scar
that is immature may be thin and flexible and be at risk for skin breakdown. Scar
never has the same breaking strength as original skin (Figure 5).
Figure 5: Road Rash Injury and Scarring
A comparative picture of untreated 7-days-healed road rash in the
form of a scar one year later. Note partial thickness wound on forearm
with full-thickness damage (dark clotted blood) at elbow. The forearm
wounds re-epithelialized without scar formation but the area of deep
injury by the elbow shows scar tissue, which will lighten as it
remodels. Source: Wikimedia Commons.
The color of scar is one indication of duration; new scar is light pink regardless of
the usual skin pigmentation. Hypopigmentation, however, may persist in matured
scar tissue in darkly pigmented skin.
Hypertrophic scars, scar that result from excessive deposition of collagen that
causes a thick scar mass within the borders of the wound, are unattractive and can
be disfiguring, and they may interfere with function if they cross a joint. Itching is
common. Keloidal scars are thickened scars that extend beyond the borders of the
original wound. The tendency to form keloids is sometimes genetic, being more
commonly found among blacks and some Asians, though equally among males and
females.
3. Edema
The visual and palpatory senses are used to observe the presence of edema,
accumulation of excess fluid in the intercellular tissue spaces. It may be localized
around a wound or extend in one or both directions from the wound. Edema is an
example of both moisture and pressure imbalance. Internal pressure from edema
can cause skin breakdown (Figure 6). Edema is one of the early symptoms of
inflammation and serves as a signal that something needs attention.
Figure 6: Vertebral Wound Showing Edema
This unstageable vertebral wound is surrounded by edematous
tissue. Source: NPUAP. Used by permission.
4. Color
Good lighting is essential for accurate skin color assessment. Avoid fluorescent light,
which gives the skin a bluish tone; natural or halogen lighting is best, and a head
holder is useful. Flash photography is recommended because it tends to highlight
the demarcation between normal skin tones and injured tissues.
Assessment of skin color of the adjacent skin and of the same area on the opposite
side of the body provides clues both about skin health and general health. For
example, cyanosis would suggest ischemia. Dependent rubor (redness) suggests
arterial insufficiency. Check medical records for vascular tests or recommend that
the patient be evaluated by a vascular professional.
Hemosiderosis (brown discoloration) around a wound or in unbroken skin of the
leg is an indicator of subcutaneous bleeding in the tissues over a period of time; it
often surrounds a chronic wound (Figure 7). The color comes from the breakdown of
red blood cells into a compound called hemosiderin, which is permanently deposited
in the tissues beneath the skin and makes it look rusty. It is a common occurrence
after a significant injury to the leg and is made worse by an underlying problem in
the veins.
Figure 7: Knee Wound Showing Hemosiderosis
This stage III knee wound shows full-thickness skin loss, red
granulation tissue at wound bed, brown hemosiderin stain in
periwound area, rolled wound edges, and lack of pigmentation.
Source: NPUAP. Used by permission.
Another use of color examination is to determine if there is capillary damage from
pressure. When there is capillary damage the skin may become erythematous and
the red color may persist even after the pressure is removed. This is termed
unblanchable erythema and is easily seen in lightly pigmented skin; it is harder to
determine in dark skin, which does not show blanching the same way (Figure 8).
Unblanchable erythema should not be confused with reactive hyperemia, which is
transient.
Figure 8: Heel Showing Unblanchable Erythema
Heel in stage I with dark skin showing unblanchable erythema.
Source: NPUAP. Used by permission.
An example of reactive hyperemia is the red circles that appear on the knee of
one leg and the popliteal space on the other after sitting with knees crossed for
some time. After pressure is removed from the areas and the skin exposed to the
ambient room temperature for 5 to 10 minutes the color spots disappear.
When checking for transient versus persistent erythema, remove the pressure for 5
to 10 minutes, cover with a light covering and allow the skin color to normalize.
Unblanchable erythema may be a hallmark of a stage I pressure ulcer as described
by the NPUAP, or it may indicate a superficial burn.
Assessing darkly pigmented skin can be challenging because the color changes are
subtle. Assess the patient by comparing the color on the equal and opposite body
part, consult with the patient (if appropriate) or with a family member about color
changes. Lighting is extremely important here. The color of the skin usually appears
bluish or purplish (eggplant) and is comparable to the erythema of light skin. If you
do not believe color to be a reliable indicator for the patient, then consider other
clinical indicators such as sensation (pain), temperature ( hot or cool), and edema to
confirm your evaluation of the condition.
Assessment of tissue circulatory status and capillary refill time may be checked by
examining the nail beds. Apply pressure at the tips of the nails or the nail beds of
the second or third fingers, which are often lighter in color than surrounding skin; if
there is blanching you can check for capillary refill time, the speed with which the
color returns to its usual tone following release of pressure. The slower the return of
color, the more the circulatory function is diminished.
Deep tissue injury appears bluish/purple, similar to a deep bruise (Figure 9); it
appears more purple in darkly pigmented skin. Discoloration is due to rupturing of
the blood vessels and hemorrhaging into the tissues and is called ecchymosis.
Hemorrhaging may occur if there is trauma to new granulation tissue, pressure, or
as an adverse effect of anticoagulant therapy, which predisposes the tissue to
bleeding. Lesions due to hemorrhaging can precipitate rapid deterioration of tissues
and may be the most significant predictor of poor healing.
Figure 9: Pressure Ulcer with Suspected Deep Tissue Injury
Unstageable pressure ulcer. Periwound: erythema
surrounding wound; suspected deep tissue injury (DTI)
along proximal wound edges. Wound: grey necrotic fat
and fascia over >3/4 wound surface; muscle tissue on
right side. Unattached flat wound edges. Source: Anne
Myers, PT, CPT, GCS, CWS. Used with permission.
On a cellular level, rapid deterioration is believed to occur (as a combination of
direct ischemic injury and reperfusion injury) from free radicals, cytokines, and
neutrophilic adhesion to microvascular endothelium. Purple hemorrhagic signs over
bony prominences are now classified by the NPUAP as suspected deep-tissue
injury, a type of unstageable pressure ulcer. Hemosiderin staining of adjacent skin
indicates prior subcutaneous bleeding (Figure 10). However, hemorrhagic signs may
also be seen in venous ulcers. Sussman and Swanson (1997) found that presence of
hemorrhagic signs were the most significant predictor of nonhealing for all types of
wound etiologies.
Figure 10: Venous Insufficiency Leg Ulcer
Venous insufficiency with leg ulcer. Lower leg adjacent skin. Edema
and erythema coincide with brown hemosiderin staining. Slough in
wound bed. Source: Courtesy of WOCN.
Blisters occur following trauma to the epidermis. They may be fluid filledas in
partial-thickness burn woundsor sanguinous-filled, indicating deeper tissue injury.
Sanguinous blister fluid can obscure the underlying tissues and the extent of injury,
so unroofing (opening) the blister may be the best course of action to ascertain the
extent of the injury.
5. Temperature
Skin temperature is one means of measuring inflammatory response to injury.
Palpation of temperature with the wrist or elbow does not provide accurate tissue
temperature. Liquid crystal fever thermometers and infrared scanning thermometers
are more sensitive to changes in tissue temperatures and thus more accurate. The
infrared thermometer is inexpensive, is easily used with minimal instruction,
provides immediate feedback, provides information about impending problems like
infection or inflammation, and has the best reliability and accuracy (Figure 11). The
usefulness of the infrared thermometer for the diabetic foot is well documented. It is
most effective when the patient or caregiver follows a pattern of temperature
measuring on an ongoing basis.
Figure 11: Patient Checking Temperature of Foot
Patient checking the temperature of the sole of his foot with an
infrared thermometer. Note the temperature of the healthy foot is
only 90.6 degrees. Photo courtesy of James Birke, PT, PhD. Used with
permission.
Patients or caregivers need to be alerted to monitor tissue temperature daily in a
prescribed pattern and to report immediately a 4F change of skin temperature.
Those not using daily temperature monitoring are 10 times more likely to develop a
complication such as Charcot arthropathy than those who regularly assess surface
skin temperature. Stage I pressure ulcers, as described below, are reddened skin-
surface areas. Reddened sacral and buttock areas are often significantly warmer
than adjacent skin or skin on the opposite side of the body. A decline in skin surface
temperature of 4F has been associated with visible skin deterioration within 7 days.
Temperature assessment is also useful for monitoring the status of surgical wounds;
for instance, wound temperate changes during the first 8 postoperative days and by
the end of that period the zone of warmth typically decreases. The zone of the
wound incision will be warmest. Surrounding tissues may be warm because of
presence of increased blood flow to the area; this is called reactive hyperemia and
it is in not indicative of infection. Ischemia may be detected by coolness compared
with adjacent skin areas on the same and opposite sides of the body. Look for other
signs of ischemia.
6. Hair Distribution
Hair is distributed over all four extremities. With aging, hair profusion declines and
in some body areas is completely lost. One reason for hair loss is diminished
circulation, so absence of hair on the legs, for example, may be an indicator of
ischemia and a potential indication for vascular testing. Hair follicles contribute skin
stem cells that support wound epithelialization so their absence predicts slower
healing. Figure 12, below, shows hair on both the dorsum of the foot and the
proximal digits of the toes.
7. Toenails
Toenails are a modification of the horny epidermal layer of the skin. They grow more
slowly than fingernails and grow more rapidly in men and young people than in
women and older adults. Fever or serious illness suppresses nail growth. Examine
toenails to see if they are ingrown, deformed, or fungal. Thick or hypertrophic nails
may indicate vascular or fungal disease or may be the result of damage to the nail,
of age, and/or of other vascular changes (Figure 12).
Figure 12: Toenail Disease
Ingrown nails and wounded, infected nail beds. Refer to a podiatrist
for treatment. Source: Wikimedia Commons.
Nails that are uncared for may become ragged and sharp and traumatize adjacent
skin areas. They will also interfere with proper shoe fit and tear shoe linings and
socks, creating abrasive surfaces that can cause skin trauma. Bathroom surgery of
damaged nails should be avoided. Referral to a podiatrist or other health provider
who is experienced in nail care is recommended.
8. Sensation
Sensations to be tested include protective response, tactile sense, kinesthesia (joint
position), and vibration. Loss of protective sensation occurs with peripheral
neuropathy; it means that the individual is unable to detect potential traumatic
injury (e.g., a rock in the shoe, a shoe that doesnt fit properly). Sensory deficits
appear first in the most distal portion of the foot and progress proximally in a
stocking distribution. The toes are the first areas to lose protective sensation.
To test for sensation, the patient is blindfolded or instructed to look away while the
examiner applies a 5.07 (10g) Semmes Weinstein 10-mg monofilament. The
following is recommended:
The sensory exam should be done in a quiet and relaxed setting.
Test the monofilament on the patient hand to show what to anticipate.
The five sites to be tested are indicated on the examination form attached to
the end of this course.
Apply the monofilament perpendicular to the skins surface (Figure 13-a).
Apply sufficient force to cause the filament to bend or buckle, using a smooth,
not a jabbing, motion (Figure 13-b).
The total duration of the approach, skin contact, and departure of the
filament at each site should be approximately 1 to 2 seconds.
Apply the filament along the perimeter and not on an ulcer site, callus, scar,
or necrotic tissue. Do not allow the filament to slide across the skin or make
repetitive contact at the test site.
Press the filament to the skin such that it buckles twice as you say time one
and time two. Have patients identify at which time they were touched.
Randomize the sequence of applying the filament throughout the
examination.
Figure 13: Monofilament Testing for Sensation
If the patient cannot feel the 5.07 monofilament that presents 10 g of force, then
protective sensation is absent. Local touch and joint position can also be tested. A
tuning fork is used to test for vibratory sensation. Insensate feet need to be
protected patient need to be educated about foot monitoring. A source for
monofilaments is listed in Resources.
For cutaneous anthrax, ciprofloxacin or doxycycline is recommended as first-line
therapy. Intravenous therapy with a multidrug regimen is recommended for
cutaneous anthrax with signs of systemic involvement, for extensive edema, or for
lesions on the head and neck. Cutaneous anthrax is typically treated for 710 days.
However, in the setting of a bioterrorism attack, the risk for simultaneous aerosol
exposure may be high. As a result, persons with cutaneous anthrax associated with
a bioterrorism attack should be treated for 60 days. Even if promptly treated with
appropriate antibiotics, cutaneous anthrax will continue to progress through the
eschar phase.
The most current recommendations on treatment of anthrax can be found on the
CDC Public Health Emergency Preparedness and Response website at
http://www.bt.cdc.gov.
Occurrence
Anthrax occurs worldwide and is most common in agricultural regions with
inadequate control programs for anthrax in livestock. These regions include South
and Central America, Southern and Eastern Europe, Asia, Africa, the Caribbean, and
the Middle East. Prior to 2001, anthrax was very rare in the United States, with no
human cases reported during 19931999.
Reservoir
The main reservoirs of anthrax are infected animals and soil. Anthrax spores are
highly resistant to physical and chemical agents and persist in the environment for
many years. The spores may remain dormant in certain types of soil for decades.
9. Footwear Assessment
Patients with neuropathy, especially when associated with sensory loss, are at risk
for ulcers, even nonhealing of ulcers, from poorly fitting shoes; therefore,
assessment of footwear is important for this patient population. Assessment should
include shoes, need for orthotic inserts, and prescribed corrective footwear.
Check inside shoes for foreign objects, torn linings, and proper cushioning. Improper
or poorly fitting shoes are major contributors to diabetes foot ulcerations (Figure
14). Counsel your patients about appropriate footwear. All patients with diabetes
need to pay special attention to the fit and style of their shoes and should avoid
pointed-toe and open-toe shoes, high heels, thongs, and sandals.
Assess the material and construction of footwear. Unbreathable and inelastic
materials such as plastic should be avoided. Recommend use of materials such as
canvas, leather, suede that are breathable and elastic. Footwear should be
adjustable with laces, Velcro, or buckles.
Properly fitted athletic or walking shoes are recommended for daily wear. If off-the-
shelf shoes are used, make sure that there is room to accommodate any
deformities. High-risk patients may require depth-inlay shoes or custom-molded
inserts (orthoses), depending on the degree of foot deformity and history of
ulceration. Medicare provides coverage for depth-inlay shoes, custom-molded shoes,
and shoe inserts for people who have diabetes and who qualify under Medicare Part
B.
Figure 14: Toe Traumatized by an Ill-Fitting Shoe
Partial thickness ulcer of the big toe of patient with peripheral
neuropathy that has been traumatized by a short shoe. Source: Nancy
Elfman, CO, CPED. Used with permission.
10. Pain
One of the components of inflammation is pain. Pain triggers the inflammatory
response, which starts at the site of injury and transmits impulses up through the
spinal cord to the brain, where signals are sent to the circulatory system,
sympathetic nervous system, and immune systemwithin 30 seconds, according to
the findings of Krmer and colleagues (2008). Acute nociceptive pain responses are
localized to the wound, periwound, and adjacent tissues. Over time, pain may
extend beyond the adjacent area of the wound and even expand to the entire region
(e.g., lower leg in a patient with leg ulcer).
Regional pain arises from central sensitization of the pain in the spinal cord.
Hyperalgesia (excess reaction) to painful stimuli spreads to segments of the spinal
cord above and below the segment receiving stimulation and travels to the cortical
level. The area of the brain that normally localizes pain may have been altered from
repetitive painful stimulation and the localization of pain becomes inexact. This
phenomenon has been recognized as a mechanism for phantom limb pain.
Assessment of the Wound
The next step is assessment of the wound. No single approach provides adequate
assessment of a wound. To help facilitate the process several algorithms have been
proposed. Two of these MEASURE and TIME, use mnemonics consisting of letters
that correspond with the items to be assessed.
MEASURE
M = measure
E = exudate
A = appearance
S = suffering
U =undermining
R = re-evaluation
TIME
T = tissue
I = infection or inflammation
M = moisture
E = edge
Note that there is some overlap between the algorithms and there are also some
items that differ. It is important to establish a consistent set of items. They should
be incorporated into a facilitys Policies and Procedures in order to improve reliability
and consistency by measuring and documenting the same items each time.
The final section of this course introduces two tools that incorporate these elements:
the NPUAP Pressure Ulcer Scale for Healing (PUSH) and the Bates-Jensen Wound
Assessment Tool (BWAT). Both have been tested for reliability and validity and are
recommended by several sources. Diagnosis is determined by examining the wound
attributes, wound etiology, and wound severity.
Anatomic Location
Anatomic location may be the first indicator of the wound etiology. Punched-out
wounds over the malleolus, tops of the toes, and lateral border of the foot are
ischemic ulcers due to arterial insufficiency. Wounds on the soles of the feet are
pressure ulcers related to neuropathy and may be diabetic foot ulcers (see Figure
2). Most common sites on the plantar surface are: metatarsal heads, heels, lateral
border of the foot, and over bony midfoot deformities, as was shown in Figure 3, a
d.
Wounds that occur when skin over bony prominences is traumatized by pressure are
called pressure ulcers. Common sites are: coccyx (Figure 15), trochanter, heel,
scapula, digits, and elbows. Ulcers that occur above the medial malleolus are often
associated with venous insufficiency (Figures 16).
Figure 15: Sacrococcygeal Wound on Dark Skin
Healing Stage III pressure ulcer in patient with dark skin. edges are
smooth and flattening and adhering as new pale colored epithelial
tissue is laid down. Source: NPUAP. Used by permission.
Figure 16: Venous Leg Ulcer
Venous leg ulcer located above the medial malleolus. Adjacent skin:
erythema, edema, hemorrhagic areas, inflammation. Wound: areas of
clotted blood, soft irregular wound edges, bleeding subcutaneous
tissue. Copyright 2012 Sussman Physical Therapy, Inc. Used with
permission.
Size
Size is the measurement of the wound dimensions on the surface. Note that this will
not account for loss of tissue integrity beneath the surface, which is the real extent
of wounding. Accuracy and reliability of wound measurements depend on consistent
measurement methods. Even so, no method is 100% accurate and measurements
are at best approximations. When a clinician applies the methodology consistently,
however, measurement error is minimized.
A standardized formprovided and approved by the facilityhelps to minimize
errors in measurement of a wound feature. The PUSH and BWAT tools (see later
section) can be used for this purpose. Variations in clinical skill sets should be
considered when making this selection. Sources for both are listed in Resources.
Three methods are used to measure wounds: linear measurement, wound tracing,
and photography. The most common method is linear measurement and the next
most common is wound tracing.
Linear Measurement
Linear measurement is achieved by using a measurement scale like a centimeter
ruler to measure the length and width of the woundusually at the greatest
diameters perpendicular to each other. The two diameters are then multiplied
together to get the area of wounding. This method tends to overestimate the size of
the wound, but if it is done the same way each time the wound is measured it will
approximate the dimensions consistently and change in wound size will be
adequately measured. The advantages of this method are:
Simplicity, easy to learn
Reliability
Most commonly recommended and used
When the surface area has been determined, it is then necessary to ascertain the
extent of the wound in terms of depth, tunneling, and undermining.
Depth measurement of the wound is performed by inserting a cotton-tipped
applicator point into the deepest area of the wound and marking the depth from the
nearest wound edge. Then the applicator is measured with a ruler from the tip to
the mark on the applicator. A depth greater than 2 mm indicates that the wound
penetrates the dermis and may be a full-thickness loss of skin; this is a more severe
injury and healing by secondary intention will occur. Depth is also used to stage or
classify the wound, as we will see.
Tunneling indicates a sinus tract that can become infected. Always probe a tunnel
very gently to avoid opening more spaces. A tunnel is measured using a long, cotton
-tipped applicator moistened with normal saline solution. The probe is inserted into
the tunnel and the edge of the wound is marked on the applicator. When the probe
is withdrawn it is measured from wound edge mark to tip to determine the depth of
the tunnel.
It is possible to map the extent of the tunneling by making markings of the pint of
the applicator around the wound border. A photo of the skin markings is useful for
future comparison. If there is long and extensive undermining (erosion of the tissue
under the wound edge), the physician should be notified because the patient is at
risk for sinus tract infection. As tissue is debrided from a wound, undermining of the
wound edge can occur.
Wound Tracings
Tracings are made by placing a clear plastic such as a baggie over the wound and
drawing along the wound edges the entire periphery of the wound with a fine point
permanent marker. Some wound product vendors have acrylic sheets for this
purpose. Next you measure the greatest length and greatest width perpendicular to
each other. Then the top half of the baggie is cut from the bottom half and can be
placed on a plain paper or graph paper and copied or the commercial product can be
separated from the contact layer and stuck to the paper and placed into the medical
record. Marking the features of the wound can be added to the tracing. For example
diagonal cross marks can be used to indicate the area of necrotic tissue or
granulation tissue. Shading can be used to mark undermining.
Photography
The ease of taking digital photos has made this method popular. Patient/family
consent must be obtained before taking photos. Cell phones should not be used to
take and store photos because of patient privacy regulations. There are other issues
related to measuring wounds from a photo including positioning of the wound,
distance of wound to camera, lighting, and shielding of the patients private parts.
Photography is best used for looking at wound attributes including shape, wound
bed tissue, wound edges, and surrounding tissue.
Age and Duration of Wound
Determine, if possible, the time when the wound was first observed; that is, its age
and duration of presence. The longer the presence of the wound, the more likely it
will need help to heal and the longer will be the predicted time until it is healed.
Problematic Tissue Attributes
Sussman and Swanson (1997) tracked wound attributes and did an analysis that
showed the following tissue attributes are not good for healing. They are ranked
here in order of significance.
Deep Tissue Injury (Hemorrhagic Tissue)
The presence of hemorrhagic tissue at baseline, representing deep tissue injury, was
ranked the most significant attribute predictive of nonhealing. Its appearance is like
bruising or ecchymosis (see Figure 9). In white skin it appears like a purple
discoloration and in darkly pigmented skin it is seen as a darkening of the natural
tones of the skin to a deep purple color. It represents the rupture of blood vessels
and subcutaneous bleeding. As noted earlier, anticoagulant medications are
commonly used especially in elders and, therefore, they bleed more easily when
pressure, shear or friction is applied to tissues. NPUAP has a category of pressure
ulcers called suspected deep tissue injury described under NPUAP Pressure Ulcer
Classification below. Flash photography can be used to better show the areas of
demarcation between suspected deep tissue injury and adjacent skin.
Maceration
Maceration is softening of tissue by soaking until the connective tissues dissolve to
the point that the tissue fibers can be easily torn apart. It is white and stringy in
appearance. Maceration occurs when moisture balance on the skin increases and is
not checked. The sources of maceration may be moisture from excessive sweat,
soaking in water, wound exudate, incontinence, and moisture-retention wound
products. Excessive sweating may be related to medication or infection. Check
wound edges and under skin flaps (e.g., the breasts, abdominal folds), for
maceration.
Erythema
Red discoloration around wounds is called erythema and is a sign of inflammation
(Figure 17). Erythema was discussed earlier under Assessment, Color (see also
Figure 6).
Figure 17: Erythema in Heel Wound
Heel stage I showing erythema. Source: NPAUP. Used by permission.
Necrotic Tissue, Eschar, and Slough
Necrosis is the term for dead tissue. The color may vary from yellow to brown to
black. Eschar is a mixture of clotted blood and dead skin (see Figure 9). It has a
hard, dry leather-like appearance and texture and may be mistaken for a scab,
which is clotted blood alone. Soft necrotic tissue may be tan, grey, or brown.
Slough, which is yellow in color, like chicken fat, is necrotic fat and fascia.
Positive Tissue Attributes
Granulation Tissue
Granulation tissue proliferates in the wound until the wound space is filled with
bright pink to red granulation (see Figure 1, ac). As this occurs, wound depth
undermining reduces and tunnels begin to close.
Adherent Advancing Wound Edges
In a new acute wound the wound edges may be diffuse, very thin, soft and pliable
and ready to advance to cover the wound surface. In a chronic wound the wound
edges may have tried to advance but were stopped by a wound edge that is not
connected to anything. Then the epidermal cells will dive down inside of the wound
edge and as they continue to reproduce they will form a rolled, thick wound edge
that over time becomes hard and fibrotic and the cells are stalled from covering the
wound. Figure 1a shows the rolled edge.
Wound Contraction
Wound contraction occurs during the late proliferative phase of wound healing.
Contractile cells develop that begin to draw the wound edges together like the stings
of a purse. This reduces the open surface area of the wound resulting in less need
for epidermal covering and speeding wound healing. Contraction is desirable in some
areas (e.g., buttocks) but in other areas of wound contraction (e.g., hands, neck)
contraction produces deformities. Medical attention is needed to prevent such
complications. Figures 1 b and 1c show the same wound as it is contraction.
Contraction in this location is acceptable.
Wound Drainage
Wound drainage is different depending on the phase of wound healing. Clean
wounds have clear serous (straw color) or serosanguinous (light red or pink)
odorless liquid drainage of moderate amount. If drainage characteristics change
from thin and watery to a thick and opaque yellow, tan, or green with an associated
odor, infection may be present. This does not immediately suggest infection,
however, because as part of the bodys debridement process dead cells are sloughed
off into the clear wound drainage and discolor it grey or brown.
Flush the wound with large amount of normal saline and re-examine to see if the
drainage that can be expressed from the wound tissues is clear or otherwise. A total
or near-total lack of wound drainage may suggest that the wound is excessively dry.
A dry wound bed will not support healing because cells need a moist environment to
proliferate.
Pain
In an acute wound, pain will be present in the surrounding and periwound skin
unless the patient has peripheral neuropathy. Even those who have peripheral
neuropathy will experience pain with deep infection. In acute wounds, pain should
subside after a few days. Chronic wounds generally have minimal pain unless they
are arterial or are infected.
Patients report that dressing changes and debridement procedures produce the
greatest amount of pain. Ask the patient:
When do you experience the most pain?
Is the pain persistent or intermittent?
What is the nature of the pain: sharp, burning, tingling, or throbbing?
What makes the pain better or worse?
Persistent pain, and some intermittent pain, are indicators of peripheral or central
sensitization of the pain system. Repetitive and persistent pain impairs wound
healing and has negative psychological effects. Chronic pain is now being referred
to as persistent pain.
Pain scales, such as the visual analog scale (VAS), are used in all healthcare
settings. Patients do not always respond appropriately, however, to a simple visual
analog scale unless they are given clues as to what the numbers mean. For
example, the professional can use a VAS plus descriptive words and numbers: 0 =
no pain, 2 = annoying, 4 = uncomfortable, 6 = dreadful, 8 = horrible and 10 =
agonizing.
Visual Analog Scale (VAS)
A 10-cm baseline is recommended for VAS scales.
Source: Adapted from Acute Pain Management Guideline Panel, 1992 (AHCPR, 1994).
The Wong-Baker FACES Pain Rating Scale consists of six cartoon faces that give the
patient clues about the quantitative value of their pain with pictures and words. This
scale works well with young patients, with non-English speakers, and with those
who have dementia.
Wong-Baker FACES Pain Rating Scale
The Wong-Baker FACES scale is especially useful for those who cannot read English and for pediatric patients. It is
also useful for patients with dementia. Source: Copyright 1983, Wong-Baker FACE Foundation,
www.WongBakerFACES.org. Used with permission.
When evaluating pain in the cognitively impaired, look for facial expressions that are
sad, pained, or worried. Frequent crying may indicate distress. Mood changes may
include negative statements, repetitive statements, or inappropriate or changed
behavior such as pacing, hand wringing, restlessness, fidgeting, picking on or
physical abuse of others.
A change in the nature of pain or its sudden onset may be associated with clinical
signs of infection.
Infection
All wounds are contaminated with micro-organisms. Immediately after wounding,
bacteria invade the open wound and colonize the wound tissues. As long as numbers
of organisms remain stable and do not produce a reaction in the host, the wound is
not considered to be infected. Small ulcers may be present for a long period of time
without showing overt signs of infection. Large acute wounds are susceptible to
invasion by skin flora. At this stage the wound needs to be monitored but not
treated for infection.
The condition of the patient determines whether the population of microorganisms
stays in balance or moves from colonization to critical colonization, the stage
preceding infection. If the bacteria overpower the host by producing enough toxins
to overcome the immune defenses, the wound becomes infected and shows clinical
signs of infection:
Heat
Intense erythema
Increased drainage (serosanguinous, seropurulent to purulent, with malodor)
Persistent pain
Breakdown of granulation tissue with increased wound size and/or depth
Edema and induration accompanied by warmth
Systemic signs include:
Systemic fever
Elevated white blood cell count
Red streaks (cellulitis) around the wound
Change in mental status especially in older adults
These signs indicate that it is time to consider wound culture and sensitivity testing
in order to diagnosis wound infection and determine the infecting organisms
response to antibiotics.
Temperature
In the acute inflammatory phase, tissue temperature of the wound and adjacent
tissue is elevated but it diminishes as inflammation progresses toward the
proliferative phase. The zone of elevated temperature will narrow gradually. If the
wound is in a chronic inflammatory phase the temperature may remain elevated or
become cooler than the surrounding tissue, indicating tissue ischemia.
Vascularity
This assessment is divided into steps, beginning with the medical history of vascular
-related factors for both arterial and venous disease. Next is the targeted physical
examination of the patients symptoms.
Arterial insufficiency symptoms include:
Claudication in calf upon walking
Rest pain in the forefoot when foot is elevated
Diminished or absent pulses when palpated
Edema is not usually present
Thin shiny hairless skin
Muscle atrophy
Tissue coolness
Ulcerations, usually on and between toes
May progress to gangrene
Ankle/brachial index (ABI) is used to measure ischemia in the lower extremity. This
is a noninvasive test. A Doppler ultrasound probe and speaker are used to amplify
the pulse signal. Systolic blood pressure is taken at the brachium and at the ankle.
Ankle pressure may be taken at either or both the dorsal pedis and the posterior
tibial artery. The pressure at the ankle is divided by the pressure at the brachium to
give the ABI ratio.
When good blood flow is present, the ratio of ankle to brachial systolic blood
pressure is equal to 1.0; however, if there is arterial insufficiency in the lower
extremity the ratio will diminish. An ABI of 0.8 to 1.0 signifies mild arterial occlusive
disease; 0.8 to 0.5 may be accompanied by rest pain, intermittent claudication, and
moderate arterial occlusive disease and calls for referral to a vascular specialist.
Compression therapy is contraindicated for this group and all groups with low ABI.
An ABI higher than 1.0 is found when vessels are calcified and is often associated
with patients who have diabetes.
Another, more advanced test is measurement of the transcutaneous partial pressure
of oxygen. Referral to a vascular laboratory where the equipment and methods are
available would be indicated for those in the lower ratio groups. Other invasive
studies may be performed there also.
Venous disease symptoms include:
Edema (may be pitting, making palpation of pulses difficult)
Weeping serous fluid from wounds
Stasis dermatitis (dry, flaky, scaling skin)
Hemosiderin deposits from blood seepage under the skin
Venous pressure testing is usually done in a vascular lab.
Wound Classification by Etiology
Classification systems have been devised to rank wound severity. All except one cite
increasing depth of tissue damage as the most severe. This section will look at both
ways of grading wound severity. It is important that the same methodology be used
across disciplines to avoid confusion by all who have need to consult the medical
records.
Four different wound etiology classifications are presented here:
Pressure ulcers
Neuropathic ulcers
Vascular ulcers, arterial and venous
Burns
Pressure Ulcers Classified by Stages
[This section is taken from NPUAP, 2009.]
The most common pressure ulcer classification system is that proposed by the
National Pressure Ulcer Advisory Panel (NPUAP, 2009). It has six classifications,
including unstageable and deep tissue injury. It is recognized internationally as
the gold standard for staging pressure ulcers. For more detailed information about
the NPUAP and pressure ulcer staging system, see Resources.
A pressure ulcer is a localized injury to the skin and/or underlying tissue, usually
over a bony prominence, as a result of pressure, or pressure in combination with
shear and/or friction. A number of contributing or confounding factors are associated
with pressure ulcers; the significance of these factors is yet to be determined.
Suspected Deep Tissue Injury
Deep tissue injury is characterized by a localized area of discolored intact skin
(purple or maroon) or a blood-filled blister, due to damage of underlying soft tissue
from pressure and/or shear. The area may be preceded by tissue that is painful,
firm, mushy, boggy, and warmer or cooler compared to adjacent tissue (Figure 18).
Figure 18: Deep Tissue Injury
Left: Unstageable wound diagram. Courtesy of NPUAP. Right: Unstageable deep tissue injury. Courtesy of Anne Myers,
PT, CPT, GCS, CWS.
Further description:
Deep tissue injury may be difficult to detect in individuals with dark skin tones.
Evolution may include a thin blister over a dark wound bed. The wound may further
evolve and become covered by thin eschar. Evolution may be rapid, exposing
additional layers of tissue even with optimal treatment.
Stage I
Intact skin with non-blanchable redness of a localized area, usually over a bony
prominence, signals Stage I (Figure 19). Darkly pigmented skin may not have visible
blanching; its color may differ from the surrounding area.
Figure 19: Wounds, Stage I
Left: Stage I wound diagram. Right: Stage I heel injury. Source: NPUAP. Used by permission.
The area may be painful, firm, soft, and warmer or cooler compared to adjacent
tissue. Stage I may be difficult to detect in individuals with dark skin tones. May
indicate at risk persons (be a heralding sign of risk).
Stage II
Stage II is characterized by partial-thickness loss of dermis presenting as a shallow
open ulcer with a red to pink wound bed, without slough (Figure 20). Stage II may
also present as an intact or open (ruptured) serum-filled blister.
Figure 20: Wounds, Stage II
Left: Stage II wound diagram. Right: Stage II buttocks injury (dark skin). Source: NPUAP. Used by permission.
Presents as a shiny or dry shallow ulcer without slough or bruising. (Recall that
bruising indicates suspected deep tissue injury. This stage should not be used to
describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.
Stage III
Full-thickness tissue loss signals Stage III. Subcutaneous fat may be visible but
bone, tendon, or muscle are not exposed (Figure 21). Slough may be present but it
does not obscure the depth of tissue loss. Stage III may include undermining and
tunneling.
Figure 21: Wounds, Stage III
Left: Stage III wound diagram. Right: Stage III knee injury (dark skin). Source: NPUAP. Used by permission.
The depth of a Stage III pressure ulcer varies by anatomic location. The bridge of
the nose, ear, occiput, and malleolus do not have subcutaneous tissue and Stage III
ulcers can be shallow. In contrast, areas of significant adiposity can develop
extremely deep stage III pressure ulcers. Bone and tendon is not visible or directly
palpable.
Stage IV
Stage IV is characterized by full-thickness tissue loss with exposed bone, tendon, or
muscle (Figure 22). Slough or eschar may be present on some parts of the wound
bed. Stage IV often includes undermining and tunneling.
Figure 22: Wounds, Stage IV
Left: Stage IV wound diagram. Right: Stage IV finger injury. Source: NPUAP. Used by permission.
The depth of a Stage IV pressure ulcer varies by anatomic location. The bridge of
the nose, ear, occiput, and malleolus do not have subcutaneous tissue and these
ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting
structures (e.g., fascia, tendon. joint capsule) making osteomyelitis possible.
Exposed bone/tendon is visible or directly palpable.
Unstageable
The wound is classified as unstageable when it exhibits a full-thickness tissue loss in
which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown)
and/or eschar (tan, brown, or black) in the wound bed (Figure 23).
Figure 23: Wounds, Unstageable
Left: Unstageable wound diagram. Right: Unstageable deep tissue injury. Source: NPUAP. Used by permission.
Until enough slough and/or eschar is removed to expose the base of the wound, the
true depth, and therefore stage, cannot be determined. Stable eschar (dry,
adherent, intact without erythema or fluctuance) on the heels serves as the bodys
natural (biologic) cover and should not be removed.
Neuropathic Ulcers
Two commonly used classification systems for neuropathic ulcers are the Wagner
Ulcer Grade Classification and the University of Texas, San Antonio Classification.
The Wagner system grades the wound by the depth of the wound and the presence
of infection. It has five numeric grades beginning with pre-ulcerative lesions, healed
ulcers, or presence of bony deformity, and concluding with gangrene of foot
requiring amputation. The University of Texas classification has four numeric grades
based on the depth of the wound. It starts the same as the Wagner, and ends with
wound penetrating to bone and joint. In addition there are four letter grades, A to
D, related to infection and ischemia. A wound with a numeric grade of 4 and letter
grade of D, for example, would be a wound that penetrates to bone or joint and is
infected and ischemic.
Vascular Ulcers: Arterial and Venous
Arterial Disease
Arterial insufficiency ulcers (ischemic ulcers) are generally found on the lateral
surfaces of the ankles (Figure 24). They are the result of insufficient blood flow to
the lower extremities.
Figure 24: Arterial Insufficiency Ulcer
Figure 25: Thermal Burn
A 71-year-old diabetic male smoker with severe peripheral arterial
disease presented with a dorsal foot ulceration that had been
chronically open for nearly 2 years. Source: Wikimedia Commons.
Two classification systems that are used to accurately report the patients status
related to arterial disease and to facilitate communication to other health
professionals are the Rutherford and the Fontaine. Rutherford classifies by 4+
stages and Fontaine by six categories. Both use clinical presentation to explain the
grade. They are very similar and include:
Asymptomatic
Mild claudication
Moderate claudication
Severe claudication
Rest pain
Ulcer or gangrene
Minor or major tissue loss
Venous Disease
Venous insufficiency is the most accurate predictor of venous ulceration, and there
is a close association between venous insufficiency and pressure ulcers of the leg.
The CEAP classification system, a consensus document written by the American
Venous Forum in 1994, is the accepted classification for this etiology. It consists of
two parts that are scored separately (see Figure 10).
Part One is classified by:
Cclinical manifestation
Eetiologic factors
Aanatomic distribution
Ppathophysiologic dysfunction
Part Two is scored by severity:
In 2004 the CEAP system was upgraded to further differentiate severity related to
each component. Since 2010 a system to improve grading is being studied. More
information about the CEAP classification system is available online at the Venous
Ulcer Form website.
Burns
Classification of burn wounds is related to depth of injury. There are five categories:
Superficial
Superficial partial-thickness skin loss (Figure 25)
Deep partial-thickness skin loss
Full-thickness dermal
Subdermal extending into muscle
The first two categories are painful to
touch but will heal with minimal to no
scarring. All other categories will heal
with some scarring. The deepest burns
are insensate to touch but the
surrounding tissue is painful due to
inflammation of associated viable
tissue. These burns also have moderate
to marked edema.
Burn wound severity is also graded by
the size of the burn injury. This is
reported as an estimated percentage of
Number of anatomic segments affected 1.
Grading of signs and symptoms 2.
Disability 3.
Superficial partial-thickness thermal burn identified by the
moist red denuded appearance of the tissue. It will be
very painful. With moist wound healing treatment this
wound should heal without scarring. Typical healing time
is 714 days and up to 21 days. The greater the depth of
injury, the longer will be the healing time. Source:
Courtesy of WOCN.
the total burn surface area (TBSA) of
the body by using the Rule of Nines,
which is a quick estimate of body
surface area. The body is divided into
nine parts: head, chest, abdomen,
back, buttocks, each arm (front and
back), each leg (front and back plus the
groin (1%).
By adding up the parts of the body that
are burned the TBSA is calculated to
determine the percentage of the body
involved in the burn. For example, if the
head and chest and upper back are
burned, the total body surface area
burned would be 3 X 9= 27%. The
percentage of body area burned is used
to establish the plan of care.
Other Classification Systems
Depth of Tissue Impairment
In the American Physical Therapy Association (APTA) Guide to Physical Therapist
Practice, the section on the integument classifies wounds by the depth of tissue
impairment. This classification is used across all types of wounds. Patterns of care
are based upon the depth of tissue impairment, each of which has inclusion and
exclusion criteria.
Wound Bed Color
Marion Laboratories devised a system of wound classification based on the color of
the surface tissue in the wound bed. Three colors are used: black, yellow, red. This
is a very simple severity system. A black wound is a wound covered with black
necrotic dried blood and skin products. it needs cleaning and debridement and is
judged most severe. A yellow wound is called slough and this signals possible
infection; the yellow wound also needs cleaning and debridement and is less severe.
A red wound indicates that the wound is clean and the granulation process is
proceeding to healing. If all three colors are present, the one most prominent is the
color severity.
Tools to Document Wound Healing Status
Tools like those described in this section serve as a framework for recording and
tracking wound healing progression is an organized, systematic way. They facilitate
communication between all stakeholders about the wound status and aid in care
planning across disciplines. Two tools commonly used to monitor and quantify
wound healing are the Pressure Ulcer Scale for Healing (PUSH), developed and
validated by the NPUAP and others; and the Bates-Jensen Wound Assessment
Tool (BWAT), developed and validated by Bates-Jensen and others. These tools are
discussed next. Check Resources for access to these tools.
Pressure Ulcer Scale for Healing (PUSH)
PUSH was designed to be a biologically accurate, easy to use, clinically practical
instrument for pressure ulcer tracking over time and across care settings. It has
since been evaluated and approved for use in quantifying healing of venous and
diabetic foot ulcers.
PUSH considers three factors with respect to wound status: size in centimeters
squared, tissue type present in wound bed, and exudate amount. Tissue type and
exudate are each given a score of 0 to 4. Size comprises ten grades, with the largest
size (>24 cm2) having the highest score. Then the subscores for the three factors
are added together for a total score. Definitions and scores from NPUAP for the
tissue types begin with the most severe:
4, necrotic tissue (eschar): black, brown, or tan tissue that adheres firmly
to the wound bed or ulcer edges and may be either firmer or softer than
surrounding skin.
3, slough: yellow or white tissue that adheres to the ulcer bed in strings or
thick clumps, or is mucinous.
2, granulation tissue: pink or beefy red tissue with a shiny, moist, granular
appearance.
1, epithelial tissue: for superficial ulcers, new pink or shiny tissue (skin)
that grows in from the edges or as islands on the ulcer surface.
0, closed/resurfaced: the wound is completely covered with epithelium
(new skin).
NPUAP allows reproducing PUSH and provides a full set of instructions for clinical
and educational uses. Look for the PUSH tool at NPUAP.org.
Bates-Jensen Wound Assessment Tool (BWAT )
The Bates-Jensen Wound Assessment Tool (BWAT) is a valid and reliable tool
developed by Bates-Jensen that is used to assess and monitor healing of all types of
wounds. It is more comprehensive than the PUSH tool. Bates-Jensen consists of 15
items, two of which (location and shape) are not scored. Scored items are:
Size
Depth
Edges
Undermining
Necrotic tissue type
Necrotic tissue amount
Exudate type
Exudate amount
Skin color
Edema
Induration
Granulation
Epithelialization
Each item can be scored 1 to 5, with 1 being the best for that attribute. After each
item is assessed and scored, the 13 subscores are summed to get a total score.
Bates-Jensen has calculated that BWAT scores can be converted to PUSH scores
since the two tools are highly correlated. Methodology for doing this is beyond the
scope of this course.
An additional asset of BWAT is using the score to measure wound severity. This is
important, since the goal of wound care is to reduce wound severity. The total BWAT
scores are divided into four severity categories:
1320 = minimal severity
2130 = mild severity
3140 = moderate severity
4165 = extreme severity
The BWAT has been adapted as a photographic wound assessment tool (PWAT) by
Houghton et al. (2000). This variation includes 6 of the 13 items, also rated on a 1
to 5 scoring system. The six item subscores can then be summed to a total score.
Like the other tools, this tool has been validated and is responsive to change in
wound status.
Reassessment of the Wound
Reassessment is an ongoing process that needs to be performed on a regular
schedule. It always begin with screening the status of the patient medically,
physically, and emotionally to see if there has been a change in condition. For
example, if the patient spiked a fever unrelated to the wound since the prior
assessment, it could account for a deterioration in the wound status.
Reassessment is usually performed weekly or biweekly using the same methodology
and documentation as previously decided by facility policy. The wound should be
showing characteristics associated with healing and size, as seen for example in
Figure 1ac.
Reassessment is an opportunity to look at the percentage of change in the wound
size since the last assessment. This is done by using a simple calculation:
(Baseline or last area size) current size / (baseline or last area size) X 100 = % of change
Percentage of change refers to the decrease in wound area over a specific period of
time. Wounds often change significantly during the early phases of healing and then
slow down. Be aware that this method of measuring healing rate can exaggerate the
progress made by larger wounds relative to smaller ones.
Percentage of change can be used to track healing rates over time. It has been
shown in a number of studies that there is a significant difference between healers
and nonhealers; for example, pressure, diabetic, and venous ulcers that do not
reduce in size between 30% and 50% in a 2- to 4-week period are not on a healing
course and probably need additional help to heal.
Percentage of change is also a method of predicting those wounds that are likely to
heal with standard care. This triage of patients and wounds is extremely valuable.
Case
Assessment of Patient Health Status
Jane D has a pressure ulcer (Figure 26). Jane is a 95-year-old white female with a
15-year history of Alzheimers disease. She is bedbound, has a catheter and a
gastric tube and is fetally contracted. She is unconscious. Other medical
conditions include history of breast cancer in remission for 20 years, COPD, and
congestive heart failure. She developed a pressure ulcer on the sacrum 2 weeks
ago coincident with an episode of pneumonia.
Figure 26: Unstageable Ulcer on the Coccyx
Unstageable pressure ulcer on the coccyx. May be a Kennedy Terminal
Ulcer. Periwound skin: large diffuse areas of unblanchable erythema
spreading over both buttocks. Wound: butterfly shape, necrotic tissue
in about of wound bed surface. Copyright 2012 Sussman
Physical Therapy, Inc. Used with permission.
Assessment of Risk Factors
i. Pressure ulcer risk:
Braden Scale: totally limited sensory, bedfast, 100% immobile
Braden score = 6/23, which indicates very high risk for skin breakdown
ii. Risk of nonhealing:
Assessment of Adjacent and Periwound Skin Attributes
Color, adjacent: streaks of unblancheable erythema
Sensation: movement away from pressure stimulus suggesting pain
Temperature: Infrared thermometer reading of 85F over adjacent tissues, which
is cooler than surrounding tissues
Pain: reactive to pressure and repositioning
Assessment of Wound Attributes
Assessment of Wound Classification by Etiology to Determine Severity
Resources and References
Resources
American Venous Forum
Promoting venous and lymphatic health. Resources for medical and allied health
Knee and hip flexion contractures inhibit blood flow to the lower legs
and feet.
1.
Immobility limits ability to reposition to relieve pressure and to pump
blood.
2.
Comorbidities of COPD and congestive heart failure also limit oxygen
delivery to the tissues.
3.
Change in skin condition occurred coincident with an episode of
pneumonia.
4.
Sudden appearance of an ulcer on the sacrum (ulcer is shaped like a
butterfly, covered with yellow slough and appears to be a Stage III
pressure ulcer.
5.
Suspect possible Kennedy Terminal Ulcer, skin changes associated with
end of life skin failure.
6.
Size: 6 cm wide, 5.5 cm long; 34 mm 1.
Color: Wound bed, partially covered with yellow slough 2.
Drainage: scant serous from right half, left half dry 3.
Pain: no response to pressure at wound bed 4.
Wound is located over a bony prominence so is probably a pressure
ulcer. It appears to be a Stage III.
1.
Since the wound appeared during an episode of pneumonia, has a
butterfly shape, and occurs on the sacrum, it may be a Kennedy
Terminal Ulcer. Patient may be dying and this pressure ulcer a part of
multi-organ failure.
2.
professionals.
http://veinforum.org/Medical-and-Allied-Health-Professionals.aspx
Bates-Jensen Wound Assessment Tool
Includes conversion to PUSH.
Retrieve the form here
Braden Scale
For home care use.
http://www.bradenscale.com
Lower Extremity Amputation Prevention Program (LEAP)
To order free disposable 5.07 (10 gm) monofilaments, maximum 50:
http://www.hrsa.gov/hansensdisease/leap/
National Diabetes Education program (NDEP)
Diabetic foot screening kits for professionals and for home use.
800 438 5383
Download kits at http://ndep.nih.gov
National Pressure Ulcer Advisory Panel (NPUAP)
Clinical practice guideline. PUSH tool and diagrams of pressure ulcer staging.
http://www.npuap.org
References
Bates-Jensen B, Sussman C. (2012). Tools to Measure Wound Healing. In C Sussman and B
Bates-Jensen (Eds.), Wound Care, a Collaborative Practice Manual for Health Professionals,
4e. Baltimore: Lippincott Williams and Wilkins.
Houghton PE, Kincaid CB, Campbell KE, et al. (2000). Photographic assessment of the
appearance of chronic pressure and leg ulcers. Ostomy Wound Manage 46(4):2026, 2830
Kramer HH, Stenner C, Seddigh S, et al. (2008, June). Illusion of Pain: Preexisting Knowledge
Determines Brain Activation of imagined Allodynia. Journal of Pain 9(6):54351.
National Diabetes Education Program (NDEP) et al. (2009). Feet Can Last a Lifetime: A
Healthcare Providers Guide to Preventing Diabetes Foot Problems. Retrieved March 28, 2012
from http://ndep.nih.gov/media/feet_hcguide.pdf.
National Pressure Ulcer Advisory Panel (NPUAP). (2009). Prevention and treatment of
pressure ulcers: Clinical practice guideline. Available from http://www.npuap.org.
Sibbald R, Williamson D, Orsted H. (2000). Preparing the wound bed: Debridement, bacterial
balance, and moisture balance. Ostomy/Wound Management 46(11):1435.
Sussman C, Swanson G. (1997). Utility of the Sussman wound healing tool in predicting
wound healing outcomes in physical therapy. Adv Wound Care 10(5):747.
Takahashi P, Kiemele L, Cha S, et al. (2010). A Cross-Sectional Evaluation of the Association
Between Lower Extremity Venous Ulceration and Predictive Risk Factors. Wounds 21(11).
Retrieved April 12, 2012 from http://www.medscape.com/viewarticle/713201.
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