Basic Wound Assessment Rosemary Jones NP-C, CWOCN-AP Home Based Primary Care NP Pueblo

Financial Disclosures O I have no financial disclosures

Objectives O Attendee will be able to identify the stages of wound healing O Attendee will be able to differentiate between an acute and a stalled wound O Attendee will be able to identify an infected wound

Skin – Largest Organ O Fluid regulation O Dermis contains about 80% water O Stratum corneum about 30% water O non-uniformly distributed O varying from around 40% in the inner layers to around 10-15% in the outermost horny layer O can increase to around 60% when the skin is immersed or exposed to a very wet environment

History O Most important aspect of initial exam O When wound occurred O Duration of wound O Current treatment O Pain level O Comorbid conditions O Medications O Patient goals

Wound Exam O Location of wound O Wound base description: red, black, yellow, grey, white etc; use percentages O Edges – closed (epiboli) or open O Periwound skin – erythema, blisters, induration O Odor O Drainage

Measurement O Length x width x depth vs 12-6 oclock, 9-3 o'clock O In cm O Technology – some cameras/HD wands will measure the wound for you, take a picture for the record

Measuring Wound

Measurement

Tunneling

Undermining

Types of Wounds O Surgically created O Wound more likely with inadequate nutrition, CAD, PVD, DM, RA, low Hg

Pressure Ulcers

Pressure Ulcer O Risk factors include: O Immobility O Inadequate nutrition O Incontinence O Neurological disorder O Low Hg O PVD O Carcinomas O Chronic pain – limits mobility O Depression

Friction and Shear

O Risk factors include: O Debility – scoot wounds O Dementia O Inadequate nutrition O Low Hg O Neuropathies O Amputations O Spinal cord injuries

Venous Stasis

O Risk factors include: O Standing for extended periods of time O Genetically predisposed O Obesity

Lower Extremity Assessment

Lower Extremity Arterial Disease

O Risk factors include: O History of tobacco use O Diabetes Mellitus O Ischemic cardiomyopathy

Lower Extremity Arterial Wound

Diabetic Foot Ulcer

Neuropathic

Auto-immune

Autoimmune O Risk factors include: O History of Ulcerative Colitis or Crohn’s disease O History of Rheumatoid arthritis O History of Psoriasis or Eczema

Calciphylaxis

O Diagnostics- skin biopsy O Risk factors: O Female O Obesity O Increased phosphorous concentration O Medications – Warfarin, calcium-based binders and vitamin D analogs, systemic glucocorticoids O Hypercoaguable state – protein C deficiency, antiphospholipid syndrome O Hypoalbuminemia O Iron administration

Necrotizing Fasciitis O Necrotizing soft tissue infection O Hx of DM and CHF O Fever/chills initially then erythema and supralesional vesiculation or bullae formation O Rapidly advancing erythema, and ulcers O Infection spreads along the fascial planes O May see black necrotic eschar at the borders O Purpura with or without bullae formation O Gas may be evident - crepitus

Necrotizing Fasciitis

Stage of Wound Healing O Inflammatory O Wound healing cycle starts O Lasts from injury to 4-6 days O Edema, erythema, inflammation, pain O Vessels form clots to prevent excessive loss of blood and fluids O Platelets release growth factors to trigger healing process O White cells go to area to "clean up"

Stages of Wound Healing O Proliferative O Lasts 4-24 days O Granulation tissue fills in wound O Fibroblasts lay network of collagen O in wound bed which gives strength to tissue Wound begins to contract - edges pull together O Epithelial cells from wound margins migrate inward to cover wound

Stages of Wound Healing O Remodeling O Lasts 21 days to 2 years O Begins when wound has filled in and re-surfaced O Collagen fibers reorganize, remodel, and mature to give wound tensile strength forming scar tissue O Scar tissue is only 80% as strong as original tissue

Acute wound O Moves through stages of wound healing O 50% reduction in size within first 30 days of treatment

Chronic or Stalled Wound O Stuck in inflammatory stage of healing O May begin to close and then stop healing O Needs to convert to an acute wound O Debridement O Address circulation issues O Nutrition

Infected vs Colonized Wound O Colonization – delay or stall wound healing O Critical colonization – becomes a chronic wound O Infected wound – local vs systemic O requires treatment

Colonization Treatment O Cleanse wound O Topical therapy O Systemic therapy O NWPT O MIST therapy O Silver products O Iodasorb paste O ¼ strength Dakin's solution O Debride/curette wound base O Anti microbial gauze

Wound Assessment O Presence of necrosis, debris, slough etc. – inflammatory stage O Erythema, induration, purulence, copious drainage – inflammatory stage O Pain – related to edema, tissue damage, infection – worse in inflammatory stage

Wound Assessment O Beefy red, granular tissue – looks like a strawberry O Minimal erythema periwound O No induration O Steady granulation and contraction

Remodeling Stage O New scar tissue O Fragile and bleeds easily O Scar tissue is thick and not very flexible

Wound Documentation O Wound bed (color, % nonviable/granulation) O Wound edges – open/closed, raised, edematous O Periwound skin – erythema, edema, induration, pain, violaceous hue, callus, maceration, scaling O Pain – chronic, new, with dressing change only O Exudate – volume, color, consistency O Odor

Treatment: O Debride wound of devitalized tissue O Prevent/treat infection O Keep wound bed moist O Protect wound bed O Manage the edges (open, not rolled) O Relieve pressure O ASSESS the PATIENT! O Nutrition Support O Evaluate for Osteomyelitis O Evaluate for carcinoma O Optimize care of co-morbidities (e.g. DM, anemia, etc.) O You can put anything on the wound except the patient! (Anonymous)

References O Acute and Chronic Wounds Current Management Concepts, 4 th Edition. Bryant, R., Nix, D. Mosby O Calciphylaxis (calcific uremic arteriolopathy); Hartle, J., Quarles, L., Santos, P. uptodate.com;Topic 1944, Version arteriolopathy; accessed 5/14/2015 O Dermatologic Manifestations of Necrotizing Fasciitis. Schwartz, R. Medscape. Accessed 5/14/ O Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 7 th Edition. Johnson, R., Saavedra, A., Wolff, K. McGraw Hill, O Skin Disease Diagnosis and Treatment, 3 rd Edition. Campbell, J., Chapman, M., Dinulos, J., Habif, T., Zug, K. Elsevier, 2011.