WOUND ASSESSMENT

DR.MOHAMMAD ANWAR HAU ABDULAH DEPARTMENT OF ORTOPEDIK, HOSPITAL RAJA PEREMPUAN ZAINAB II

Learning points
1.Wound types 2.Acute/chronic wounds 3.TIME in wound bed preparation 4.Wound assessment

Different between wound and ulcer

Wound A wound is an injury to the integument or to the underlying structures that may or may not result in a loss of skin integrity. Physiological function of the tissue is impaired. Wounds are the visible result of individual cell death or damage. (Wounds occur due to trauma by external

means accidental or intentional, by contact or radiation)

Ulcer An interruption of continuity of an epithelial surface with an inflamed base.

(Ulcers occur as a result of an underlying or internal etiology.)

Types of wound
Small --------- Big Simple ------ Complex Acute -------- Chronic Clean -------- Dirty Healthy ----- Infected

TYPE OF WOUNDS
Underlying etiology: Trauma wound Diabetic ulcer Malignant Tracheotomy Venous ulcer Episiotomy Arterial ulcer Burn Pressure sore Stoma Surgical/incision wound

Traumatic

Diabetic foot

Malignant

Vascular

Pressure sore

Surgical wound- infected

Expectation:
Wound ------> heal

Questions
Acute wound? Chronic wound? Non-healing wound?

Acute wound:
Follow a well-defined healing process: -Coagulation (0 3 hours)
-Inflammation (0 3 days) -Cell proliferation and repair of the matrix (3 21 days) -Epithelialisation - maturation and remodelling of scar tissue

Heal within an expected time eg. surgical and traumatic wounds

Chronic wound:
Does not heal within expected time Stuck in the healing process; inflammatory and proliferative stages of healing (Ennis and Menses, 2000) which delays closure. The epidermis fails to migrate at the wound margins, which interferes with normal cellular migration over the wound bed

Chronic wound:
Causes: pressure, infection, poor nutrition, diseases, and poor circulation. Usually required active wound treatment for healing.

Wound bed preparation

Definition: the management of a wound in order to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures Dynamic and rapidly evolving concept

Wound Bed preparation:

focus systematically on all of the critical components of a non-healing wound to identify the cause of the problem, and implement a care programme so as to achieve a stable wound that has healthy granulation tissue and a well vascularised wound bed. Dependent on effective and accurate

patient and wound assessment

 Four components in wound bed preparation:

T.I.M.E

(i) Tissue management

I (ii) Inflammation and infection control M (iii) Moisture balance E (iv) Epithelial (edge) advancement
TIME framework offers clinicians a comprehensive approach where basic science can be applied to develop strategies that maximise the potential for wound healing

T.I.M.E
TIME framework is not linear: different wounds require attention to the different elements. - eg. diabetic foot ulcer: infection--- > radical and repeated debridement of the wound. - Venous ulcer: restoring and maintaining moisture balance Any intervention can have impact on more than one element of TIME.

WOUND CARE: effective and accurate patient and wound assessment

WOUND ASSESSMENT
Patient assessment Local wound assessment

Patient assessment
Identify and eliminate any underlying causes or contributing factors which may impact the healing process

Patient assessment
Medical history Underlying cause of wound/ulcer Age Medication/Allergies Other diseases such as: - Diabetes, vascular disease - Immune compromise

Patient assessment
Nutrition Lifestyle - Obesity, tobacco/alcohol abuse Environment: mobility Social network/support Psychological problems

Local wound assessment

Requires some training and skills Identify any local factors which might delay healing Prerequisite to the selection of an appropriate dressing.

Local wound assessment

Cause: determine duration and etiology Earlier treatment and progress Wound: shape - Dimensions - TIME - Surrounding skin

Local wound characteristics

Location, shape Size (length x width x depth) Wound bed (black, yellow, red, pink, undermined) - Tissue, infection, exudate (copious, moderate, mild, none) - Wound edge (callus and scale, maceration, erythema, edema) - Odor (absent, present)

Wound Size
Extreme Lengths

Depth

Wound dimensions:
Tunneling Tunneling is a course or pathway that can extend in any direction from the wound and results in dead space with potential for abscess formation.
Undermining Area of tissue destruction underlying intact skin along the wound margins Space between the surrounding skin and the wound bed

Tissue wound bed

Necrotic tissue Slough tissue hematoma

Supporting structure (bone, tendon, etc)

Granulation tissue Re-epithelization Exudate

 Volume Dry Moist Wet Heavily exudative

Moisture- exudate

Color & Consistency Serous - thin, clear Serosanguineous - thin, pale red Sanguineous - bloody, bright red Purulent - thick & yellow/tan

Types of exudate:
Description of exudate
Serous
Fibrinous Purulent

Components of exudate
Clear and watery. Bacteria may be present Cloudy. Contains fibrin protein strands

Milky. Contains infective bacteria and inflammatory cells Haemopurulent As above but dermal capillary damage leads to the presence of red cells Haemorrhagic Red blood cells are a major component of the exudate

Infection:
Erythema (Rubor) Edema (Tumor)

Heat (Calor)
Pain (Dolor) Loss of Function (Functio laesa)

Additional Indicators of Wound Infection

Delayed healing

Discoloration
Friable granulation tissue Elevated white blood cell count

Abnormal wound drainage

Odor

 Induration Pocketing at the base of the wound (undermine)

Epitheliasation
The final stage of wound healing is epithelialisation, which is the active division, migration, and maturation of epidermal cells from the wound margin across the open wound.

Failure of epitheliasation
Epidermal margins of a wound fail to migrate across the wound bed or the wound edges fail to contract and reduce in size.

TIME
Clinical observations Tissue nonviable or deficient WBP clinical actions Effect of WBP Clinical actions outcome Debridement Restoration of Viable wound wound base + base functional extracellular matrix proteins Infection controlled Bacterial balance + inflammation

Infection or Remove Inflammation infection

Clinical WBP clinical observations actions Moisture imbalance Apply moisturebalancing dressings

Effect of WBP actions

Clinical outcome Moisture balance

Restored epithelial cell migration, desiccation avoided Edge of Edge of Migrating wound wound keratinocytes nonnonand responsive advancing or advancing or wound cells. undermining undermining

Advancin g edge of wound

Wound Bed Preparation

Bacterial Balance

Debridement

Exudate Management

THANK YOU