It is Friday afternoon at 4 p.m. and you pull into the driveway of your last home care patient for the week. As you sit in your car preparing to see a new client, you notice from the record that the patient has a wound. “This is the third new patient this week that suffers from a wound. What do they think I am, a wound care expert?,” you say to yourself. Actually, you are not imagining things. The prevalence of chronic pressure ulcers cared for in the home is approximately 19 percent. Understanding wound assessment is imperative to caring and providing equipment for these clients and their families. Let’s examine the basics of wound assessment.
Anatomy of the Skin
In order to provide assessment of a wound, we must first have knowledge of the anatomy and physiology of the skin. The skin is the body’s largest organ and its main functions are protection, sensation, synthesis of vitamin D from sun exposure and temperature regulation. A relatively light organ at only six to eight pounds, the skin is made up of two distinctive layers, the epidermis or the outermost layer which actually is composed of five separate layers, and the dermis or the thicker layer lying just below the epidermis.
The foremost question we must ask ourselves is, What is the cause of this wound?
The epidermis is avascular meaning it does not have a blood supply and sheds itself constantly. It is composed of tightly packed cells and is about the thickness of a business card in many areas of the body. Although it can be thicker in certain areas such as the sole of the foot, and thinner in others such as the eyelids, it turns over about once a month. This process of regeneration slows as the body ages. The dermis is the thicker vascular layer and houses the blood supply, the hair follicles, sweat glands and nervous inervention. It is beefy red and granular in appearance. Beneath the dermis lies the subcutaneous or fatty tissue and beneath the subcutaneous layer lies the underlying tissue consisting of muscle, bone and supporting structures such as tendon.
The foremost question we must ask ourselves is, What is the cause of this wound? This might necessitate the need for more information from our client and their chart. A thorough history will help in discovering how the wound developed. Are there any underlying medical conditions such as vascular insufficiency, chronic diseases such as diabetes or other systemic conditions present? Often a wound located on the lower extremities, for instance, commonly occurs from arterial insufficiency, incompetent venous system, neuropathy or a combination of these conditions. Is the wound acute or chronic? An acute wound normally proceeds through an orderly and timely reparative process that results in sustained restoration of anatomic and functional integrity. An example of an acute wound is cutting yourself while shaving. A chronic wound is one that has failed to proceed through an orderly and timely process to produce anatomic and functional integrity, or proceeded through the repair process without establishing a sustained anatomic and functional result (Lazarus et al, 1994). An example of a chronic wound is a pressure ulcer.
Wounds may be classified by degree of tissue layer destruction and by color. If the etiology or cause of the wound is mixed or unknown, the wound can be classified using depth. Wound depth is important since it has a direct effect on how long it may take to heal. Partial thickness and full thickness are terms used to describe wounds other than pressure ulcers. Partial thickness wounds extend through the epidermis and into, not through the dermis. These superficial wounds usually heal rather quickly by reepithelialization. Full thickness wounds extend through the dermis and may involve the subcutaneous tissue, muscle and underlying tissue such as bone. These wounds heal more slowly by granulation, contraction and epithelialization.
Pressure ulcers are described or classified by stage, as recommended by the National Pressure Ulcer Advisory Panel and the Agency for Healthcare Policy and Research. Once a pressure ulcer is assessed, the stage remains constant. In other words, a stage 4 does not heal to become a stage 3 or stage 2. It may be a healing stage 4 that has granulated 80 percent, but it remains a stage 4. Pressure ulcers should never be reverse staged or back staged. The wound bed must be visible in order to be staged. If not, the wound is considered unstageable until the necrotic tissue is removed.
A stage 1 pressure ulcer is an observable pressure-related alteration of intact skin. The indicators as compared to the adjacent skin or opposite area on the body, may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel), and sensation (pain, itching). The ulcer presents as a defined area of persistent redness in lightly pigmented skin, whereas in darker tones, the ulcer may appear with persistent red, blue or purple hues.
A stage 2 pressure ulcer is a partial-thickness skin loss involving the epidermis and the dermis. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.
A stage 3 is full-thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
A stage 4 pressure ulcer is full-thickness skin loss with extensive destruction, tissue damage to muscle, bone or support structures (for example, tendon or joint capsule). Tunneling and sinus tracts may also be associated with state 4 pressure ulcers.
A wound also can be classified by color: red, yellow and black. The three-color concept is designed for use with surgical, traumatic and other wounds like pressure ulcers that heal by granulation. Red indicates a clean, viable and healthy granulation tissue. There is good blood supply and the wound appears beefy red or deep pink. A yellow wound indicates the presence of slough or thick exudate and needs to be cleansed or gently debrided. Hues of yellow include beige, light green, or white. The black wound indicates the presence of necrotic tissue or eschar. Dead tissue such as this is a prime breeding ground for infectious microorganisms and halts healing. This color wound needs to be aggressively debrided unless the area is stable and located on the heel.
The anatomic location of tissue breakdown should be documented consistently. An easy way to accomplish this is by utilizing an anatomical location chart or diagram. Using correct terminology and vocabulary that is uniform, is imperative. Location is important since it often can help pinpoint the cause of the ulcer.
Measurement of wound size consists of length, width, depth and sometimes volume (usually only used in research situations). Linear measurement of length, width and depth in centimeters is accomplished using a wound ruler or measuring device that is disposable. They are available for sale or often provided as value-added tools from manufacturers. Length is considered the distance from the top of the wound (toward the patient’s head) and the bottom of the wound (toward the patient’s feet) or with reference to the face of a clock, from 12 o’clock to 6 o’clock. Width is from 9 o’clock to 3 o’clock or from side to side. The wound’s depth is the distance from the viable surface to the deepest point in the wound bed. Another method of measurement is wound tracing. Any tunneling (sinus tracts) should be documented and include measurement of length and direction. The face of a clock again, represents a good point of reference.
The wound’s shape also is an important aspect to note. Pressure ulcers that are elliptical or elongated frequently indicate damage as a result of shear and friction forces. Arterial ulcers and diabetic ulcers usually have even wound margins whereas venous ulcers tend to have irregular boarders.
Wound Bed and Surrounding Skin
The examination and assessment of the wound bed is probably the most telling sign of the wound’s health and ability to heal. Color, as described above, indicates the need for certain treatments and possible debridement. The appearance of the surrounding tissue or periwound skin is also of importance. Observe the color and temperature and if the skin is intact or open, moist, macerated or dry. Is there redness or steaks surrounding the wound? Any warmth, tenderness or swelling? These could be signs of infection. Any undermining (epibole) or turning under of the wound edge should be measured. A chronic wound will often stagnate and fail to heal when epithelial cells meet other epithelial cells as with undermining. These wounds sometimes need to be kick started turning them into an acute wound by removing the undermined edge with sharp debridement or silver nitrate.
The amount, color, consistency and odor of the wound drainage should be assessed. Document the amount by describing how many times the dressing needs to be changed and what type of dressing is being used. For example, two 4x4s and an ABD pad saturated every three hours. Terms like scant, moderate and copious are ambiguous and mean different things to different observers. Color can be described using the following terms: serous or a clear or watery plasma, sanguienous or bloody, serosanfuineous or plasma with red blood cells present or purulent, thick white, yellow, green or brown pus-like consisting of white blood cells and living or dead organisms and often is indicative of infection. Malodorous drainage can indicate the presence of dead material (example: drainage as a result of autolytic debridement from an occlusive dressing or pungent, strong, foul fecal or musty smell often suggests infection.
Wound pain and tenderness can be divided into incident pain, recurrent episodic pain and continuous pain (Krasner DL, 2001). Continuous pain can be an indicator of inadequate wound management, infection, vascular insufficiency (ischemic pain), or underlying tissue destruction that is not visible. Incident or episodic pain results from dressing changes, debridement or trauma and can be alleviated with the use of analgesia, administered either locally or systemically, prior to the dressing change, debridement or causative event. Wound pain can easily be assessed using the visual analog scale (0 = no pain and 10 = excruciating pain). Allowing the patient to call time-out during treatments and dressing changes or perform their own care and treatments can substantially decrease the experience of wound pain.
Action and Outcomes
Wound assessment should be accurate and comprehensive and include written documentation and possibly serial photography, which allows for evaluation of the treatment regimen. However, this is only the beginning. Action, in the form of measurable goals of care, must be determined and periodically evaluated for effectiveness. Development of protocols based on current valid research and best practices must be carried out in order to promote overall positive outcomes. To accomplish favorable wound healing, providers must follow prudent wound management, which begins with assessment and continues with planning and protocol development, implementation of treatment, and evaluation of care. Assessment is supported by the plan of care and treatment interventions which includes topical care (wound bed irrigations and dressings) pressure and tissue load management devices such as cushions and recumbent support surfaces like overlays, mattress replacements, and other therapies such as nutrition intervention and adjunctive treatments like warmth therapy. Patient and wound assessment is ongoing and continues through wound closure.
Next time you encounter a patient or client with a wound, don’t become frustrated. Ask questions, review history, observe, classify, measure and evaluate. Consider assessment the beginning of uncovering the keys to healing, achieving positive outcomes and improving the quality of your patient’s life.