Wound Assessment & Treatment

Cathy Lyle
Advanced Practice Nurse
Providence Care, SMOL site

LTC Physicians CME June 2011

Outline

 Is it healing?
 Will it heal?
 What colour is it?
 How wet is it?
 Is it infected?
Canadian Association of Wound
Care (CAWC)
Wound Measure

 Size (cm) – L x W x D
– Length – greatest distance across in any direction
– Width – greatest width at 90 degrees to length
Wound Measure

 Size (cm) – L x W x D
– Depth – measure from deepest part of wound to top
of wound margin
Wound Assessment Form
Date Jan 13 Feb 10 Apr 4 Apr 18 May 2
Size (cm) 9x6 5 x 4.5 3 x 1.75 1 x 1.5 Closed
Wound 80% 20% black 100% 100%
Base black granulation granulation
Periwound White Intact Intact intact
Exudate Large Mod – Small - Small
Amt large moderate
Exudate Purulent Serous Serous Serous
Type
Odour 1 (faint) No No No
Stage X X 2 2
Pain No No No No
Measure Undermining

 Undermining (cm) – extent of wound unseen

below the wound edges
– Probe distance from the edge of the wound with
sterile Q tip
– Place thumb at Q-tip where it appears at edge of
wound
– Record distance in cm.
– Use face of clock to record location with 12 o’clock
towards patient’s head
What colour is it?

 Black – eschar
 Yellow – slough
 Red – granulation tissue
 Pink – epithelial tissue
Wound Assessment Form
Date Jan 13 Feb 10 Apr 4 Apr 18 May 2
Size (cm) 9x6 5 x 4.5 3 x 1.75 1 x 1.5 Closed
Wound 80% 20% black 100% 100%
Base black granulation granulation
Periwound White Intact Intact intact
Exudate Large Mod – Small - Small
Amt large moderate
Exudate Purulent Serous Serous Serous
Type
Odour 1 (faint) No No No
Stage X X 2 2
Pain No No No No
Black – Eschar

 Black or brown
 Soft or firm
 Leather-like cap
Stage X
Hydrogel

 Description: amorphous gel which hydrates

granulation tissue and rehydrates dry eschar and
slough liquefying the necrotic tissue for easy
removal.
 Indications: used on pressure ulcers (stage 2,3,4),
partial- and full-thickness wounds, tunneling
wounds, wound with minimal drainage, wounds
with purulent drainage, and red, yellow, or black
wounds.
Debridement

 Removes dead tissue which is medium for

bacteria growth
 Reduces wound drainage and odour
 Reveals true extent of wound – can’t determine
true size until healthy wound bed is uncovered
 Only for healable wounds
Types of Debridement

 Autolytic
– body’s own enzymes break down necrotic tissue
– moist wound environment helps
– pain free but slow
– contraindicated for infected wounds
Types of Debridement

 Mechanical
– Gentle irrigation (syringe, 250 mL Normal Saline)
– Wet-to-dry dressings
– Be a “Picker” – cut off dead tissue that you can lift
from wound bed
– Painful
– Nonselective – damages healthy tissue
Types of Debridement

 Sharp
– Conservative – at bedside by physician with
scissors and scalpel – need skill and a way to stop
bleeding that may occur if wound debrided to
healthy, bleeding base – painful if debrided to
bleeding base – faster
– Surgical – under anesthetic by surgeon – fastest
and most effective method
When to debride?

 Debride only healable wounds

– There is a potential to heal
– There is adequate arterial perfusion
– The overall goal is healing
When to debride?

 Do not debride when:

– Unknown wound origin
– Dry gangrene or ischemic wound
– Affected limb has no pulse or decreased perfusion
– Wound due to inflammatory or vasculitic process
– No necrotic tissue
– Treatment goal is wound maintenance
Hydrogel

 hydrates granulation tissue and rehydrates dry

eschar and slough, liquefying the necrotic tissue
for easy removal
 used on wounds with minimal drainage, wounds
with purulent drainage, and red, yellow, or black
wounds
Yellow - Slough

 Creamy yellow or grey

 Firmly attached to wound bed or
 Loosely-attached strings of tissue
Red – Granulation

 Bright red, moist, shiny

 Granular, bumpy
 If bleeds easily (friable) – may indicate
infection
 If darker red – may indicate poor perfusion
Pink – Epithelial

 Whitish pink or pinky-purple

 At first, seen as islands of white in midst of
wound bed – epithelial buds
 Seen as ring of pink around rim of wound bed
Will it heal?

 Treatment decisions based on heal-ability of

wound
 Not all chronic wounds heal
 Healing potential influenced by cause of
wound, underlying co-morbidities, patient’s
level of commitment to treatment plan
Wound Assessment

Assess the whole patient…

not just the hole in the patient
What affects healing?

 Low oxygen perfusion

– Smoking
– Chronic obstructive pulmonary disease, anemia
– Peripheral vascular disease, coronary artery
disease, hypertension, diabetes, congestive heart
disease
What affects healing?

Malnutrition
– More calories and protein needed when healing
– Serum albumin (3.5-5 gm/dl)
– Prealbumin (20-40 mg/dl)
– Vitamin C, zinc, iron needed for collagen formation
– Vitamin A needed for epithelialization
Dehydration
– Large amounts of wound drainage contribute
What affects healing?

 Age
– Skin thins, higher risk for trauma
– Slower inflammatory response
– Healing takes longer
What affects healing?

 Other chronic diseases

– Rheumatoid arthritis, renal failure, cancer
– Immunocompromised patients (unable to mount
adequate inflammatory response)
 Medication and treatments
– Radiation, chemotherapy – disrupts cell formation
– Anti-inflammatory meds (NSAIDS) – suppresses
inflammatory response
What affects healing?

 Psycho-physiological stress
– Includes pain and noise
– Stimulates sympathetic nervous system –
vasoconstriction
 Local factors
– Foreign bodies
 packing left in or causing too much pressure
 sutures
What affects healing?

 Patient’s expectations and level of commitment

to treatment
– What is important to patient?
– What is patient’s goal? Healing or maintenance
– How does patient want to spend time?
Is it healable?

 Yes, wound has good potential to heal,

treatment goal is to close wound – proceed
with best practices in wound care
 No, wound will probably not close – poor
potential for healing, treatment goal is to
maintain condition of wound – focus on
promoting client function and comfort with
wounds (living with wounds)
Periwound Assessment

 Intact – normal epithelial skin

 Macerated/excoriated – wet, white opaque skin
 Induration – feels firmer than surrounding
tissue
 Erythema – bright red, blanches or doesn’t
 Callus – thick, dry epidermis
 Dehydrated – dry, flaky with fissure, cracks
Tissue Injury from Moisture

 Wet skin becomes soft and macerated

– more prone to breaking down with pressure/friction
– more prone to bacteria and yeast infection
 Incontinent patients 5X more likely to have skin
breakdown
 Where damage occurs?
– perineal area, skin folds, around wounds
Moisture Prevention & Treatment

 Protect periwound skin

– No Sting barrier film
– Zinc oxide, vaseline
– Cover wound edges (picture frame) - hydrocolloid
(Tegasorb)
– Use products that wick drainage away from
periwound (foams cut to fit wound bed size)
Product Categories

 Gauze
 Films
 Hydrocolloids
 Calcium Alginates
 Hydrofibres
 Foams
 Silver Impregnated
 Cadexomer Iodine
Gauze

 Minimal absorbency – small to mod

draining wounds
 Wear time: dependent on amount of
exudate, usually daily
 Does not promote a moist wound
environment
 Painful (#1 painful dressing)
Transparent Film

 Adhesive, semipermeable, waterproof and

impermeable to bacteria and contaminants,
permits water vapour to cross the barrier
 For wounds with little or no exudate,
wounds with necrotic tissue or slough, can
be used in high friction areas
 Wear time: 7 days
Hydrocolloid

 Impermeable to bacteria & other

contaminants, moist wound healing
environment, promoting granulation and/or
autolytic debridement, self-adhesive and
mold well.
 For wounds with light to moderate exudate
 Wear time: up to 7 days (usually 3-5)
Acrylic

 Transparent, breathable
membrane that allows
vapour to transfer out
 Exudate solutes remain,
colouring dressing
 Change in 21 days or
when dressing leaks
Calcium Alginate

 Derived from brown seaweed, interacts with

wound exudate to form a soft gel that
maintains a moist healing environment
 Used for wounds with moderate to heavy
drainage, can absorb up to 20 times it’s
weight
 Requires secondary dressing; can be used
in combination with hydrocolloid or foam to
increase wear time
Hydrofibre

 Man-made fibrous dressing (100% pure

carboxymethylcellulose), interacts with wound
exudate to form soft gel that maintains a moist
healing environment, can absorb up to 30 times its
weight.
 For wounds with moderate – heavy drainage
 Requires secondary dressing; can be used in
combination with hydrocolloid or foam to increase
wear time
Foam
 non-linting absorbent dressings that vary in
thickness
 have a non-adherent layer allowing for
nontraumatic removal
 provide a moist environment and thermal
insulation.
 moderate to large draining wounds
Preventing Tape/Adhesive Damage

 Protect periwound skin

– No Sting barrier film
– Picture frame wound – hydrocolloid (Tegasorb)
 Remove adhesive carefully
– Alcohol dissolves adhesive bond
– Clear film removal technique
Managing Bacterial Burden

 Proven effectiveness in wound healing

 Inflammation is helpful in acute wound healing
– Induces vasodilatation and increases blood flow
– Brings antibodies and phagocytic cells to remove
wound debris, microorganisms, foreign debris,
– Usual signs are pain, redness, swelling, increased
temperature, purulent drainage
Managing Bacterial Burden

 In chronic wounds infected with persistent

microbial burden, the inflammatory response is
prolonged and actually releases enzymes and
cell mediators that harm the tissue host
 Thrombosis and vasoconstriction lead to tissue
hypoxia – promotes bacterial proliferation
Managing Bacterial Burden

 Chronic wounds may become “stuck” in the

inflammatory phase – excessive drainage,
increased slough on wound bed – usually due
to presence of bacteria, fungi, viruses in wound
bed
 Bacterial Burden Continuum

Colonization Local Systemic

Contamination infection infection

Critical
colonization
Managing Bacterial Burden
 Local infection vs  Critical colonization
– Pain
– Redness in periwound
tissue
– Swelling in periwound
tissue (induration)
– Increased temperature
– Purulent drainage
– Foul odour
– Delayed healing
– Increased exudate
– Discolored granulation
tissue – friable, exuberant
– New areas of breakdown
or slough on wound
– Foul odour
– New pain
Superficial Increased
Bacterial Burden

NERDS
N – nonhealing wound
E – exudative wound
R – red and bleeding wound
D – debris in the wound
S – smell from the wound

Reference: Sibbald, Woo, Ayello, Increased Bacterial Burden and Infection: The Story
of NERDS and STONES, Advances in Skin & Wound Care, October 2006
Deep Compartment Infection

STONES
S – size is bigger
T – temperature increased
O – os (probes to or exposed bone)
N – new areas of breakdown
E – exudate, erythema, edema
S – smell
Reference: Sibbald, Woo, Ayello, Increased Bacterial Burden and Infection: The Story
of NERDS and STONES, Advances in Skin & Wound Care, October 2006
Managing Bacterial Burden

 Clean the wound

– Cleansing and irrigation with normal saline or sterile
water to remove exudate and surface debris
– Irrigate with syringe (20 – 30 cc) plus angiocath (18
- 20 gauge)
– Debride necrotic tissue
 Use topical antimicrobial agents
Managing Bacterial Burden

 Nanocrystalline silver has antiinflammatory and

antimicrobial effect
– Effective against broad range gram positive and
negative bacteria, aerobes, anerobes, fungi, yeast,
viruses
– Affects bacteria DNA, enzymes, cell membranes
– Low possibility of developing resistance
– Minimum inhibitory concentration (20 - 40 ug/mL)
Managing Bacterial Burden

 Nanocrystalline silver has antiinflammatory and

antimicrobial effect
– Actisorb Silver (Johnson & Johnson)
– Silvercell (Johnson & Johnson)
– Aquacell Silver (Convatec)
– Acticoat Silver (Smith & Nephew)
– Acticoat 7 Silver (Smith & Nephew)
Cadexomer Iodine

 combines iodine and a modified starch in

the form of a gel or a pad in order to reduce
bacterial load
 time-released antimicrobial
 change when the colour changes from
brown to a yellow-grey
Other Antimicrobial Dressings

 Mesalt (hypertonic saline gauze)

 Medihoney (hospital grade manuka honey)
 10% Povidone-Iodine (Betadine)
Staging Pressure Ulcers

 National Pressure Ulcer Advisory Panel

(NPUAP)
 4 stages of tissue injury
 Stage X
Stage 1

 Persistent redness as a result of inflammation

response
 Skin intact
 Very painful
 Blanch test – normally turns white with
pressure
 Usually repairs itself when pressure removed
Stage 2

 Skin is open
 Partial thickness injury (epidermis, dermis)
 Very superficial (blister, abrasion, shallow crater)
 Heals in a few days with moist wound healing products
if pressure relieved
 Exception: if moisture is the cause of skin breakdown
Stage 3

 Full skin thickness is damaged and into

subcutaneous tissue
Stage 4

 Damage extends through subcutaneous tissue

to the muscles, bones, tendons, joints
 Undermining may occur
Stage X

 Stage X – unable to
stage, wound covered
with slough or eschar
Negative Pressure Wound Therapy:
VAC

 Description: Noninvasive active therapy using

localized negative pressure. It removes excess
interstitial fluid, decreases edema and bacterial
colonization, increases blood supply and granular
tissue formation, and enhances epithelial and cell
migration.
 Indications: Granular draining wounds; full-
thickness wounds; venous, arterial, diabetic, and
pressure ulcers; surgical wounds; flap and grafts;
and acute traumatic wounds.
Negative Pressure Wound Therapy:
VAC

 Contraindications: necrotic tissue, enteric fistulas,

untreated infection or osteomyelitis, malignancy
 Change indicator: dressings are change M-W-F for
most wounds, leave on for 5 days for graft.
 Wear Time: dependent on goal of therapy