Wound Assessment
Wound Assessment in practice
This Clinical Focus on Wound Assessment is presented by Mark Bolton an independent Tissue Viability Consultant working across a number of fields in both a Clinical and Advisory capacity. He is involved in the development of Procedures and Policies providing structure to the Management and Documentation of wounds particularly within the Nursing Home Sector that help both Care Staff, Nurses and Nursing management simply and enhance the standard of wound care while ensuring compliance within a demanding regulatory environment.
“Wound Assessment has always been an aspect of Tissue Viability practice in which I have had a keen interest. I truly believe that the observations and subsequent decisions we make as a result of a comprehensive and structured wound assessment are the first steps to ensuring a positive healing outcome while also allowing us as wound care practitioners to assess and evaluate the efficacies of our chosen approach, strategies and dressing selection, in turn leading to continuous opportunities for us to learn and expand our own skill base.
Identifying an effective wound assessment tool and structure became increasingly important in my work within the nursing home environment, working with generalist practitioners to support their practice, documentation and compliance with the implementation of such as system.
Having identified the criteria I believed were important to be integral to a system/tool for wound assessment and having reviewed numerous potential options I eventually adopted ‘The Triangle Of Wound Assessment’ as part an overview of the approach in one of the ‘MADE EASY’ series articles published by Wounds International in 2018.
The following is an overview of this approach which I have found to be very effective in terms of its implementation and ease of use by both experienced and non experienced wound care practitioners.”
Background & Challenges
Similarly to a focused approach to wound prevention the efficient assessment of a wound in many respects is the most important step to take in achieving a positive healing outcome with any wound.
Poorly implemented wound assessment can lead to inappropriate wound management, leading to delays in healing increasing costs in nursing time, use of inappropriate products and a decrease in patient quality of life (1).
Conversely an Accurate assessment will allow the identification of the Wound Management Priorities of a given wound and allow the development of a clinically focused approach based on these priorities facilitating the development of a strong rationale supporting appropriate dressing choice and care structure.
While this concept may be apparent to professional wound care practitioners, the fact is that up 79% of wounds are treated in the community by non specialist nurses (2). Additionally, evidence has been provided to show that circa 70% of wounds are surrounded by unhealthy peri-wound skin (3).
Many assessment tools lack a truly Holistic Approach and in a study of 14 popular wound assessment tools revealed that ‘NONE’ met all criteria for optimal wound assessment.
Criteria for Optimum Wound Assessment Tool
“While wound assessment has a vital role in improving healing outcomes, many wound assessment tools can be confusing, lengthy and difficult to implement within various care settings especially when generalist and non specialist practitioners are required to facilitate their implementation. For this reason it is important to identify some key criteria in the development and implementation of a wound assessment tool or aid.”
- Facilitates a Holistic Assessment of all factors that directly or indirectly can potentially affect wound healing.
- Intuitive in its structure and easily followed and applied by generalist practitioners across multiple care settings.
- Identifies and provides an assessment structure for all elements of a wound – Wound Bed, Wound Edge & Peri-Wound Skin
- Ensures accurate documentation of key wound data allowing for an ongoing objective review of both healing progress and evaluation of the effectiveness of the wound care and dressing strategies implemented
"Asking questions is the ABC of diagnosis, however, if you don't ask the right questions you don't get the right answers"
Edward Hodnett
The Triangle of Wound Assessment
The Triangle of Wound Assessment (TWA) is an extremely practical and comprehensive wound assessment tool that can be implemented across many different care settings by both Specialist and Generalist Wound Care Practitioners and insures we ‘Ask the right questions’.
TWA is a holistic framework that considers both Environmental and Patient Specific factors while also guiding the practitioner in assessing all areas of the wound extending out to the Peri-Wound Skin.
This straightforward and structured framework guides the wound care practitioner through a comprehensive wound assessment to the establishment of Wound Care Priorities and management goals establishing a strong rationale in the selection of appropriate dressing and generating an optimal holistic wound care plan.
T.W.A. - Holistic Assessment
Wait! ..... We don't start with the wound?
The simple answer is…. No!
By starting our assessment only looking at the wound in isolation we miss the opportunity to identify factors external to the wound and sometimes indeed the patient that may impede healing and possibly undermine the specific wound management strategies derived from our wound assessment.
We may also lose the opportunity to integrate ‘Supporting Actions’ into our overall care plan such as Nutritional support that can have a significant impact in improving and supporting the healing process.
Therefore inline with a holistic ethos we take time at the very beginning to identify factors from an Environmental/Social and Patient perspective that may negatively impact or retard the healing process and/or may require additional interventions to reduce their negative impact on wound healing or enhance and support the healing process.
“Underestimating the impact of Environmental or Systemic Factors on wound healing will often lead to an undermining of good Wound Care Practice and ultimately lead to a less than positive experience for both the Patient and Wound Care Practitioner”
Three Levels Of Assessment
Environment & Social
Here we look at factors external to the patient that may have an impact wound healing or the provision of optimal wound care. These may include:
- Where is care being provided – Hospital/Community
- Specialised Service Requirements
- Availability of Services / Materials
- Care Provider –
- Professional(Nurse)
- Carer (Relative or HCA)
- Self Caring
Patient
Here we look to gain an overview of the patient’s medical condition, including some baseline data on the wound. This should include Type/Diagnosis, Aetiology, Location, Duration and Current Status of the wound along with other systemic factors that may influence or impede healing.
- Age, Lifestyle & Psychological Status.
- Comorbidities; Diabetes, Coronary Vascular (CV) Disease, Circulatory disorders, malignancy
- Medications – Corticosteroids, Anticoagulants, Immunosuppressants etc
- Infection – Systemic or Localised
- Reduced Oxygenation & Tissue Perfusion
- Dietary & Hydration Status
- Pain Generalised or Specific to wound
Wound
The Wound is Assessed from the inside outwards.
- Wound Bed Assessment
- Wound Edge Assessment
- Peri-Wound Skin Assessment
Prior to assessing each of the wound tissue areas we must take some baseline data with regards to size, so a measurement of the Length ( Head to Foot direction), Width (From either L-R or R-L Lateral position), Depth can be measured using an appropriate wound probe.
CLick on the icon below to view brief video on proper wound measurement.
Focused Wound Assessment
The Wound Bed
Record the types and percentage of each tissue visible on the wound bed.
Record the level and type and consistency of Exudate. i) Serous, ii) Seropurulent iii) Purulent iv) Serosanguinous v) Sanguineous.
A wound will go through stages of bacterial intrusion before signs of infection may occur. – Contamination, Colonisation, Critical Colonisation & Infection.
Therefore, recording all signs and symptoms is important in detecting the potential onset of infection. This will help to avoid same and/or an extension to a localised Soft Tissue Infection increasing the risk of Systemic Sepsis.
Remove of devitalised tissue is important as it is a barrier to healing and increases the risk of infection.
Protect and promote the growth of new granulation tissue.
Aim to treat underlying cause of exudate and manage the moisture balance at the wound bed through the application of an appropriate absorbency dressing. (Hydrofibre, Foam or Superabsorbent)
Aim to identify infection. Manage wound bioburden through the application of an Proactive Wound Hygiene process to reduce the risk and avoid wound infection.
The Wound Edge
Assess the moisture level at the wound edge
Assess the moisture level at the wound edge
Use the a Clock diagram to record the position of any Undermining or Tunneling from the wound edge and the note the extent of same.
Accurately describe the structure of the wound edge as changes here may indicated an onset of healing (Graduated & Granulating) or stasis in the healing process (Rolled & Thickened)
Determine the cause of the of any increase in moisture and associated tissue damage utilise appropriate strategies to correct same. (Barrier Protectant, Super absorbent dressing)
Determine the cause of dehydration and correct same as a biologically Moist wound environment is essential for the movement of cells within the healing process. Dehydration can lead to tension at the wound edge leading to irritation, inflammation and wound breakdown.
Where Undermining or Tunneling is evident the aim is to stimulate granulation to facilitate reattachment of the edge. Where Tunneling is evident the wound must remain open until this is full granulated to the level of the wound bed.
The aim is to maintain the wound edge in a condition that will facilitate Epithelial Advancement across the wound bed.
The Peri-Wound Skin
The Peri-Wound Skin is the skin immediately surrounding the wound extending out from the wound edge for 1 to 4cm.
This skin should be assessed as part of the wound assessment with any problems and their extent recorded.
Aim to protect the peri wound skin and maintain intact healthy skin in this area, avoiding over hydration (eg from excessive exudate) or dehydration.
Remove Hyperkeratotic Skin, dead skin plaques to rehydrate/recondition skin
Remove Callus and offload area to prevent recurrence
Aim to relieve irritation and avoid allergens especially to dressing materials
Wound Priorities & Treatment Objectives
It is highly unlikely that a single wound care regimen will be appropriate across the entire healing process of a given wound. Therefore a comprehensive, holistic assessment and the definition of ‘Wound Priorities’ will facilitate the development of a clear rationale for the choice of an optimal treatment strategy at each assessment and reassessment as the care or the wound progresses.(4,5,6) This process also allows for the practitioner to evaluate the effectiveness of the chosen wound care regimen and make adjustments as required.
Wound Bed Priorities
Assessment
Management Priorities
Treatment Option Examples
Tissue Type
Necrotic
Sloughy
Remove devitalised tissue and encourage proliferation of granulation tissue.
Debridement of devitalised tissue through Active Wound Cleansing, Autolytic Debridement or Sharp Debridement
Granulating
Epithelialising
Protect new Granulation & Epithelial Tissue and encourage angiogenesis and new tissue growth.
Encourage pinpoint bleeding of granulation tissue during wound cleansing.
Light Honey Dressing, Hydrocolloid
Exudate
Dry
Rehydrate the wound bed.
Heavy Honey Dressing, Hydrogel
Reassess the suitability of the primary dressing and dressing frequency.
Low
Medium
High
Appropriate management of wound exudate
Hydrofibre, Lite Foam
Foam Dressing
Superabsorbent Dressing
Infection
Clinical Signs of Infection
Proactive Management of WOund Bioburden and the prevention of Critical colonisation of the wound bed.
Implement ‘Wound Hygiene’ process from the start of treatment replacing Saline with a non-cytotoxic antiseptic wound cleansing solution (eg Microdacyn60)
Wound Edge Priorities
Assessment
Management Priorities
Treatment Option Examples
Dehydration
Rehydrate the wound edge.
Barrier Cream to maintain wound edge hydration.
Reassess the suitability of the primary dressing and dressing frequency.
Maceration
Appropriate management of wound exudate
Use an appropriate absorbent dressing for the level of exudate as with wound bed.
Undermining
Tunneling
Rolled Edges
Removal of devitalised tissue.
Encourage growth of Granulation Tissue
Protect new granulation tissue.
NB – Maintain wound aperture until wound edges are fully granulation and undermining/tunneling is resolved
Debridement of devitalised tissue.
Heavy honey Dressing, Hydrocolloid
TIP – If the wound has been debrided and is infection free the use of a Topical Negative Pressure dressing like PICO can be useful in encouraging granulation growth and the filling out of undermined wound edges or cavities.
Peri-Wound Skin Priorities
Assessment
Management Priorities
Treatment Option Examples
Dry Skin
Rehydrate and recondition dry skin removing all flakey skin. This needs to extend to the skin in general and be part of a daily skin care regimen.
Barrier Cream to maintain peri-wound skin hydration.
Reassess the suitability of the primary dressing and dressing frequency.
Maceration
Appropriate management of wound exudate
Use of an appropriate absorbent dressing for the level of exudate as with wound bed.
Excoriation
Eczema
Irritation / Dermatitis
Removal of devitalised tissue.
Encourage growth of Granulation Tissue
Protect new granulation tissue.
NB – Maintain wound aperture until wound edges are fully granulation and undermining/tunneling is resolved
Barrie Cream (eg Aldanex, Cavalon)
Barrier Film – Cavilon Spray, Cavilon Advanced Protect.
Hyperkeratosis
Callus
Removal of devitalised tissue.
Encourage growth of Granulation Tissue
Protect new granulation tissue.
NB – Maintain wound aperture until wound edges are fully granulation and undermining/tunneling is resolved
Debridement of dead devitalised skin.
TIP – Skin Plaques should be rehydrated prior to removal and removal should be gradual in order to protect the epidermis beneath. Aggressive removal can cause damage to the skin beneath the plaques potentially leading to an extension of the wound.
TIP – Removal of callus should only be performed by experienced practitioners trained in ‘Sharp Debridement’ especially with foot wound where Diabetic Foot Ulcer is either diagnosed or suspected. If in doubt seek advice or refer to specialist.
Reassessment & Documentation
Reassessment
Continuous Reassessment of the wound across the full healing process is essential and will insure focused continuity of care along with identifying points at which changes in the treatment strategy may be required. Reassessment will help identify the following:
- Improvement, Deterioration or Stasis
- Effectiveness of Treatment Regimen
- Significant changes both Positive and Negative
- Previously undocumented problems – Local & Systemic
- Patients Perspective and Compliance with treatment.
In general reassessment should take place regularly and coincide with a scheduled dressing change. For example if my dressing frequency is every 2 days (2/7) I reassess on Day 8 or if my dressing frequency is every 3 Days (3/7) then i can schedule my reassessment to coincide with the dressing change on Day 9 and so on. This allows for the dressing regimen to have effect prior to reassessment.
5 Points at which Assessment / Reassessment is necessary:
- Initial Assessment
- Scheduled Reassessment – as above
- Unscheduled Reassessment due to significant change in the condition of the wound – eg major dislodgement of devitalised tissue, or major increase or decrease in wound exudate.
- Alteration of the wound care regimen and establishment of a dressing regimen. This provides a baseline for the new approach.
- Final Wound Assessment when closing the wound off as Healed.
Documentation
"If it hasn't been documented it hasn't happened"
Concise and Accurate documentation of assessment data is as important as the assessment process itself. Good documentation will ensure Continuity of Care and facilitate a greater insight into the wound response t treatment and the healing process itself.
Characteristics of an optimum documentation process:
- Standardised Structured Process
- Standardised Format
- Standardised Language
- Collects Quantitative / Objective Wound Data
- Concise but allows for observation or comment.
- Facilitates continuity of care.
- Incorprates wound imagery to support assessment data.
Documentation should also demonstrate:
- A full account of the practitioners assessment ancare planned for the wound from a localised and patient perspective.
- All relevant patient information about the patient any given point.
- Measures taken to address patient needs
- Evidence that the wound care practitioner has understood and honoured their duty of care within the scope of their practice and has taken all reasonable steps to carefor the patient/wound and that any action or omission has not compromised patient care or safety.
Wound Assessment Product Focus
Advancis Wound Probe
One of the most useful tools in any wound assessment is an effective Wound Probe.
A wound probe allows for a complete assessment of the wound from measuring and logging the wound dimensions (Height, Width & Depth) to investigation further into the wound and assessing for Wound Edge Undermining or Tunneling beneath the wound edge which can not be determined purely by visualisation.
Additionally the probe can be utilised to aid the positioning of a given dressing within a wound cavity should this be required.
Ideally a the probe should be solid but flexible and allow for tactile feedback with a rounded atraumatic tip. It should be preferably of One Piece design removing the risk of any portion of the probe breaking off in the wound. Finally it should have indelible length to facilitate the accurate measurement of all wound dimensions.
The Advancis Wound Probe is available for supply from Biofact Pharma Ltd.
For more information contact:
Joe Mayne, Managing Director – Biofact Pharma Ltd.
Email: jmayne@biofactpharma.ie
Tel: +353 87 9087506
Useful Documents
Reference List
- Wounds International International Consensus: Optimising wellbeing in people living with a wound. London, UK: 2012.
- Posnett J, Gottrup F, Lundgren H, Saal G. The resource impact of wounds on healthcare providers in Europe. Journal of Wound Care 2009; 18(4): 154-161
- Ousey K, Stephenson J, Barrett S et al. Wound care in five English NHS Trusts. Results of a survey. Wounds UK 2013; 9(4): 20-8
- Dowsett C et al. Taking wound assessment beyond the edge. Wounds International 2015;6(1):19-23
- Dowsett et al. The Triangle of Wound Assessment Made Easy. Wounds International. May 2015
- Romanelli M et al. Advances in wound care: the Triangle of Wound Assessment Wounds International, 2016