22/1/2013

HK ENTERSTOMAL THERAPIST ASSOCIATION

CONTEMPORARY WOUND COURSE 2013

WOUND ASSESSMENT & DOCUMENTATION

Wound care management

Not only treat the wound, treat

the patient as a whole.

APN Lam Ming Chu

NTEC FM & GOPC
26th Jan 2013

Phases of Wound Healing

Factors that impede healing

The entire wound healing process is a complex series

Systemic factor

of events that begins at the moment of injury and can

continue for months to years.

Usually follow well-defined process
Inflammation (3 - 4 days)
Proliferation (2 days 3 weeks)
Remodeling (3 weeks to 1 year)

Systemic diseases(e.g. diabetic, cardiac, renal and

respiratory)

Insufficient oxygen & perfusion

Malnutrition

Medication (corticosteroids, chemotherapy,

immunosuppressant)

Age

Local factors:

Infection

Foreign body

Pressure

Wound assessment

General Assessment

Purpose

Age / sex

Examine the severity of the wound

Determine the status of wound healing
Establish a baseline for the wound
Assess and plan the wound management
Facilitate the continuity of care

Physical including: level of mobility, degree of

dependence, nutritional status, the presence or

absence of concurrent illness, medication, treatment
(RT / chemotherapy)

Social background: martial stage, family support,
financial support

Education level: illiterate / primary/ secondary / tertiary

Personal habit: Smoking, drinking, soft drug abuser

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General Assessment

General Assessment

Systemic disease processes / medication / treatment

that adversely affect metabolism, perfusion and are

likely to delay wound healing.
Psychological status.
Healing is dependent on the delivery of adequate
supplies of nutrients and oxygen to the injured area
for cell metabolism and effective waste product
removal.
Investigation: e.g. blood test / ABI

Skin assessment
All patients require a routine and systemic skin
assessment, which includes daily evaluation of the
integrity, temperature, texture and presence of lesion on
the skin.

Wound Assessment

Wound Classification System

Etiology / type of skin damage

Classification by depth of tissue injury

Classification of Burn Depth

Duration of wound

Pressure ulcer staging system (National Pressure Ulcer

Wound condition

Advisory Panel)
Wagner staging for grading severity of dysvascular ulcer

Classification of tissue injury

Classification Burn Depth

Thickness of skin
loss

Definition

Clinical example /
healing process

Thickness of skin
involved

Definition

Clinical example

Superficial wound

epidermis

Sunburn, stage 1 pressure

sore / heal by inflammation

Superficial
(1st degree burn)

epidermis

Sunburn

Partial-thickness skin loss

Extends through the epidermis

but not through the dermis

Skin tear, abrasion, tape

damage, blister / heal by
epithelialization

i)

i)
ii)

Full-thickness skin loss

Epidermis, dermis and

subcutaneous fat and deeper
structure

Donor sites, venous ulcer,

surgical wound / heal by
granulation tissue formation
and contraction

Partial-thickness
(2nd degree burn)
- i) Superficial
- ii) Deep

Subcutaneous tissue
wound

Extend into or beyond

subcutaneous

Surgical wound, arterial

wound / heal by granulation
tissue formational and
contraction

Full-thickness
(3rd degree burn)

Destroy all layer of the

skin

ii)

Involve epidermis
and upper layers of
dermis
Destruction of
epidermis and most
of dermis

Blister
Blister but most
appear slightly moist
to dry and are dark
red to pale in color

Dry and leathery and

firm

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Pressure ulcer staging system (NPUAP 2007)

Suspected deep tissues injury

Stage

Stage

Pressure sore Staging system

Purple or maroon localized area of discolor

intact skin or blood. Filled-blister due to
damage of underlying soft tissue from
pressure and or shear.

Stage

Non-blanchable redness of intact skin

over bony prominence

Stage

Partial thickness loss of dermis

presenting s a shallow open ulcer with
red pink wound bed, without slough

DM foot ulcer Wagner grading system

Grade 0

Intact skin, may have body deformity.

Grade 1

Superficial skin loss, not involving subcutaneous

tissue.

Grade 2

Full thickness skin loss, involving subcutaneous

tissue, may expose bone, tendon and joint.

Grade 3

Presence of deep ulcer with abscess, osteomyelitis

or joint abscess.

Grade 4

Gangrene localized to the forefoot or heel.

Grade 5

Extensive gangrene

Unstageable

Subcutaneous tissue / fat exposed (slough

/ undermining / tunneling but not obscure
the depth of tissue loss)

Full thickness tissue loss with exposed

bone / tendon / muscle / fascia

Full thickness skin loss, the base is

cover by slough / eschar

Wound Assessment

Wound Type

Site

Size

Wound bed (tissue status)

Exudate

Periwound skin

Odor

Pain

Wound Type

Wound type

Arterial ulcer

Burn / scald

Cancerous

Diabetic foot ulcer (Neuropathic)

Skin tear

Surgical

Pressure ulcer

Traumatic

Venous leg ulcer

Fistula

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Wound location

Wound Size

Description: head, face, chest, abdominal, sacral, lower

Two-dimensional measurement techniques

Wound photography

limbs, upper limbs

Body chart

Wound tracings
Linear measurement paper or plastic ruler (does

not acknowledge wound depth)

Wound Size

Tissue Status

Three dimensional measurement

Classification of tissue injury

Length x Width x Depth

Pressure Ulcer Staging system

Length = from head to toe

Pts head

Width = cross section

(National Pressure Ulcer Advisory Panel 2007)

Depth = deepest

Wagner grading system for Diabetic foot ulcer

Undermining

w
Head

Wound base tissue

Pts toes
4.5x4.2 x 1 cm and
undermining
4cm deepest at 5 oclock

Exudate

Wound Base Tissue

Wound base

Description

Granulating tissue - Inflammation /

proliferative phase
- Pale pink to beefy red

Slough

- Non-viable tissue,
yellowish
- Loose / hard

Necrotic tissue

- Dead tissue
- Dry eschar

Color

%
25%
50%
75%
100%

Color & texture:

serous / haemoserous / purulent (pus) /greenish
abnormal drainage e.g. bile, urine, fecal matter, ascites

etc.

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Periwound skin

Exudate

Amount depend on wound status and dressing used:

Description

Amount

Intact
Minimal

5 ml / 24hrs(inner dressing soaked through <

2 cm)

Moderate

5 10 ml ml/24hrs (inner dressing soaked

through > 2 cm not to outer dressing)

Excessive

>10 ml / 24hrs
(inner dressing soaked through >2 cm and
also to outer dressing)

Erythema

Periwound skin

Hyperpigmentation

Maceration

Odor
Foul smell e.g. infected wound / fungated wound

Edema

Scaling
Some occlusive dressing may have a smell on removal &

disappear when dressing discard

Cellulites

Pain

Wound documentation

Visual Analogue Scale (VAS)

Descriptive pain intensity scale

No pain

Mild pain

moderate pain

Severe Pain

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Documentation

Documentation

Past history / allergy history:

Wound condition

Social background:

 Site:

Occupation:

 Size : (L) x (W) x (D) cm

Education level:

 Exudate : minimal / moderate / excessive

Smoker / non-smoker / drinker / non-drinker

 Wound bed : pink / red / yellow / black (%)

ADL: dependent / partial dependent / dependent

 Periwound skin : intact / maceration / erythema /

Mobility: walked unaided / with stick/ frame/ one assistance

hyperpigmentation / hypo pigmentation / oedema / scaling

/ cellulites
 Odor : nil / mild / offense
 Pain (VAS) :

Wound occurred:

Wound type : Surgical / Burn & scald / Skin tear / Traumatic

/ Leg ulcer / Pressure sore / Cancerous /

bite

Investigation: e.g. blood test, ABI

Other: Dog

Treatment

Treatment

Cleansing lotion : NS / Hibitane / Betadine

Other:

Primary dressing : Medipore / Jelonet / melolin/ Mesalt

Wound care

/ Hydrocolloid / Foam / Alginate

Secondary dressing : gauze / combine

Outer dressing : bandage / surgifix

Frequency of dressing : QD / Alt day / Q 2-3 days /
Q 3-4 days / Q 1W

Diet advices : high protein / vit C / low purine / low

salt / fluid restriction, DM diet with even CHO

distribution
Skin care : apply moisturizer / emollient daily
Minimize edema by elevating the legs / put on
tubigrip
Improve venous return by putting on pressure
garment / calf cuff exercise

Documentation

Documentation

Past history / allergy history:

Wound occurred :scald by hot pack few days ago and

 DM, HT, End stage renal failure on HD three days/ week

 No allergy history

treated by A/B

Wound type : scald

Social background : lived with wife with good family support

Site: left heel

Financial support : Pension self

Size : 7x5.3cm

Occupation : retired GS

Exudate : moderate

Education level : F.3

Non-somker / non-drinker

ADL: independent

Mobility: walk unaided

Investigation: HbA1c 8% on 31/12/12, afrebrile

Wound bed : 100% necrotic

Periwound skin : maceration and erythema and edema

Odor : mild

Pain (VAS) : 5, treatment: oral analgesic

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Treatment

Follow up documentation

Cleansing lotion: NS

Push Tool 3.0

Primary dressing: Bactigras (antimicrobial agent)

Other wound assessment form

Secondary dressing : gauze

puBWAT

Outer dressing: bandage

Frequency of dressing : QD

Other:
 Wound condition and care plan explained, Mr. X and his wife
showed understand
 Elevated the heel by pillow and avoid pressure
 Nutrition: DM diet with even CHO distribution
 Skin care educated

Reference

Baranoski, S & Ayrllo, EA (2008). Wound Care Essentials Practice Principles 2nd ed., Lippincott,

U.S.A.

Barnard, AR & Allison, K (2009). The classification and principles of management of wounds in

trauma. Trauma. 11: 163-176

Benhow, M (2007). Patient assessment and wounds. Journal of Community Nursing. Sutton,

Vol. 21, lss. 7, p.18.20.22 (3 pp.)

Murphy F (2006). Assessment and management of patients with surgical cavity wounds.

Nursing Standard. Vol 20, lss. 45, p57-8, 60, 62.

Push Tool Version 3.0 : 9/15/98, National Pressure Ulcer Advisory Panel.

Saunders, K. & Rowley, J. (2006). Implementing a wound assessment and management

system. Australia Nursing Journal : May, 13, 10: 31-33

Sussman. C & Jensen, B.B., (2007). Wound Care A Collaborative Practice Manual for Health

Professional , 3rd ed., Chap 1 5, Lippincott, U.S.A.

White R (2008) Delayed wound healing: in whom, what, when and why?

Primary Health Care, 18, 2, 40-46.

Wiebelhaus, P. & Hansen, SL. (2001). Nursing management: July; 32, 7, 31-35.