Describing wound details

Describing the details

Wounds are described as either partial or full thickness. A partial-thickness wound involves tissue damage to the epidermis and dermis. A full-thickness wound involves damage to the subcutaneous tissue, muscle, and bone. Various classification systems have been designed to help you assess specific wound types, document accurately and completely, and gauge healing. (See Definitions for Pressure Ulcers and Wagner's Foot Ulcer Grade Classification.)

In addition to general wound characteristics, examine what's in and around the wound to further assess it.

Type of tissue. Although a healthy fully granulating wound bed is ideal, many wounds consist of varying amounts of healthy granulation tissue and nonviable tissue, such as slough or eschar. Granulation tissue includes new blood vessels and immature collagen. Initially pink, it turns beefy red as it accumulates. Slough is moist, devitalized tissue that may adhere strongly or loosely to the wound bed and walls. The color normally ranges from yellow to tan. Eschar is dry, dead tissue that's dark brown or black. As tissue damage continues, eschar usually thickens and attaches more firmly to the wound.

As you identify the types of tissue in the wound bed, estimate how much of each is present, such as 60% granulation, 20% slough, and 20% eschar. Document the percentages on a flow sheet to allow for assessment of wound healing or deterioration.

* Wound integrity. If your patient has a fullthickness wound, assess for undermining, a hollow between the skin surface and the wound bed that occurs when necrosis destroys the underlying tissue. wTunneling, on the other hand, is a passageway within and beyond the wound walls or base.

To document undermining or tunneling, relate its location to a clock, with 12 o'clock toward the patients head. For example, "Undermining of 4 cm from the 2 o'clock to the 6 o'clock position" or "The wound tunnels 6 cm at the 5 o'clock position."

Next, examine the wound for the presence of supporting structures, such as tendons or bones. Note any orthopedic hardware and be alert for foreign bodies, such as sutures and staples, all of which increase infection risk. Wounds with tunneling or undermining are especially vulnerable for retained dressings. Lastly, assess for foreign bodies, such as a forgotten suture or lint.

* Exudate. Follow your facility's guidelines for defining "small," "moderate," and "high" amounts. Describe the exudate as serous, serosanguineous, or purulent. Infection can affect the color, consistency, and amount of exudate as well as cause an odor.

* Wound edges. In full-thickness wounds, particularly when undermining is present, the edges may curl under and delay healing. A white, shiny appearance at the wound edges may be the result of epidermal cells migrating across the wound to resurface it, which signals healing.

* Periwound skin. Assess the skin around the wound for color, moisture, intactness, induration, edema, pain, and presence of a rash, trophic skin changes, and infection. The color can be pink, red, blue, pale white, or gray; in darker skin, you may note deeper skin tones. Pink usually indicates healthy skin; red may indicate friction, pressure, or beginning infection; blue or pale white is often a sign of compromised circulation. Erythema may or may not blanch when you apply pressure.

The skin surrounding a wound may have too much moisture (maceration), which could increase the patients risk of fungal or yeast infection. Assess the periwound skin for primary skin lesions. Note the presence of a hyperkeratotic rim (a calluslike growth), often associated with neuropathic wounds on a weight-bearing surface. Infection of the periwound tissue often presents with erythema; induration; warmth; change in the color, odor, or consistency of the exudate; and pain.

For more information regarding wound assessment and for a complete wound measuring and documentation solution please visit www.woundassessment.co.uk

Sharpen your wound assessment skills?

Learn how impeccable assessment and documentation can help your patient heal.

Accurate assessment holds the key to all aspects of wound care. Besides pointing to the cause and guiding treatment, it serves as a baseline for subsequent assessments. In this article, I'll spell out the components of comprehensive assessment so you can tune in to the processes behind wound formation and help promote healing.

Looking at the big picture

The initial wound assessment takes in the big picture: location, shape, and size.

* Location. This can give you clues to the cause. For example, a trochanteric wound (on the bony prominence at the upper end of the femur) indicates pressure from a side-lying position, and an ischial wound (on the lower portion of the hip bone) indicates pressure from sitting. A sacral wound may be the result of sitting if the patient is elderly or has a weakened musculoskeletal system that causes him to slide down when he sits, applying pressure on his sacrum.

Whenever possible, use anatomic landmarks and language to document the location of a wound. Left trochanter is preferred to left hip, and right medial malleolus is preferred to right inner ankle. A body diagram with separate views of the feet is useful to document wound location.

* Shape. Wound shape also can shed light on the cause. A triangular sacral or coccygeal wound could be due to shearing and pressure forces caused by movement in bed. A linear wound on the posterior midthigh of someone who uses a wheelchair could be caused by pressure from the edge of the seat.

* Size. Measure the length, width, and depth of your patients wound in centimeters. If possible, the same nurse should measure the wound and the patient should be in the same position for each subsequent assessment.

Length is the largest area from a head-to-toe perspective; width, the largest area from a side-to-side perspective. When a wound has an irregular shape, a tracing is useful to document size. Use manufactured tracing sheets or a sheet of plastic wrap folded in half. Place it against the wound and trace around the perimeter. Remove the sheet, cut it along the fold, and place the half that touched the wound in a biohazard container. The part with the tracing is clean and can be included in the medical record.

If you photograph a wound, be sure to have written consent and adhere to your facility's policies and procedures. Use wound film with size markings included or place a ruler in the photograph for perspective.

To measure wound depth, moisten a sterile, cotton-- tipped applicator with 0.9% sodium chloride solution. (Don't use a dry one, which could injure newly formed granulation tissue.) Place the applicator tip in the deepest aspect of the wound and measure the distance to the skin level. If the depth is uneven, measure several areas; document the range and which part of the wound is the deepest.

Visit www.woundassessment.co.uk for an accurate and intuitive measurement solution.

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