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Wound Series Part 2a: Wound Assessment

2 Contact Hours
This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Nursing Student, Registered Nurse (RN)
This course will be updated or discontinued on or before Friday, March 22, 2024

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


Outcomes

≥ 92% of participants will know how to assess a wound.

Objectives

After completing this continuing education course, the participants will be able to meet the following objectives:

  1. Define acute versus chronic wounds.
  2. Differentiate expected pathways to healing for acute versus chronic wounds.
  3. Identify characteristics of a partial-thickness versus a full-thickness wound.
  4. Describe the phases of wound healing.
  5. Identify the components of effective wound management.
  6. Outline the elements of wound measurement.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
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Author:    Linda J. Cowan (PHD, ARNP, FNP-BC, CWS)

The Scope of the Problem: Wounds

Worldwide, millions of individuals experience chronic wounds, which represent a global health dilemma resulting in increased morbidity and healthcare costs. It has been estimated that more people throughout the world have chronic, complex, or non-healing wounds than the total population of the United States (US) with cancer (16.9 million) (National Institutes of Health [NIH] National Cancer Institute, 2020), asthma (25 million) (Centers for Disease Control and Prevention [CDC], 2021), or diabetes (34.2 million) (CDC, 2020a). In 2016, over 130,000 diabetics underwent a lower extremity amputation in the US alone. Many were due to complications of chronic/non-healing diabetic foot ulcers (CDC, 2020a).

Chronic, complex, or non-healing wounds represent a major health problem and a growing economic concern. Common chronic wounds include diabetic foot ulcers, venous leg ulcers, arterial ulcers, pressure ulcers/injuries, non-healing surgical wounds, and complicated trauma injuries (such as burns). Evidence-based wound prevention and treatment strategies are necessary to improve wound healing outcomes and decrease the number of chronic or non-healing wounds worldwide (Gupta et al., 2017; Doughty & McNichol, 2015).

Expected Pathways to Healing: Definitions

Wounds occur due to a disruption in the skin's integrity due to injury (such as surgery or trauma) or disease.

Acute vs. Chronic Wounds

Acute wounds are those that follow an orderly, expected pathway to healing. The anticipated timeline for the expected pathway to healing is dependent upon intrinsic factors (such as age, body build, and genetic factors), extrinsic factors (such as mechanical stress, temperature, smoking, radiation, debris, chemicals/medications, and infection), and the size of the wound or extent/depth of the tissue disruption. In other words, normal, acute wound healing may not occur the same number of days or weeks for all individuals. Acute wound healing for most open full-thickness wounds of human tissue follows an orderly (though sometimes overlapping) 3 or 4-step process immediately after wounding (Alhajj et al., 2020; Goldberg & Diegelmann, 2020; Raziyeva et al., 2021; Maheswary et al., 2021):

  • Step 1: Activation of the clotting cascade (hemostasis)
  • Step 2: Inflammation
  • Step 3: Proliferation (cellular proliferation, deposition of collagen/new extracellular matrix, granulation tissue formation, and angiogenesis)
  • Step 4: Scar tissue maturation/remodeling

When described as a 3-step process, hemostasis and inflammation are combined into one step or phase of wound healing (inflammation or inflammatory phase).

Chronic wounds do not follow the expected orderly healing steps quickly (Raziyeva et al., 2021; Maheswary et al., 2021). Why and how wounds get "stalled" or "stuck" and become chronic will be discussed further along in this course.

Partial-Thickness vs. Full-Thickness Wounds

When an alteration in skin integrity occurs, such as when a teenager falls from a skateboard and scrapes their knee, it results in an acute wound. Suppose the wound is superficial and extends only through the epidermis and perhaps involves the uppermost part of the dermis (but does not extend through the dermis or involve subcutaneous tissue or underlying structures). In that case, it is considered a partial-thickness wound (Doughty & McNichol, 2015).

We anticipate this type of wound will heal by regenerating skin cells and re-epithelialization (superficial skin cells will migrate over the injury and "close the wound").

This wound may not scar permanently.

If the wound extends through the epidermis and the dermis and includes subcutaneous tissue or underlying structures, it is considered a full-thickness wound (Doughty & McNichol, 2015).

We expect this type of wound to heal by the more complex 3 or 4-step process listed above, ultimately resulting in scar tissue formation. The wound's location determines the depth of tissue loss required to establish if a wound is partially or fully thick (Goldberg & Diegelmann, 2020).

Some parts of the body (over the anterior shin, the knuckles of the hands, bridge of the nose, eyelids, etc.) have very thin skin and do not have a significant amount of subcutaneous fat/tissue. A shallow wound over these areas would be a full-thickness wound though they may only extend 2mm deep (or less). Alternatively, wounds over the buttocks or fleshy parts of the body may be of a similar depth yet remain partial-thickness wounds because they do not extend through the dermis into subcutaneous tissue. Areas of the body, such as the ears and bridge of the nose, have cartilage directly covered by the dermis and epidermis. Any wound that involves cartilage is a full-thickness wound, even if it appears very superficial (Goldberg & Diegelmann, 2020).

Primary vs. Secondary Intention

Wounds are said to be healing by primary intention if a linear wound (such as a surgical incision) is re-approximated (edges pulled together) and sutured, stapled, glued, or taped together (without gaps) as an initial treatment approach. These wounds will typically form a "healing ridge" by post-operative (post-closure) day 5 in healthy individuals (Doughty & McNichol, 2015). This healing ridge is evidence of collagen deposition "knitting" the two separate wounded edges together, eventually resulting in a healed surgical site. In such a case, the wound site's skin should have the same tensile strength as surrounding tissue after the healing process is completed. This point is important to remember as we discuss wounds that heal by secondary intention.

Full-thickness wounds are described as healing by secondary intention if they are left open to heal or "fill in" with new granulation tissue and finally close by re-epithelialization (Goldberg & Diegelmann, 2020; Doughty & McNichol, 2015). Scar tissue in full-thickness wounds that heal by secondary intention (or scar tissue formation) will continue to mature 12-18 months after complete closure of the wound opening. The tensile strength (the ability of the skin fibers to resist breaking if pulled in different directions) of the resulting "matured scar tissue" in the area of a wound healed by secondary intention will never reach more than 80% of the surrounding tissue's tensile strength (Sussman & Bates-Jensen, 2012, Chapter 2). Therefore, this will always be a "weak spot" in skin integrity, prone to breakdown before the surrounding tissue. Therefore, a full-thickness pressure ulcer in a location likely exposed to repeated pressure such as the ischia or coccyx, which healed by secondary intention instead of flap closure, will be at greater risk of recurrence. This is one reason that surgeons sometimes prefer to create surgical skin flaps to close certain wounds such as clean, uncomplicated, full-thickness pressure ulcers in relatively healthy individuals (with the best chance of surgical healing), instead of leaving these wounds open to heal by secondary intention (Goldberg & Diegelmann, 2020).

On the other hand, full-thickness wounds that are initially sutured closed, re-opened (or left open at the start) for a while, and finally sutured, stapled, glued, or taped closed again, are said to be closed by tertiary closure. These wounds heal by combining scar tissue formation and surgical wound healing. Therefore, their suture lines may or may not reach the surrounding tissue's tensile strength, depending on the amount of scar tissue formation (Goldberg & Diegelmann, 2020; Doughty & McNichol, 2015).

Wound Healing

As discussed above, open full-thickness wounds healing by secondary intention heal by scar tissue formation and wound contraction. When wounded, the human body sets into motion a cascade of processes resulting in new collagen production to fill the open defect of a full-thickness wound in the skin/tissue.

If the skateboarder we talked about earlier (who skinned their knee) is young and healthy (e.g., with adequate tissue perfusion, oxygenation, nutrition, and without serious comorbid conditions), their knee will bleed for a few seconds, while clotting factors and fibrin will start clotting the blood. Chemical signals (cytokines) will be initiated, which will result in localized edema, redness at the area, slight warmth, and pain. The localized pain, edema, warmth, and redness will typically resolve in 3-7 days (inflammatory phase of acute wound healing). If the wound bed is not kept moist, the wound will dry out, and a scab will form.

Next, the body will produce enzymes (matrix metalloproteinases or MMPs) under the scab to lift it, especially at the edges. The wound bed under the scab will be moist to promote cellular communication, proliferation, and movement (Raziyeva et al., 2021). The young skateboarder may pick the scab off of the wound, especially if it feels tight or "itchy." However, the scab will become smaller this time as the wound contracts. The wound will completely close (re-epithelialize) in a few weeks if all goes as expected. As described, this is an example of an acute wound following the expected pathway to healing.

Open wounds (not sutured surgical wounds), which are kept continuously moist, actually heal almost 50% faster than those allowed to dry out and scab over. The skateboarder's scenario demonstrates uncomplicated acute wound healing. The typical needs of acute wounds versus chronic wounds are described below.

The typical needs of the uncomplicated ACUTE wound in a healthy individual include:

  1. Moisture balance:
    1. Keeping the wound bed moist
  2. Protection:
    1. Keeping the wound covered

In contrast to acute wounds, any wound that does not follow the expected orderly pathway to healing is a chronic wound. Many factors contribute to an acute wound developing into a chronic wound. The factors are the patient's immune function, comorbid conditions, moisture imbalance, poor nutrition, biofilm/excessively high bioburden in the wound, and the presence of necrotic tissue (Sibbald et al., 2021).

Inflammation in chronic wounds typically starts as it does in acute wounds:
Wounding → Bleeding → Clotting cascade → Release of cytokines → Edema, warmth, redness, pain

However, unlike acute wounds, in a chronic, complex, or recalcitrant wound, the expected pathway to healing may never progress out of a chronic inflammatory state. Chronic wounds most often get "stalled" or "stuck" in the inflammatory phase of healing, resulting in delayed wound healing and, often, persistent edema, redness, and pain (Maheswary et al., 2021; Sibbald et al., 2021).

One of the main treatment aims in chronic wound management is to try and convert the chronic wound back into an acute wound healing trajectory. However, some wounds may not be healable. Therefore, at the start of a chronic wound assessment, it should be determined how likely the wound is to heal with optimal management. What is the goal of treatment or chronic wound management? Healing / complete closure? Maintaining the wound/preventing it from worsening or becoming infected? Or palliative care / bothersome symptom management (such as odor, pain, or drainage?). All of the patient's care team and the patient and their family/caregivers should know the main goal of treatment (Sibbald et al., 2021).

Wound Management

In general, a holistic, multidisciplinary approach to wound management is recommended for both acute wound and chronic wound management. Common considerations for wound management may include:

  1. Exploring the patient and families' understanding of their wound status (Sibbald et al., 2021).
  2. Reviewing contributing factors that will impact the patient’s healing to include (Gupta et al., 2017; Sibbald et al., 2021):
    1. Medications
    2. Immobility
    3. Nutrition
    4. Comorbid medical conditions
    5. Age
    6. Tobacco use
    7. Personal wound management goals, expectations, physical limitations, and needs
  3. A thorough patient and wound assessment, accurate differential diagnoses of wound etiology, and assessment of important contributing factors (such as sensation and adequate tissue perfusion/ oxygenation) are essential. For instance, some non-healing wounds that do not respond to evidence-based treatment may require a biopsy to rule out malignancy and/or auto-immune components that contribute to the wound's chronicity (Sibbald et al., 2021).
  4. Optimal management of comorbid conditions such as (Sibbald et al., 2021; CDC, 2020a):
    1. Anemia
    2. Diabetes (glycemic control)
    3. Cardiovascular disease
    4. Lymphedema
  5. Addressing any medications that may interfere with wound healing are important (Sibbald et al., 2021; CDC, 2020a).
  6. Maintaining adequate nutrition and hydration. Assuring adequate nutritional intake (especially protein) and vitamins and minerals that may be depleted or deficient is important to provide the building blocks for tissue repair (Sibbald et al., 2021).
  7. Maintaining moisture balance of the wound. Keeping the wound bed moist will allow optimal cellular communication, fibroblast proliferation, keratinocyte differentiation, and migration. Preventing too much moisture will prevent maceration and avoid excess enzyme levels (such as MMPs) in the wound fluid (Sibbald et al., 2021).
  8. Protecting the wound. Keeping the wound covered with an appropriate dressing will protect from external contamination (bacteria, parasites, foreign bodies, etc.) as well as friction and repeated trauma. It will also provide thermal protection, and of course, prevent the wound bed from drying out if a moisture retentive dressing is used (Sibbald et al., 2021).
  9. The application of optimal wound cleansing and debridement methods to the wound site when needed. Using non-cytotoxic wound cleansers helps to protect important cells like fibroblasts and keratinocytes, and newly formed granulation tissue. It is also important to use an optimal debridement method to remove any necrotic, non-viable tissue in the wound bed, which may impair cellular migration, wound contraction, and wound healing (Moya-Lopez et al., 2020; Sibbald et al., 2021).
  10. In addition to debridement, it is important to reduce or remove excessive bioburden (bacterial/fungal/viral biofilm) present in the wound bed, which may impair wound healing and add to high levels of inflammation (Sibbald et al., 2021).
  11. The wound edge and surrounding skin are often overlooked but important in wound healing. If wound edges are "rolled" or otherwise not in contact in an expected manner, it may result in a "stalled" wound. Or, if the wound edges pull together too quickly before the underlying defect has a chance to fully granulate (fill in), it may result in an abscess formation and, ultimately, a complicated or non-healing wound.
  12. Monitoring of wound and skin pain as well as providing pain management (Sibbald et al., 2021).
  13. Providing patient and caregiver education as needed. Verbal, demonstrated, and written wound care directions are optimal.
  14. Conducting an ongoing evaluation of patient adherence to wound treatment plan.
  15. Providing emotional support to the patient and caregiver if possible. Chronic wounds can take an emotional toll on patients (and their caregivers). Chronic wound patients have identified lower quality of life with increased worry, fear, frustration, and unhappiness (Sibbald et al., 2021).

A continuous monitoring progress with regular follow-up (including telehealth) is needed (Bolton, 2019). In general, when a wound is improving, bi-weekly monitoring by the healthcare provider may be adequate. If the wound is not improving or worsening, weekly or more frequent monitoring by the healthcare provider may be required. In general, if a wound unexpectedly worsens after two weeks of a new treatment, it may be necessary to consider another treatment and/or make sure the above considerations have been addressed (Sibbald et al., 2021).

Once the wound is closed/healed, a wound prevention plan should be developed to prevent a recurrence.

General Wound Assessment and Monitoring

As a general rule of thumb, the wound care provider ordering the wound care should re-evaluate the wound for progress at least two weeks after the initial wound orders are placed. The topical wound treatment is performing as anticipated if the wound is stable. The wound is progressing as expected. The wound treatment may be continued, and the follow-up could be extended to once every 2 to 4 weeks. Studies indicate that >50% wound healing (size reduction) in 4 weeks may predict the likelihood of healing by 12 weeks (Sibbald et al., 2021). If the wound has not improved within 2 to 3 weeks or if there has been a significant change in the patient's condition, the wound should be reassessed. The clinician should decide if a change in wound treatment is in order or if other factors need to be addressed that might be impairing wound healing (nutrition, medications, glycemic control, infection, etc.). After addressing these factors, have the patient return to the clinic in another week to re-evaluate progress with the current treatment. If no progress is noted or the wound worsens, a change in treatment may be warranted (Sibbald et al., 2021).

Documentation

Many algorithms and forms now exist to assess, document and monitor wounds. Documentation consistency between healthcare providers is essential for effective communication. Consider using a standardized skin and wound assessment template in your documentation or electronic health record (EHR).

The Bates-Jensen Wound Assessment Tool (BWAT), the Pressure Ulcer Scale for Healing (PUSH), and the Wound Bed Score (WBS) are just a few examples of wound assessment tools that can be used (Sibbald et al., 2021).

Essentials of wound documentation (especially at initial evaluation) include (but is not limited to) (Sibbald et al., 2021):

  • Chief Complaint (including pain level)
  • History of Present Illness and Comorbid Conditions
  • Type of Wound (including suspected etiology)
  • Location of Wound
  • Duration
  • Types of Wound Treatments Already Tried
  • Patient / Caregiver Knowledge Level
  • Medical, Family, and Social History
  • Review of Systems
  • Physical Assessment
  • Risk Assessment (especially for pressure injury risk, if applicable)
  • Skin and Wound Assessment (including key components of T-I-M-E-S or D-I-M-E)
  • Wound measurements (at least Length cm X Width cm x Depth cm), including the extent of any peri-wound (skin surrounding the wound) erythema or rashes or other disruption
  • Tunneling or Undermining
  • Exudate Amount and Color
  • Exudate or Wound Odor
  • Wound Bed Description (% of viable versus non-viable tissue in the wound bed, tissue color, etc.)
  • Localized or Generalized Edema Noted
  • Procedures Performed
  • Supplies and Tests Ordered
  • Patient/Caregiver Education Provided (and response)
  • Care Plan
  • Discharge/Follow-up Plan

Measurement

Measuring the wound is an essential component of wound monitoring and documentation. Wounds may be measured using various techniques, but the two most common techniques are the clock and longest axis methods.

The measurement method used should be performed consistently by all care providers. Only one method should be used for all wound measurement documentation for the entire facility to minimize confusion and inconsistency in the patient's charts.

Clock Measurement Methodology

The clock method consists of imagining the top of the patient's head at the 12 o'clock position of a clock and the feet' soles to be at the 6 o'clock position of an imaginary clock. All wounds are measured, with the length being the wound's measure and the 6 to 12 o'clock axis and the width being the measure of the wound opening along with the 3 to 9 o'clock axis. This works well to get the same measures no matter what position the patient is lying or sitting in.

Longest Axis Measurement Methodology

The longest axis method consists of taking the wound opening measurements along the wound's longest axis as the length and the width measurement as the measurement of the wound opening along the perpendicular axis.

Measuring Wound Depth

Wound depth is measured the same way for both of these methods discussed above.

Using the blunt end of the cotton-tipped applicator, hold the stick lightly resting upon the deepest portion of the wound, and using a gloved hand, grasp the stick at the wound edge, and measure the wound's straight depth at the deepest portion of the wound and record this as straight depth.

Tunnels or tracking in the wound or undermining (lip under the wound edge's inner aspect) should be measured at the most shallow and deepest points.

It should also be noted if tunneling or tracking connects two wounds or connects with any joint space or underlying structures.

In addition to wound measures, other measurements include the girth of the extremity if the wound is on an extremity (to monitor edema of the limb).

Photographic Documentation

Photographing the wound, if desired, as an additional component of wound monitoring includes establishing a routine frequency of photographic documentation, a consistent camera and distance from the wound for all photographs, and a measuring ruler in the frame next to the wound for size reference (Sibbald et al., 2021).

It is also essential to consider the individual who will be taking the photographs. If another person is taking the pictures, make sure they follow infection control practices and do not touch the patient with the camera or anything in the patient's room, especially if they take the camera back to a central work area or other patient's room. If the same clinician performs the dressing change, care should be taken to follow strict infection control protocols concerning handling the camera and storing it during wound care. For example, it should not be laid on the patient's bed or bedside table without a clean barrier under it. It should not be handled after touching the patient, the wound dressing, or wound care supplies without first washing your hands (CDC, 2020b). Hands should be washed again after handling the camera. The camera should not be close to the wound during dressing changes if at all possible.

During dressing changes, bacteria may be aerosolized and could contaminate the camera. The camera should not be taken from one patient's room to another for other photos without using some kind of disinfecting wipe or changing camera covers if disposable covers are used.

Suppose photographs are to be used in the electronic health record. In that case, the author recommends that a photo of the patient's ID bracelet be taken, followed by a photo of the wound, then the ID bracelet again, so that this sequence of photos may be uploaded into the appropriate electronic health record and minimize the chance of the picture being uploaded to the wrong patient's chart. In most cases, identifiers such as patient name, initials, date, etc., should not be included in any photo used for educational purposes. However, follow your facility's protocols for taking and uploading wound photographs to ensure you remain in compliance with rules and regulations.

Conclusion

This course covered a comparison of acute versus chronic wounds as well as the pathways involved in their respective healing, descriptions of partial versus full-thickness wounds, the phases of wound healing, the components of effective wound management, as well as the measurement and documentation processes appropriate to wound care. For more information regarding wound care, wound bed cleansing, and wound dressings, please continue forth within the wound care series to Wound Series Part 2b: Wound Care.

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References

  • Alhajj, M., Bansal, P., & Goyal, A. (2020). Physiology, granulation tissue. In StatPearls. StatPearls Publishing. Retrieved Oct 22, 2021. Visit Source.
  • Bolton, L. (2019). Telemedicine Improves Chronic Ulcer Outcomes. Wounds: A compendium of clinical research and practice, 31(4), 114–116. Visit Source.
  • Centers for Disease Control and Prevention. (CDC). (2021). Most recent national asthma data: 2019. Retrieved Oct 22, 2021. Visit Source.
  • Centers for Disease Control and Prevention. (CDC). (2020a). CDC National Diabetes Statistics Report 2020: Estimates of Diabetes and its Burden in the United States. Retrieved October 22, 2021. Visit Source.
  • Centers for Disease Control and Prevention (CDC). (2020b). Handwashing: Clean Hands Save Lives. Retrieved October 22, 2021. Visit Source.
  • Doughty, D., McNichol, L. (2015). Wound Ostomy Continence Nurses Society Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer. Visit Source.
  • Goldberg, S. R., & Diegelmann, R. F. (2020). What makes wounds chronic. The surgical clinics of North America, 100(4), 681–693. Visit Source.
  • Gupta, S., Andersen, C., Black, J., de Leon, J., Fife, C., Lantis Ii, J. C., Niezgoda, J., Snyder, R., Sumpio, B., Tettelbach, W., Treadwell, T., Weir, D., & Silverman, R. P. (2017). Management of chronic wounds: Diagnosis, preparation, treatment, and follow-up. Wounds: A compendium of clinical research and practice, 29(9), S19–S36. Visit Source.
  • Maheswary, T., Nurul, A. A., & Fauzi, M. B. (2021). The insights of microbes' roles in wound healing: A comprehensive review. Pharmaceutics, 13(7), 981. Visit Source.
  • Raziyeva, K., Kim, Y., Zharkinbekov, Z., Kassymbek, K., Jimi, S., & Saparov, A. (2021). Immunology of acute and chronic wound healing. Biomolecules, 11(5), 700. Visit Source.
  • Sibbald, R. G., Elliott, J. A., Persaud-Jaimangal, R., Goodman, L., Armstrong, D. G., Harley, C., Coelho, S., Xi, N., Evans, R., Mayer, D. O., Zhao, X., Heil, J., Kotru, B., Delmore, B., LeBlanc, K., Ayello, E. A., Smart, H., Tariq, G., Alavi, A., & Somayaji, R. (2021). Wound bed preparation 2021. Advances in Skin & Wound Care, 34(4), 183–195. Visit Source.
  • Sussman, C. & Bates-Jensen, B. (2012). Wound care: A collaborative practice manual for health professionals. (4th ed.) Philadelphia, PA: Wolters Kluwer. Visit Source.