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INTRODUCTION

Wound assessment is more than just looking at the lesion. It is a holistic approach to care that identifies
systemic, psychosocial, and local factors that may precipitate a wound or impede its healing.

MEDICAL HISTORY

Professionals performing assessments start with obtaining medical and psychosocial histories from the
patient. By doing this before starting the physical exam, rapport and trust can be established to
decrease the patient's anxiety.

A medical history has numerous components. The provider should ask about past or present systemic
illnesses, such as:

Diabetes

Cardiovascular disease

Respiratory abnormalities

Digestive problems

Musculoskeletal issues

The provider should also inquire about previous hospitalizations and surgeries.

At this point, the nurse should ask about any prescriptions, over-the-counter medications, or herbal
supplements the patient is taking, as well as any allergies to food, drugs, latex, or other items within the
healthcare setting.

It is also important to learn if the patient smokes tobacco products, drinks alcohol, or uses recreational
drugs, and if so, the frequency and quantity.

Another part of the medical history is gathering information about the patient's family. For example, if
there are any inherited or genetic disorders or if specific pathologies are common in his family. The
nurse should also ask about the usual state of health or cause of death of the patient's parents and
siblings.
The nurse should ask about the patient's eating habits as well to determine if the patient is consuming
enough protein to support wound healing, or if his diet is too high in fat, too rich in carbohydrates, or
lacking in fruits and vegetables.

PSYCHOSOCIAL HISTORY

The psychosocial history is important, as it helps the healthcare professional determine the ability of the
patient to care for him or herself as well as to identify available resources.

During this part of the interview, the nurse also asks the patient if he or she resides at home with others,
alone, or in a facility.

At the same time, they can learn about the patient's activities of daily living.

For example:

Is the patient able to bathe, dress and feed him or herself?

Is the patient able to shop for food and prepare meals?

Does the patient work or is the patient retired?

How does the patient spend free time?

Is the patient physically active?

Does the patient go out with friends and family?

What hobbies does the patient have?

What is the patient's normal means of transportation: does he drive, take taxis, or have others take him
out and to appointments?

While listening to the patient's answers, the nurse can determine if there are any cognitive limitations or
barriers to understanding.

Once this part of the evaluation is complete, the healthcare professional can begin the physical
examination.
PHYSICAL EXAMINATION

The physical assessment of a patient with a wound is the same as for any other individual. However,
when performing it, it is essential to consider how an individual's medical conditions, allergies, and
comorbidities can either cause wounds or impact the healing process. Each body system, then, should
be evaluated with this fact in mind.

Most physical exams begin with obtaining vital signs, which include: the temperature, heart and
respiratory rates, blood pressure, and pain level.

If peripheral artery disease is suspected, an ABI, or ankle-brachial index, should also be measured. The
blood pressures in both arms should be taken using the brachial artery. Then, the blood pressure in both
lower legs should be obtained, using the dorsalis pedis pulse. The highest value of the ankle blood
pressure should then be divided by the highest value of the brachial blood pressure. Results can
determine the degree of peripheral vascular compromise:

Normal ABI is greater than or equal to one.

Lower extremity arterial disease has a value of less than or equal to 0.9.

Borderline perfusion is between 0.6 and 0.8

Severe ischemia is less than 0.5

To further assess perfusion, proximal and distal pulses can be palpated and graded and recorded in the
medical record as 0 for absent, 1+ for barely palpable or weak, 2+ for normal, and 3+ for bounding or
full. Capillary refill time should also be measured and should be less than 3 seconds.

In addition, staff should note any edema and document it as 1+ for a 2-centimeter or less indent, 2+ for
a 2 to 4 centimeter indent, 3+ for a 4 to 6 centimeter indent, and 4+ for a 6 to 8 centimeter indent.

Another evaluation is the Buerger's test, in which both lower extremities are elevated to an angle of 45
degrees and held there for 1 to 2 minutes. Normally, toes will stay pink. If the limbs become pale, there
is evidence of vascular compromise. The patient is then asked to sit up with legs dangling over the side
of the bed at a 90-degree angle. With ischemia, color returns to the affected limbs slowly, passing from
blue to red. Normally, color returns within 10 seconds and the veins fill within 15 seconds.
Patients with compromised perfusion to their lower extremities are at risk for the formation of lesions,
which can be either arterial or venous.

If a wound is present on the lower legs, ankles, feet, or toes, healing can be delayed or impaired, as
oxygen, nutrients, blood components, and other chemicals cannot reach the site of injury in a timely
manner.

When assessing the respiratory system, the lungs should be auscultated for air exchange and
appreciation of any adventitious sounds. Pulse oximetry should be measured, and in individuals without
chronic lung or heart disease, it should be above 95%.

In addition, the chest should be observed during inspiration and expiration to note the use of any
accessory muscles that can indicate respiratory distress, or a barrel-shaped chest, which is associated
with COPD.

Any type of respiratory disturbance in which there is either hypoxia or hypoxemia will diminish wound
recovery, as oxygen is vital to this process.

Providers should keep in mind that the use of steroids for asthma or other conditions impairs the
inflammatory stage of healing.

The musculoskeletal and neurologic systems should be evaluated by assessing the patient's range of
motion, strength and ability to move independently. The use of assistive devices should also be
assessed: Is a cane, crutches, walker, or wheelchair used, or is the patient bedbound?

The nurse should assess for signs of absent or diminished sensation, as this is associated with skin
breakdown.

Individuals with musculoskeletal or neurological problems, such as those who suffer from arthritis and
who have had strokes, are at high risk for shear or friction injuries as well as pressure ulcers because of
impaired mobility and/or joint contracture.

Many people with arthritis are medicated with steroids or other anti-inflammatory drugs, which impede
wound healing.
When evaluating the genitourinary system, providers need to keep in mind that poor nutritional intake
compromises wound recovery. If the patient has nasogastric or gastrostomy tube feeds, there is a high
risk of diarrhea, which can cause skin breakdown of the perineum.

In regards to wound care, one of the biggest obstacles of the genitourinary system is urinary
incontinence, which causes maceration of the perineal area, and may lead to a breach in the integrity of
the skin. Maintaining clean, dry skin is of utmost importance.

When looking at endocrine function, the presence or control of diabetes is the most critical concern, as
abnormal glucose levels, peripheral neuropathy, and impaired circulation all contribute to wound
formation as well as delayed healing.

Laboratory values should be monitored. It is important to note if the patient is anemic, as low
hemoglobin impairs oxygen delivery to the lesion. In addition, fluid and electrolyte imbalances can lead
to inadequate nutrient availability for healing. Reduced HDL and elevated lipoproteins are suggestive of
lower extremity arterial disease.

One of the most important parts of the physical exam is assessing the skin, the largest organ of the
body. Careful inspection and palpation, in a head-to-toe fashion, should be done, with a focus on high-
risk areas.

Those areas are:

Body or skin folds

The temporal and occipital portions of the skull

Ears

Scapulae

Spinous processes

Shoulders

Elbows

Sacrum

Coccyx
Ischial tuberosities

Femoral trocanters

Knees

Malleoli

Metatarsals

Heels

Toes

Areas covered by restrictive clothing or anti-embolic stockings, or sequential compression devices

Areas where pressure, shear, or friction can be exerted

Skin should be evaluated for color, temperature, moisture, swelling, pruritus, changes in texture and
sensation, and the presence of any lesions.

In addition, color and uniform appearance, thickness, symmetry, and the appearance of any breakdown,
lesions, or trauma should be noted.

All of the findings of the medical and psychosocial histories and physical exam should be recorded in the
patient's record.

WOUND EVALUATION

Wound evaluation involves assessment of the lesion and the area directly surrounding it by inspection,
palpation, smelling, and listening. It should be performed according to the facility's policies and
procedures and with each dressing change.

The evaluation should be done in a systematic manner to ensure it is complete and that no pertinent
data is omitted. Documentation must be clear, concise, accurate, and as detailed as possible. Pictures of
the wounds are extremely helpful when available, as they complement and enhance the written record.

LOCATION, SHAPE AND SIZE

The first part of the evaluation is location. Wounds in specific parts of the body can be associated with
certain pathologies. For example:
Bony prominences are susceptible to pressure ulcers.

Skin folds are associated with shear injuries.

Toes are prone to trauma from diminished circulation, friction from poor-fitting shoes, and pressure of
bed linens.

Lesions on the plantar surfaces of the foot are related to diabetes, pressure from ill-fitting shoes, foot
deformities, or impaired gait.

Wounds to the shin or calf are associated with trauma or vascular insufficiency.

The shape of the wound is also important to observe:

Round wounds are common in pressure ulcers.

Lesions with jagged or linear edges are seen as a result of friction, shearing, or trauma.

Irregularly shaped wounds are usually vascular in nature.

Next, the size of the wound should be calculated in centimeters. Linear measurements include those of
length, width, and depth.

When calculating length and width, the wound should be considered like the face of an analog clock,
with 12 o'clock pointing to the patient's head and 6 o'clock at his feet.

Using a ruler or paper measuring tape, measure the length as the distance between 12 and 6 o'clock
while width is the span between 3 and 9 o'clock.

Another way to do a linear measurement is from wound edge to wound edge, noting the diameter of
the greatest length as well as that of the longest width.

Depth is the longest distance from the visible surface of the wound to its deepest area. This represents
the amount of tissue loss.

To calculate depth, a cotton-tipped applicator should be inserted into the deepest portion of the wound.
It should be then marked at the wound surface, withdrawn, and then that distance from tip to marking
measured against a ruler.
It should be noted that this procedure may have to be done a few times to assure that the deepest part
of the wound has been measured.

Documentation of these findings will include the location of the wound in addition to its measurements
and methods used to obtain them.

For example:

Wound on the medial aspect of the left lower leg 5 cm above the ankle, is irregular in shape. From 12 to
6 o'clock, it is 2.5 cm. From 3 to 9 o'clock, it is 1.8 cm. Depth in the center of the wound is 1.2 cm.

Undermining is tissue destruction underlying intact skin along the edges of a wound. Providers need to
determine if there is undermining and if so, its exact location and extent.

Begin the evaluation at 12 o'clock, and using a cotton-tipped applicator, gently probe around the wound
margins in a clockwise direction.

If undermining is noted, the applicator should be inserted using the same technique as for determining
tissue depth to measure the amount of the undermining.

Tunneling is a narrow passageway that can extend in any direction from a wound that results in dead
space and has the potential for abscess formation.

The location and size of the tunneling are done using the same methods as for undermining.

For both undermining and tunneling, documentation should be specific as to the size and location, again
using the analog clock as a guide.

For example:

Undermining of the wound noted at 1 o'clock, 3.5 centimeters and 5 o'clock, 4.2 centimeters.
WOUND BASE

When examining the wound itself, providers should start in the center of the lesion and work outward.
The types of tissue seen should be noted and recorded.

There are two types of necrotic, or nonviable, tissue. Eschar is desiccated and has a firm, leathery, black
or brown appearance. As eschar breaks down, it turns into slough. Slough is a wet, soft, thin, fibrinous,
stringy, or mucoid substance that can be yellow, gray, tan, or brown in color.

Epithelial tissue can be seen during wound healing, as these cells regenerate across the wound surface,
moving from the edges of the wound toward its center. It is usually deep to pearly pink in color.

Granulation tissue, which is formed at the base of the lesion and replaces the dead tissue in healing
wounds, is beef-red and has an irregular texture, which can look bubbled or pebbled.

Muscle, tendons, fascia, and bone may also be visualized.

The color of the tissue is an important indicator:

Red is healthy, viable tissue

Pale pink is a sign of poor blood flow or low hemoglobin

Purple with engorged, swollen tissue is indicative of trauma with high levels of bacteria

Black, brown, yellow, and gray are signs of nonviable, necrotic tissue

Green is related to infection and nonviable tissue

White tissue is a symptom of poor blood flow and maceration

The location, percentage amount of each type of tissue, and the color should be documented. The
amounts of the different types of tissue observed should then be added together to equal 100%.

For example:

Wound bed is scattered with 50% yellow slough, 15% eschar, 35% red, beefy granulation tissue.
The amount and types of exudate (the liquid produced by the body in response to tissue damage) must
also be assessed and documented.

There are several types of exudate:

Serous, which is seen in partially thick wounds and venous ulcerations; is thin and clear to light yellow in
color

Sanguineous, more common in deep partial thickness and full thickness lesions; is bloody

Serosanguineous is thin, watery, pale red to pink

Sero-purulent is thin, watery, cloudy, and yellow to tan, a mixture of serum and pus

Purulent, which is not healthy and associated with infection; is thick, opaque and tan, yellow, brown, or
green, and may be malodorous

The amount of exudate should be estimated:

None indicates the wound is dry.

Scant describes moist tissue but no measurable drainage.

Small or minimal denotes very moist to wet tissue, but less than 25% of the dressing is affected.

Moderate signifies wet tissue with between 25% and 75% percent of the bandage involved.

Large or copious means that the wound is filled with fluid and over 75% of the dressing is wet.

An example of documentation can be:

Serosanguineous exudate noted, small amount, with about 15% of the dressing involved.

Wounds may have odors that can be described as strong, foul, pungent, fecal, musty, or sweet. Causes
of these odors include bacteria, necrotic tissue, saturated dressings, and contamination from bodily
fluids such as urine or feces. Here, documentation should be as precise as possible describing the smell.

The final part of the wound bed examination is doing a pain assessment, using a standardized tool to
quantify its intensity and asking the patient about its duration. In addition, he should be asked to
describe its quality: Is the discomfort throbbing, aching, stinging, burning, or stabbing?
After the evaluation, interventions should be immediately initiated to diminish the pain. Some things as
simple as position change or covering the area may be all that is needed. At other times, medications
may be warranted.

In any case, documentation about the evaluation must be complete. For example:

0750: Patient stated his right medial thigh wound pain was a 3 out of 10 on the pain scale, and that he
had an aching sensation at the wound site that began about 20 minutes ago. Patient's position was
changed to his left side.

Within a half hour, the patient should be re-evaluated and the findings documented:

0820: Patient reported no further discomfort.

EVALUATION OF THE SURROUNDING TISSUE

Periwound tissue, or the area encompassing at least 4 centimeters around the wound, needs to be
observed.

Color must be noted. The surrounding area may be erythematous, or bright red, if there is infection. The
appearance can range from diffuse and indistinct to intense, which is an area with precise borders and
streaking.

Redness can also be associated with irritation from drainage, exposure to urine or feces, dermatitis,
sensitivity to adhesive, or trauma from tape removal.

Other colors to watch for include:

Pink: indicative of inflammation or a high bacterial count

Blue: a sign of poor perfusion

Purple: related to trauma


White: symptomatic of moisture or diminished blood flow

Brown staining on the lower leg: evidence of venous insufficiency

Black: an indication of tissue death

Staff should also look at this area for edema, which if accompanied by warmth, may point to infection.

The texture of the skin surrounding the wound should also be examined:

Desiccation and scaling are associated with dehydration

Weeping or extremely moist skin is related to acute conditions

Excessive thickening is seen with chronic shearing or friction injury

In addition, the nurse should evaluate for maceration, which occurs with excessive moisture.

The skin should also be assessed for ecchymosis. This results from trauma vasculitis, or damage to
vascular walls, which appears as a non-blanching discoloration of variable size and shape.

The periwound area also needs to be palpated. Induration is a hard, thick mass with defined edges that
can be made discernable by touch. It is sometimes associated with undermining, tunneling, or infection.

In addition, the tissue around the wound should be evaluated for crepitus, which is an accumulation of
gas or air in tissues that rises from an anaerobic bacterial infection. On palpation, the nurse will feel a
crackling sensation under the skin as well as hear faint popping-like sounds.

Finally, skin temperature should be noted. Warmth can reflect a new wound or infection, while coolness
can be related to poor perfusion.

Documentation of the periwound area must be precise, describing in detail what is seen and felt. Again,
pictures should be taken and placed in the patient's medical record.

WOUND COMPLICATIONS
There are many complications associated with wounds. One of the most common is infection. Signs of
acute infection are erythema, edema, heat at the site, purulent exudate, and pain.

Symptoms of chronic infection are increasing pain, drainage, foul odor, delayed healing or wound
closure, and dull, ruddy granulation tissue. In addition, there can be breakdown of the wound itself.

Cultures should be taken using a 10-point zigzag motion after the wound has been cleansed to identify
the causative agent so that proper antibiotics can be prescribed. It is not unusual for the results to show
multiple organisms.

Wound infections that are associated with surgery are under tight scrutiny by the Joint Commission,
who has created core measures or specific guidelines to prevent them from occurring.

Another sequela is dehiscence, or the spontaneous opening or separation of suture line or wound.

Documentation of these occurrences must describe exactly what the provider assesses. Again,
photographs should accompany the notes entered into the record so that subtle changes can be
carefully noted in order for the staff to determine if interventions are successful or need adjustment.

CONLCUSION

In conclusion, it is critical that the patient with a wound be carefully evaluated so that any comorbidities
or risk factors can be taken into account when planning his care.

It is also important that the wound itself be assessed per facility policy and with each dressing change so
that healing can be noted or complications averted.