ProCare Training Manual Chapter 3

Wound Assessment and Monitoring

Wound assessment requires focusing on the entire patient not just the wound. There are many factors that influence the body’s ability to heal itself, regardless of the type of wound. These factors include: • Blood glucose levels • Hydration • Nutrition • Blood albumin levels • Oxygen and vascular supply • Immune status • Pain Blood glucose levels Blood glucose levels should be below 200 mg/dl for satisfactory healing. Levels over 200 mg/dl can impair the function of white blood cells which help prevent infection and are important to wound healing. Hydration Skin and subcutaneous tissues need to be well hydrated from the inside to optimize the healing process. Dehydration impairs the healing process by slowing the body’s metabolism. It also reduces the turgor of the skin and makes it more vulnerable to new wounds. Nutrition Nutritional status helps you determine the patient’s ability to heal as well as their vulnerability to further skin breakdown. The wound care team should closely monitor this. There are four parts of the nutritional assessment they are: health history, body system assessment, laboratory tests, and anthropometrics measurements (weight, BMI, etc.). Laboratory studies used to assess Protein There are four laboratory studies that can be used to determine the patient’s protein stores. Albumin and Pre-albumin are the two most commonly utilized of the four. Albumin is a large protein molecule that acts like a magnet to attract water and hold it inside the blood vessel. Blood albumin levels are an essential factor in wound assessment for two reasons:

1) The skin is primarily constructed of protein, and albumin is a protein. If albumin levels are low, the body lacks an important building block for skin repair.

2) Albumin is the blood component that provides colloid osmotic pressure – the force that prevents fluid from leaking out of blood cells into the nearby tissues. If albumin levels fall below 3.5 g/dl, the patient can develop edema (leakage into tissue), which compromises wound healing. The patient can also develop hypotension as fluid leaks out of the bloodstream into tissues.

Serum albumin is probably the most frequently measured but it is not sensitive to rapid changes in nutritional status. The half life of serum albumin is 18-20 days; therefore, a serum albumin level will give you a picture of the patient’s nutritional status over the last month. Serum pre-albumin is a plasma protein with a short half life of 2 days. Therefore, measuring a patient’s pre-albumin will give you a better picture of the patient’s current nutritional status. This is especially helpful when you have asked the patient to increase their protein intake to aid in healing. Table 3-A contains the four laboratory values used when assessing a wound care patient’s protein stores.

Table 3-A Laboratory studies used to assess protein

Once a deficiency has been noted, it is helpful to determine the severity of the malnutrition. It is recommended that patients with moderate to severe malnutrition be referred to a dietician for consultation in diet and supplements. Table 3-B provides a guide to be used for the severity of each abnormal result. Table 3-B Protein levels in normal and malnourished states Oxygen and vascular supply

Healing requires oxygen and anything that impedes full oxygenation also impedes healing. Your assessment should consider any factor that may reduce the amount of oxygen available for healing. Possible problems include: • Impaired gas exchange, causing decreased oxygen levels in the blood • Hemoglobin levels too low to transport adequate oxygen • Insufficient arterial and capillary supply in the area of the wound • Low blood pressure that fails to drive oxygenated blood through the capillaries

Laboratory

Study Normal Value

Level in Mal-

nutrition Half life Influences

Albumin 3.5-5.5 gm/dl <3.5 mg/dl 18-20

days

Late indicator of malnutrition. Hydration sta-

tus will either dilute or concentrate level. Reli-

able changes are seen in 2-3 weeks.

Pre-albumin 15-25 mg/dl <15 mg/dl 2 days

Best used as a monitor of current protein sta-

tus. Reflects immune status, inflammatory

state and nutritional status. Changes with

hydration status but not as much as with

Albumin levels. Usually measured 1-2 times

per week.

Total Lympho-

cyte Count

(TLC)

1500-3000

cells per mm3

<1500 cells per

mm3 N/A

Tests immune function and protein status.

Depressed by chemotherapy, autoimmune

disease, stress and infection.

Transferrin

(TF) 200-400 mg/dl < 100 mg/dl

8-10

days

¯TF levels=acute phase response, chronic

inflammation,, and hereditary TF deficiency.

-TF levels= iron deficiency, early-mid

pregnancy, acute hepatitis, and estrogen use.

Laboratory Study Normal Mild Moderate Severe

Albumin 3.5-5.5 gm/dl 2.8-3.5 2.1-2.7 < 2.1

Pre-albumin 15-25 mg/dl 10-15 5-9 < 5

Total Lymphocyte Count (TLC) 1500-3000 cells per mm3 151-200 100-150 < 100

Transferrin (TF) 200-400 mg/dl 1200-1500 801-1200 <800

Any of these problems can deprive the wound of the oxygen needed for successful healing. This brings us to our next point and that is smoking. Smoking affects wound healing and you must encourage the patient to stop smoking in order to heal. You need to explain to the patient that smoking has the following effects on their ability to heal:

• Nicotine is a vasoconstrictor that narrows peripheral blood vessels, thereby compromising blood flow to the skin

• Because it’s easier for hemoglobin to bind to the carbon monoxide in cigarette smoke than to bind to oxygen, the blood that does get to the peripheral areas carries much less oxygen than it should

• Lung tissue damaged by smoke doesn’t function as well as it should, resulting in decreased oxygenation Pain It is important to control your patient’s pain not only for their comfort but also to control the amount of epinephrine released in the blood. The body releases epinephrine in response to pain, which also causes vasoconstriction and reduces the blood flow. Immune status The immune system plays a big role in wound healing. Anything that decreases the patient’s immune system can delay the healing process. This can be anything from AIDS to chemotherapy drugs and radiation. Remember that chemotherapy drugs are not only used to treat cancer but also used for arthritis, psoriasis, and several other immunosuppressant conditions. It should also be noted that corticosteroids might also depress the immune system function. Consider the type of wound It’s important to focus on the cause of the wound when doing your assessment. By doing this, you are more likely to consider all factors that can influence healing. If you are assessing a venous wound it is important not only to measure the wound but also to measure calf circumference at each visit to determine if efforts to reduce edema are successful. A venous insufficiency ulcer won’t heal if edema is left unattended. Similarly, if you’re assessing a diabetic patient you should check their blood glucose levels and check to see if you have a hemoglobin A1C ordered. The diabetic patient should also have their feet checked on a regular basis for any neuropathy or calluses. The best way to classify wounds is to use a basic system that includes these three categories of fundamental characteristics: • Wound age • Wound depth • Wound color Wound age – When determining the age of a wound, you need to determine if it is a chronic wound or an acute wound. However, this determination can present a problem if you adhere solely to a time line. Rather than basing your determination solely on time, consider a wound an acute wound if it’s new or making progress as expected and a chronic wound as any wound that isn’t healing in a timely fashion. The main idea is that, in a chronic wound, healing has slowed or stopped and the wound is no longer getting smaller and shallower. Even if the wound bed appears healthy, red and moist, if healing fails to progress, consider it a chronic wound. Wound Depth – Wound depth is another fundamental characteristic used in classifying wounds. In your assessment, record wound depth as partial-thickness or full-thickness. Partial-thickness – Partial-thickness wounds normally heal very quickly because they involve only the epidermal layer of the skin or extend through the epidermal layer of the skin into but not through the dermis. The dermis remains at least partially intact to generate the new epidermis needed to close the wound. Partial-thickness wounds are less susceptible to infection because part of the body’s first level of defense is still intact. These wounds tend to be painful and need protection from the air to reduce pain.

Figure 3-C Partial Thickness Wound Full-thickness – full-thickness wounds penetrate completely through the skin into underlying tissues. The wound may expose adipose tissue (fat), muscle, tendon, or bone. In the abdomen, you may see adipose tissue or omentum (the covering of the bowel). If the omentum is penetrated, the bowel may protrude, through the wound (evisceration). Granulation tissue may be visible if the wound has started to heal. Full-thickness wounds heal by granulation and contraction, which require more body resources and more time than the healing of partial-thickness wounds. When assessing a full-thickness wound, report the depth as well as the length and width of the wound. Figure 3-D Full Thickness Wound In the case of pressure ulcers, wound depth allows you to stage the ulcer according to the classification system, developed by the National Pressure Ulcer Advisory Panel (NPUAP). Once a wound has been staged, it is not to be “upstaged”. Meaning as the stage III wound heals; it does not become a Stage II. It is simply a healing Stage III. Below figure 3-E lists the recommendations for staging pressure ulcers or classifying the non-pressure related wound.

Figure 3-E Classification of Wounds and Pressure Ulcers Wound Color –The wound color will help the physician and staff determine if a debridement is needed. The only color that a wound should be is red, not just red, but blood red. One way to describe the wound bed is with the RYB model or, Red, Yellow and Black. If your wound is red (healthy granulation tissue) the wound is healthy and normal healing is under way. When the wound begins to heal, a layer of pale pink granulation tissue covers the wound bed. As this layer thickens, it becomes beefy red. Figure 3-F Red wound base

Yellow – A yellow color in the wound bed may be a film of fibrin on the tissue. Fibrin is a sticky substance that normally acts as glue in tissue rebuilding, however, if the wound is unhealthy or too dry, fibrin builds up into a layer that can’t be rinsed off and may require debridement. Tissue that has recently died due to ischemia or infection may also be yellow and must be debrided. Figure 3-G yellow base Black – A black wound bed signals necrosis. Eschar (dead, avascular tissue) covers the wound, slowing the healing process, and providing microorganisms with a site in which to proliferate. When eschar covers a wound, accurate assessment of wound depth is difficult and should be deferred until eschar is removed. Figure 3-H black base Debridement is usually required for black wounds; however, ulcers caused by ischemia (damage due to inadequate blood supply) and uninfected heel pressure ulcers are exceptions. Ischemic wounds won’t heal until blood supply is improved, and they’re less likely to become infected if kept dry. The wound can be debrided and kept moist after blood supply is reestablished. The body can then fend off infection and heal the wound. As long as they’re uninfected, heel pressure ulcers tend to heal from beneath the ulcer and don’t require debridement. Multicolored wounds – If you note two or even three colors in a wound, classify the wound according to the least healthy color present. Treatment of this type of wound should be focused on the color that is present in 50% or more of the wound. Figure 3-J Multicolored wound

Wound Drainage – The first step in assessing the wound drainage is to inspect the dressing as it is removed. Some of the questions that you need to answer are:

• Is the drainage well contained, or is it oozing from the edges? If it’s oozing, consider a more absorbent dressing.

• In the case of an occlusive dressing, were the dressing edges well sealed? If the dressing is in the groin or pelvic region, it is important to check for incontinence; this can be a breeding ground for bacteria.

• Is the dressing saturated or dry? How much drainage is there is it scant, moderate or large? • What is the color and consistency of the drainage? • What is the texture of the drainage? If it is thick and creamy it may have an excessive amount of bacteria.

Drainage Color and Consistency

Description Color and Consistency

Serous

• Clear or light yellow

• Thin and watery

Sanguinous • Red (with fresh blood)

• Thin

Serosanguinous • Pink to light red

• Thin or watery

Purulent • Creamy yellow, green, white, or tan

• Thick and opaque

To Swab or Not to Swab? If the drainage has a thick, creamy texture, the wound contains an excessive amount of bacteria. However, this doesn’t necessarily mean a clinically significant infection. The drainage is also contaminated with surface bacteria that naturally live in moist environments on the human body. Because of this bacterial colonization, guidelines developed by the Agency for Health Care Policy and Research, now the Agency for Healthcare Research and Quality, recommend against using swab cultures to identify wound infections. If the physician orders a swab you should obtain a swab of the clear fluid expressed from the wound tissue after it has been thoroughly cleaned. This is more likely to produce a sample of the bacteria in question. Punch biopsy of tissue or needle aspiration of fluid may also be used and are more likely to reveal accurate results. Assessing the wound bed Assessing the wound bed should include the following information:

• Wound dimensions, including size and depth • Tunneling and undermining • Bed texture and moisture • Wound odor • Margins and surrounding skin

Dimensions – Because recording the dimensions of a wound is important we use photography as a tool in wound assessment. When photographing a wound it is important to be sure you have the same axis on each picture. Take a photograph and draw the axis of the wound on it to ensure that with each new picture you are taking it at the same angle. In order to measure a wound, use a disposable tape measure. We suggest getting these from Pic-a-Poc. Record the length of the wound as the longest overall distance across the wound (regardless of orientation), and record the width as the longest measurement perpendicular (at a right angle) to your length measurement. Record all measurements in millimeters.

Tunneling and undermining- It is important to measure tunnels, or sinus tracts (extensions of the wound bed into adjacent tissue), and undermining (areas of the wound bed that extend under the skin). Measure these with a swab as you did the depth of the wound. If a tunnel is large, palpate it with a gloved finger rather than a swab, this will give you a more accurate measurement and avoid damaging the tissue. Figure 3-K Dehisced abdominal wound with tunnel

Texture – The texture of the wound bed provides much information about the wound. If you see a smooth, red tissue in a partial-thickness wound, it is most likely the dermis. In a full-thickness wound, it is probably muscle tissue –not granulation tissue. In a full-thickness wound, healthy granulation tissue has a soft, bumpy appearance much like tapioca (only red) – this is a sign of proper healing. Moisture – The wound bed should be moist, but not overly moist. Moisture allows the cells and chemicals needed for healing to move about the surface. As the cells divide during wound healing, they move from the outer edges to the inner most portion of the wound. If the wound is too dry, the cells have a much more difficult time moving inward. Imagine children playing leap frog. Each child jumps aver the back of the child in front of them. Epithelial cells move in the same manner as long as the wound bed is moist. See figure 3-L below Figure 3-L Leap frog theory

Arid Wound (Dry) – In a dry wound bed, the cells involved in healing, which normally exist in a moist environment, cannot move. WBCs can’t fight infection, enzymes like collagenase can’t break down dead material and macrophages cannot carry away the debris. The wound edges will curl up to prevent moisture loss and the new skin will fail to grow over and cover the wound. This anomaly is referred to as epoboli. When this occurs, the new epithelial cells are unable to migrate toward the center of the wound. The body is actually fooled into thinking it is healed as the edges have rolled under. When this happens, fibrin and necrotic tissue can build up and delay or stop all wound healing. See figure 3-M

Too Moist – Too much moisture will flood the wound and spill onto the outside of the wound bed. This can cause maceration of skin. See figure 3-M. Figure 3-M Moist vs. Dry wound bed

Odor – When kept clean an uninfected wound doesn’t usually have any odor (one exception is the odor normally present under a hydrocolloid dressing that develops as a by-product of the degradation process). A newly detected odor might be a sign of infection, record it in your findings and report it to the physician. When documenting a wound odor it is important to note when it was detected and whether it went away with wound cleaning. Margins and surrounding skin – When assessing wound margins, you want to see skin that’s smooth, not rolled, and tightly adherent to the wound bed. Rolled skin may indicate that the wound bed is too dry. Loose shearing skin may indicate damage to the wound during transfer of the patient and can lead to tunnel and sinus tract formation. The color of the skin around the wound can alert you to potential problems. If the skin is white it indicates maceration, or too much moisture, and signals the need for a protective barrier around the wound and a more absorbent dressing. If the skin is red it can indicate inflammation, injury from a burn, excessive pressure, or infection. Inflammation is healthy only during the inflammation phase of healing not after. Purple skin can indicate bruising from trauma. Calluses form on the periwounds of plantar surface ulcers, often indicating an increase in pressure. See Figure 3-N. Figure 3-N Macerated peri-wound

Use your fingers to help assess the periwound. Gently probe the tissue around the wound. Indurated tissue can feel hard and warm or boggy (soft and fluctuant), both of these are an indicator of possible infection. If a dark skin person has shiny skin around the wound it can also indicate inflammation. Pain – Pain assessment is an important part of wound assessment. To fully understand the patient’s pain you need to talk with your patient. Remember, pain is subjective and it is whatever the patient says it is. Have your patient rate his pain before and during each dressing change. If your patient rates his pain higher before a dressing change it may indicate an impending infection. If your patient says the dressing change itself is painful you might consider administering pain medication before the procedure or changing the dressing. Removal of dressing can be painful, however, there are ways to make it less painful. When you are removing adherent dressings it is less painful if you soak the dressing or use an adhesive remover. Keep the skin taut; press down on the skin to release the dressing, rather than just pulling the dressing off. If the patient still says it is painful you may wish to use a less adherent type dressing. Wound documentation – Your documentation of the wound should paint a picture of the patient and his wound. When assessing a wound the words “WOUND PICTURE” can be used to help you remember all of the necessary doc-umentation for the patient’s wound. W – Wound or ulcer location O – Odor? U – Ulcer category (for pressure ulcer) or classification (for diabetic ulcer), and depth (partial-thickness or full thickness) N – Necrotic tissue D – Dimension of wound (shape, length, width, depth) Drainage color and consistency and amount (scant, moderate, and large). P – Pain? Rate on scale of 0 to 10 I – Induration? (surrounding tissue hard or soft?) C – Color of wound bed (red, yellow, or black, or combination) T – Tunneling? Record length and direction. U – Undermining ? Record length and direction, using clock references to describe E – Edge of skin, is it loose or tight? Edges flat or rolled. Wound monitoring is the next step after assessment. It is important to reassess the status and document it at each visit. This is a good way to determine progress and is a CMS requirement. We will be assessing the patient at each visit and entering the data into our data base to achieve the healing rates and days to healing score. Your initial assessment sets the benchmark for subsequent monitoring and reassessment activities. There are other tools that are used for monitoring wounds and you should have some knowledge of them, a few are: PUSH – this is a tool developed by the NPUAP and is only used for pressure ulcers. When working with this tool you develop three scores: one for the surface area (length X width), one for the drainage amount and one for the tissue type in the wound. The sum of these scores yield a total score for the wound on a given day. This is done at each visit and the scores are then plotted on a graft to show the healing progress over time. The PUSH tool is used primarily by long-term care facilities and some hospitals. It is flawed in that it does not take into consideration the complete area of the wound involvement in that it only records the wound by length and width and excludes depth, tunneling or undermining measurements. It measures its rate of healing by the decrease in the surface area, decrease in drainage and color of wound base. PSST – The Pressure Sore Status Tool allows you to track scores for eleven factors over time. This tool does give a precise record of wound changes but is time consuming to fill out and is used more in research than in clinical practice. Sussman Wound Healing Tool is another tool for pressure ulcers and is used mostly by physical therapists. It lists 10 wound attributes and classifies each as “good” or “not good” The Wound Healing Scale is a simple classification system that combines a designation for wound stage, or thickness, with a tissue descriptor.

Stage

(Pressure

Ulcer ON-

LY)

Class

Wag-

ner

Scale

Merck Description

I Superficial 0 1

Involving but not through the epidermis. The skin is intact,

erythema may be present or the ulcer is healed or there is a

deformity

II Partial 1 2 Through the epidermis and dermis but no subcutaneous

involvement. Appears as an abrasion, blister or shallow crater.

III Full 1 3 Through the epidermis, dermis and the subcutaneous tissue. No

muscle, tendon, bone or joint involvement.

IV Full 2 4,5,or 6 Extensive destruction including muscle, tendon, bone or joint

capsule.

IV Full 3 4,5,or 6 As above with abscess, osteomyelitis, or tendonitis. Necrosis

with damage to muscle, tendon, bone or joint capsule.

IV Full 4 5 or 6 As above with gangrene (wet or dry) of some portion of the toe,

toes, and/or forefoot.

IV Full 5 6 Gangrene (wet or dry) of the entire foot making any procedures

impossible.

The Wagner Scale should be used for diabetic foot ulcers. This system is based on three features, depth of the ulcer, the degree of infection, and the presence or absence of gangrene and its extent. Grades 1 to 3 are mainly based on neuropathy, while grades 4 and 5 represent mainly ischemic lesions. CMS requires this scale to be used when assessing a patient for hyperbaric therapy. The Merck Scale is also a classification system for grading wounds, whether they be diabetic, venous or arterial in nature. The difficulties with this scale is that the higher grade levels all tend to run together. For your convenience, the table 3-O is a cross reference of the many different wound grading, staging or other classification systems. Table 3-O Wound staging, grading or classifications Recognizing complications in a wound – Recognizing complications of a wound is not only important to the patient and their family but also the health care industry. Treating chronic ulcers is expensive because they are can be very hard to heal and the financial impact can be tremendous. Government and insurance companies are placing increased emphasis on early intervention and prevention. Please refer to the included chart on wound complications. See table 3-P on the next page. How should a healing wound look? You can expect to see the following characteristics in a patient whose wound is progressing well:

• Patient is well hydrated, well nourished, comfortable and warm • Patient is well managed for contributing diseases, such as diabetes, vascular and renal problems • Patient exhibits normal immune system responses. • Patient has adequate vascular supply • Wound is moist and protected from the environment • Wound is free from necrotic tissue

Recognizing complications that warn you of a failing wound and knowing the appropriate intervention can ensure that your patient will have a better chance of healing their wound.

Table 3-P wound complications

Sign Cause Intervention

Too Dry • Exposure to air • Inadequate hydration

• Use a dressing that maintains

moisture such as a

hydrocolloid or hydrogel

• Add moisture regularly

No change in size or

depth for 2+ weeks

• Pressure or trauma to area

• Poor nutrition, poor circulation, inadequate hydration,

or medications

• Poor control of disease process (diabetes, etc.)

• Infection

• Inadequate pain control

Reassess the patient for local or

systemic problems that impair

wound healing and intervene as

needed

Increase in Depth or Size • Infection

• Debridement

• Ischemia due to excess pressure or poor circula-

tion

• Increase in size due to

debridement is normal

• Do vascular studies to find

poor circulation, also consider

adding warmth to the area and

administering a vasodilator or

anti-platelet medication

Necrosis Ischemia Perform debridement if the

remaining tissue has adequate

circulation

Increase in drainage or

change in color from

clear to purulent

• Infection

• Autolytic or enzymatic debridement

• No intervention if caused by

autolytic or enzymatic

debridement

• Assess the wound for infection

Tunneling • Deep infection

• Presence of foreign body

• Pressure over bony prominences

• Protect the area from pressure

• Irrigate and inspect for any

foreign body (dressing, etc.)

• Thoroughly clean and obtain a

tissue biopsy for infection and

with a chronic wound for

possible malignancy

Red, hot skin,

tenderness, and

induration

Inflammation due to excess pressure or infection If pressure relief doesn’t resolve

the inflammation within 24 hours

use a topical antimicrobial

medication

White skin (maceration) Excess moisture • Protect skin around wound

with a protective barrier

• Use a more absorptive

dressing

Rolled skin edges Too dry of a wound bed • Use a moisture dressing

• If it doesn't resolve the

problem, the edges may need

to be trimmed by debridement