Mr. Jones is a 70-year-old male who is seen in the primary care clinic with a non-healing wound on his left lower leg that he reports having for about 2 months.
Would you know where to start?
Below is an example of one possible approach:
Evaluate the patient’s chief complaint (wound on the lower leg that is not healing). Note the duration/date of onset (2 months duration).
How did the patient say he got the wound (trauma, stepped on a dirty nail, animal or human bite, maybe the patient doesn’t know)? Mr. Jones says he thinks he must have hit the outer part of his leg on his lawnmower 2 months ago, but can’t really remember how the wound started. When considering possible etiologies, asking the patient how he thinks he got the wound as well as why he believes the wound is not healing is important (but realize the patient is not always correct about this). Other information to ascertain about the patient includes what treatments he/she has tried so far, and any changes in the wound since wounding.
Describe Past Medical History/Co-morbid Conditions and Physical Limitations
Review important past medical history: Co-morbid conditions can lead you to suspect certain etiological factors. Diabetes, hypertension, high cholesterol, or cardiac diagnoses? Peripheral arterial disease (PAD) is likely in patients with an existing diagnosis of coronary artery disease (CAD) or related risk factors (diabetes, smoking, high cholesterol, and hypertension). The distal blood vessels are the smallest, so it is logical that atherosclerotic arterial disease would first affect distal blood vessels before the involvement of the larger coronary arteries is obvious. Respiratory problems or pneumonia (as well as cardiovascular problems and anemia) are associated with potential wound oxygenation/perfusion issues. Rheumatoid arthritis, Crohn's disease, ulcerative colitis and other autoimmune diseases are associated with impaired wound healing and a higher incidence of pyoderma gangrenosum (an autoimmune disease typically causing chronic wounds especially of the lower extremities).
Physical limitations are important to note because neuropathies and arthritis in the hands could make dexterity an issue in the patient’s self-care of wounds.
Allergies may lead you to consider why treatment may not have been very successful so far, as well as what treatments to avoid in the future.
It is important to ask about (and document) the patient’s last tetanus shot, especially if it has been 10 years or more since the last tetanus vaccine or the wound was traumatic/dirty (stepped on a nail, hit lower leg on the lawnmower). Tetanus is a bacterial infection that is now rare (thanks to vaccination), but still very dangerous and there is no cure. Two out of every 10 people who get it will die. In the United States deaths attributed to tetanus have dropped by 99% since 1947, largely due to current CDC vaccination guidelines.
Clinical Tip: Be aware that certain injuries (especially outdoor puncture wounds) and animal bites have much higher incidence of serious infections. Particular types of bacteria are associated with particular animals or humans and cultures are recommended, but treatment may be started presumptively based on type of bite/injury. Individuals should be offered a Tetanus vaccine as soon as possible after injury, especially puncture wounds, but this also includes animal or insect bites (spider bites). In addition, certain animal bites may also warrant rabies vaccines and rabies immune globulin. See the Centers for Disease Control (CDC) website for more information.
Social and Dietary History
Assess and document all pertinent information, including social and current dietary/nutritional information. Pertinent social information (literacy level, health insurance, smoker, place of residence, electricity, running water, a caregiver at home, heavy alcohol or illegal drug use) are important to note and can influence the clinician’s diagnosis as well as treatment options and management approaches available to the clinician and the patient. Assess the current nutritional intake and dietary habits of the patient (3 meals per day versus 1 meal per day, portion size, types of food). Poor nutritional intake is often overlooked despite the fact that adequate nutrition (especially protein and essential micronutrients and amino acids) is imperative for wound healing.11, 17, 19, 29
Any medications the patient is taking (even over the counter medications) are also important to document. Corticosteroids and non-steroidal anti-inflammatory drugs (NSAIDs) are common medications that may impair wound healing.11, 17, 19
General Exam and Vital Signs
While a focused exam of the wound is reasonable if that is the main purpose for the patient’s visit, it is good to document general findings (especially general appearance, hygiene , skin lesions or rashes, edema) and vital signs (blood pressure, pulse, respiration, and temperature), height and weight (useful to calculate body mass index or BMI).
Assess the Wound
Document the location, size and characteristics of the wound (left lateral lower leg – you inspect it and note it is just above the malleolus/ankle). The wound size and characteristics should be noted as length x width x depth at deepest point in centimeters (cm) (for our case example: 2.0cm Length x 2.0cm Width x 0.4cm Depth at 6 o’clock). The clock face is visualized over the wound with 12 o’clock always pointing towards the head of the body and 6 o’clock pointing at the foot of the body - as a way to document the exact location of particular features of the wound such as tunneling, undermining, etc. When the wound is measured (Length in cm x Width in cm x Depth in cm), take care to note any tunneling or tracking in the wound bed (and where it tracks to if possible, for instance, if wound #1 tracks to/communicates via tunneling to wound #2) or any undermining present (a “lip” or “shelf” under unattached wound edges). Note the wound bed appearance for the presence of non-viable tissue and describe the color (white, grey, yellow, or black non-living tissue) versus healthy pink or red “granulating” tissue. List the amounts of these tissues in estimates of percentages covering the wound bed. Note any exposed bone, muscle, tendons or ligaments in the wound bed. Be careful not to confuse any exposed tendons or ligaments, which have a linear flat white or yellow appearance, as non-living tissue Drainage is documented as the amount, color and odor (for our case example: scant amount of clear yellow fluid with no remarkable odor). The location and appearance of the wound provides the clinician with important clues about the etiology or contributing factors to the wound. Physically assess the wound as described above as well as the surrounding skin and the whole extremity (for example, are there any rashes, lesions or other remarkable findings?).
Pain and Sensation
It is also important to remember to ask the patient about any pain related to the wound, and document their answers. What are relieving or aggravating factors (pain worse at night or when leg is elevated, or worse after all day on feet and better when elevated at night?) What is their pain level on a scale of 1 to 10, and what is the character of the pain (constant, intermittent, throbbing, etc.)?17 Also assess sensation and pain in the affected extremity, especially if the patient is a diabetic.17, 30, 31
Pulses: Check Dorsalis Pedis and Posterior Tibial Pulses
Always assess dorsalis pedis (DP) and posterior tibialis (PT) pulses for any wound involving the lower extremities! Check Popliteal pulses if warranted. In general, if there are strong DP and PT pulses (and capillary refill of the distal affected extremity appears normal/no other circulatory warning signs of arterial, venous or lymphatic insufficiency), they probably do not need further vascular evaluation by a specialist. However, if there are no palpable pulses in the affected lower extremity below the level of the wound, perform an Ankle Brachial Index (ABI) of both lower extremities. This is a quick screening assessment for arterial insufficiency.9,17, 32, 33 If this is difficult to obtain, consider referral for further vascular studies such as doppler arterial blood flow studies and/or transcutaneous oxygen tension (TcPO2) testing to the peri-wound skin (> 40 mmHg is desired) to determine adequate arterial blood supply and/or perfusion to the affected extremity/wound area.17, 32, 33
Clinical Tip: There is a very nice quick reference guide for clinicians on how to perform ABI assessment on the Wound, Ostomy, Continence Nurses (WOCN) Society website.