Update Guidelines Wound assessment

Eun Jin Han,

RN,CWCN, CFCN, KPCN, WOCN
Severance Hospital, Yonsei University Health System, Seoul, Korea
Strengths of Evidence
A The recommendation is supported by direct scientific evidence from properly
designed and implemented controlled trials on pressure ulcers in humans (or humans
at risk for pressure ulcers), providing statistical results that consistently support the
recommendation (Level 1 studies required)
B The recommendation is supported by direct scientific evidence from properly
designed and implemented clinical series on pressure ulcers in humans (or humans at
risk for pressure ulcers) providing statistical results that consistently support the
recommendation. (Level 2, 3, 4, 5 studies)
C The recommendation is supported by indirect evidence (e.g., studies in healthy
humans, humans with other types of chronic wounds, animal models) and/or expert
opinion

Strengths of Recommendation
Strong positive recommendation: definitely do it
Weak positive recommendation: probably do it
No specific recommendation
Weak negative recommendation: probably don’t do it
Strong negative recommendation: definitely don’t it
⚫
⚫
A complete comprehensive initial assessment of the
individual with an ulcer.

1. A focused physical examination

2. Health/medical and social history
3. Nutrition
4. Pain related to ulcers
5. Psychological health, behavior, and cognition
6. Social and financial support systems
(Strength of Evidence = C; Strength of Recommendation = )
A complete comprehensive initial assessment of the
individual with an ulcer.

Why do they recommend it

strongly ?
(Strength of Evidence = C; Strength of Recommendation = )
Factors Affecting Wound Healing

Systemic Factors That Influence Healing

Oxygenation Infection Age Nutrition

Medications Smoking Diabetes Stress

Obesity Perfusion Immunity Fever

Factors Affecting Wound Healing

Systemic Factors That Influence Healing

Oxygenation Infection Age Nutrition

Medications Smoking Diabetes Stress

Obesity Perfusion Immunity Fever

 The environment

The individual

The wound

(Strength of Evidence = C; Strength of Recommendation = )

Cause of the Wound Why?

Mechanical damage
Chemical damage
Damage due to Eliminate
temperature
Cytotoxic damage the cause!
Vascular damage
Allergic damage
Infectious damage
Wound Assessment

A. Location F. Peri-wound condition

B. Size G. Wound edges
C. Extent of tissue H. Sinus tracts
damage I. Undermining
D. Tissue type J. Tunneling
E. Color K. Exudate
L. Odor

(Strength of Evidence = C; Strength of Recommendation = )

A. Location

The correct anatomical terms

Sacrum and Coccyx
Iliac crest and Trochanter
Iliac crest and Trochanter

A. Iliac crest
B. Trochanter
Ischial tuberosity
Anatomical terms of location foot

Ankle

Medial Ankle, Lt.

Posterior Ankel, Rt.
B. Size

1. Position the individual in a consistent neutral position for

wound measurement. (Strength of Evidence = C; Strength of
Recommendation = )
It is possible to distort soft tissue with variations in positioning
yielding a larger or smaller measurement depending on position of
the individual.
B. Size

2. Select a uniform, consistent method for measuringwound

length and width or wound area to facilitate meaningful
comparisons of wound measurements across time. (Strength of
Evidence = B; Strength of Recommendation = )
B. Size
B. Size

the greatest length Ⅹ the greatest width (perpendicular )

8cm

10cm
80cm2
B. Size

Maximum length from head to toe X Maximum width

(perpendicular )
9cm

8cm

72cm2
B. Size

Surgical wound
B. Size

Care should be taken to avoid causing injury when probing the depth of a wound bed
or determining the extent of undermining or tunneling.
B. Size

Dead space
B. Size

Dead space
B. Size
B. Size
B. Size
B. Size
Predicting wound healing
Predicting wound healing
C. Extent of tissue damage
Dermis
Fat tissue
Tendon
Bone
D&E. Tissue type, Color

Wound healing continuum

D&E. Tissue type, Color

Wound healing continuum

 Eschar Slough

Epithelialization

Granulation
D&E. Tissue type, Color

▪ Black -------Eschar/necrosis
D&E. Tissue type, Color

▪ Black -------Eschar/necrosis

▪ Yellow -------Slough
D&E. Tissue type, Color

▪ Black -------Eschar/necrosis

▪ Yellow -------Slough

▪ Red --------- Granulation

D&E. Tissue type, Color

▪ Black -------Eschar/necrosis

▪ Yellow -------Slough

▪ Red --------- Granulation

▪ Pink --------Epithelialization
F. Assessment of the surrounding skin
F. Assessment of the surrounding skin

Maceration Excessive moisture in the skin resulting in the tissues becoming

waterlogged.
Excoriation Stripping of the upper layers of the epidermis as a result of
prolonged exposure to toxins on the surface of the skin – can
occur when there is excessive wound fluid;
F. Assessment of the surrounding skin

Healing sign
G. Wound edges

Epiboles
G. Wound edges

Epiboles
H. Sinus tracts
I. Undermining
J. Tunneling
K. Exudate

Good VS Bad

•Controled infection through removal of necrotic tissue

• When the growth factors are properly mixed
L. Odor
Wound Assessment documentation

A. Location G. Wound edges

B. Size H. Sinus tracts
C. Extent of tissue I. Undermining
damage J. Tunneling
D. Tissue type K. Exudate
E. Color L. Odor
F. Periwound condition

(Strength of Evidence = C; Strength of Recommendation = )

Photo documentation at severance hospital
Reassess & Documentation

1. Assess the wound initially and re-assess it at least weekly. (Strength of Evidence =
C; Strength of Recommendation = )
1.1. Document the results of all wound assessments. (Strength of Evidence = C; Strength of
Recommendation = )
A two-week period is recommended for evaluating progress toward healing. However, weekly
assessments provide an opportunity for the health professional to assess the ulcer more
regularly, detect complications as early as possible, and adjust the treatment plan accordingly.
2. With each dressing change, observe the wound for signs that indicate a change in
treatment is required (e.g., wound improvement, wound deterioration, more or
less exudate, signs of infection, or other complications). (Strength of
Evidence = C; Strength of Recommendation = )
2.1. Address signs of deterioration immediately. (Strength of Evidence = C; Strength of
Recommendation = )
Signs of deterioration (e.g., increase in wound dimensions, change in tissue quality, increase in
wound exudate or other signs of clinical infection) should be addressed immediately.
Reassess

Reassess the individual, the ulcer and the plan of care if the ulcer
does not show signs of healing despite appropriate care.
(Strength of Evidence = C; Strength of Recommendation = )
1. Expect some signs of pressure ulcer healing within two weeks.
(Strength of Evidence = B; Strength of Recommendation = )
2. Adjust expectations for healing in the presence of multiple factors that
impair wound healing.
(Strength of Evidence = B; Strength of Recommendation = )
Reassess

8. Consider further diagnostic investigations of wound bed tissue

when healing does not progress. (Strength of Evidence = C;
Strength of Recommendation = )
In some cases tissue biopsies can improve understanding of the healing
process and potential for healing. Differential expression levels of specific
wound proteins assayed by mass spectrometry and multiplexed microassays
are predictive of healing in the wound.
Take home message
Take home message
With the Love of God, Free Humankind from Disease and Suffering