Skin and Wound Care

Assessments

The completion of a comprehensive assessment is important, as the findings will guide the creation of an individualized care plan and goals of care.

A comprehensive assessment must include: assessment of the client, assessment of the wound, and the current treatment.1-7,9-21

Patient Assessment

A comprehensive health history is needed to identify all medical conditions, prior conditions and surgeries.

  •  Common co-morbidities that affect wound healing1-8:
    • Peripheral vascular disease
    • Arterial insufficiency
    • Venous insufficiency
    • Cardiopulmonary disease (affects oxygen-carrying abilities)
    • Heart failure, COPD
    •  Diabetes mellitus
    •  Spinal cord injury
    •  Immunocompromised
    •  Obesity

Medications that could affect wound healing include1,3,4,8:

  •  Steroids
  •  Anticoagulants
  •  Anti-inflammatory agents
  •  Immunosuppressive medications

Adequate nutrition is necessary for wound healing.

Components for nutrition assessment include5,7,22:

  • Dependency on others for food prep and/or feeding
  • Weight status (history, current and changes): frequent weight monitoring is non-invasive, time efficient and reliable
  • Adequacy of intake, quality and quantity of intake (i.e., proteins, carbs, fats, etc.)
  • Blood work
  • Routes and extents of losses: intake – losses = net nutritional status
  • Blood work for anemia (Hgb and iron studies) and dehydration (BUN, CR)
Test Normal Value Relationship with Wound Healing
1. Hemoglobin Male: 130-170 g/L
Female: 123-157 g/L
  • Anemia delays wound healing
  • Need above 100 g/L for wound healing
2. White Blood Cells 4.0-10.0 x 109/L
  • infection or inflammation
  • potential immune suppression 
3. Platelets 130-400 x 109/L
  • Ability to move through coagulation cascade and healing phases impaired when abnormal
4. Hemoglobin A1C 4-6 %
  • Hgb A1C leads to many complications and impaired wound healing
5. Creatinine Male: 17-120 µmol/L
Female: 50-90 µmol/L
  • Reflects hydration status and renal function
6. BUN 2.5-8.0 mmol/L
  • Reflects hydration status and renal function
7. C-Reactive Protein <8 mg/L
  • Inflammatory marker - infection or inflammatory process
8. Albumin 35-50 g/L
  • Marker for risk of malnutrition
  • Reflects severity of illness
9. Pre-Albumin 180-450 mg/L
  • Marker for risk of malnutrition
  • Reflects severity of illness

Medical Council of Canada (2018)
Wounds Canada BP Recommendations for the Prevention and Management of Pressure Injuries (2017)
Posthauer (2012) Assessment and Treatment of Nutrition

  • Smoking
  • Excessive alcohol consumption
  • Substance abuse
  • Skin-care products

Living with a wound, acute or chronic, can have a devastating effect on a person's quality of life. Asking about our clients' concerns regarding their health and wound is an important part of the assessment. Care planning must be individualized for each client.

  • Psychosocial factors:
    • Supports from family and friends
    • Coping mechanisms
    • Stress due to situation and health status
    • Cognitive ability to understand illness
  • Socio-economic status and supports:
    • Income, employment and working conditions
    • Food security
    • Housing
    • Education and literacy
    • Social support
    • Access to health care

Quality of life is greatly affected by pain. Appropriate pain assessment and treatment is an important part of the wound care plan.

  •  Monitor levels of pain prior to and after dressing changes. Ask about the quality of the pain throughout the day and night.
  • Sometimes anxiety can be masked by, or interpreted as, pain. Anti-anxiety medications can be of benefit prior to dressing changes.
  • Care plan should include appropriate analgesic and anxiety interventions.
  • Use a reliable pain scale (i.e., 1-10, faces) in addition to monitoring for non-verbal signs of pain.

Pain Scale

Wound Assessment

  • Any previous wounds (healed or amputated):
    • How did it happen?
    • How long was it present?
    • Where was it?
    • How was it treated? What worked and what didn’t?
  • Current wound:
    • How did it happen?
    • When did it happen?
    • Where is it?
    • Were there any previous treatments? What worked and what didn’t?

Determining the cause of the wound can differentiate the wound etiology and assist in directing the goals of care and care planning.

The cause of the wound is determined based on the comprehensive patient assessment and the presentation of the wound. Causes may include:

  • Trauma
  • Pressure
  • Venous insufficiency
  • Arterial insufficiency
  • Diabetic factors
  • Surgery

Wound location can provide insight as to the cause of the wound. For example: venous ulcers are typically located on the distal, medial aspect of the calf, while arterial ulcers are typically located on the toes.

  • Wound location is needed for documentation and reporting purposes.
  • Be specific, especially if the client has multiple wounds.

The initial wound assessment will be the baseline for monitoring healing, so an accurate recording of the size and depth of the wound is important.1-7,9-21

  • Measure:
    • Longest length, widest width and deepest depth
    • Width perpendicular to length (avoid diagonals)
    • Surface area (cm²) = L (cm) x W (cm)
    • Depth (keep tool upright, not at an angle)
  • Always measure the wound with the same orientation to increase consistency.

The wound must be cleansed before assessing the base of the wound, as debris could interfere with visualizing the tissue. Estimate the percentage of the wound bed covered by each type of tissue:

Terminology Description
1. Epithelial
  • Translucent or white cell layer, migrate onto granulating tissue
2. Granulating Tissue
  • Pink/red "beefy" tissue
  • Granular cells, moist
  • Necessary for healing
3. Slough/Necrotic Tissue
  • Soft, moist dead tissue
  • White, yellow, brown, green
  • May be loose or adhered to wound bed
4. Eschar
  • Brown or black necrotic tissue
  • Texture: hard, soft or boggy
  • Can be adhered to wound bed or separated from edge

Sussman (2012)

Assess1-7:

  • Amount
  • Consistency
  • Colour
  • Odour
Amount Description
1. None
  • No exudate
2. Small (scant)
  • Exudate fully controlled
  • Nonabsorptive dressing may be used
  • Wear time up to 7 days
3. Moderate
  • Exudate controlled
  • Absorptive dressing required
  • Wear time 2-3 days
4. Large (copious)
  • Exudate uncontrolled
  • Absorptive dressing required
  • Dressing overwhelmed <1 day
Type Consistency Colour Odour
1. Serous
  • Thin watery
  • None
  • None
2. Serosanguinous
  • Thin watery
  • Pink
  • Usually none
3. Sanguineous
  • Active bleeding
  • Bright red
  • Blood
4. Sero-purulent
  • Thin watery
  • White, tan
  • Possible foul smell
5. Purulent
  • Thick translucent opaque
  • White, tan, greenish
  • Possible foul smell

Sussman (2012) & Orsted, et. al (2017)

Assess the appearance of the wound edge.1-7

There can be different edges around the wound. Document a description of the edge, then the location using clock face orientation (head = 12 o’clock).

Terminology Description
1. Advancing
  • Epidermal cells migrating across wound bed
2. Attached
  • Edges attached but not advancing
3. Rolled
  • Curled wound edge, thick
4. Callus
  • Thick hyperkeratotic tissue around all or parts of wound edge
5. Indistinct
  • Cannot distinguish wound boundaries from peri-wound skin

Sussman (2012)

Undermining:

Separation of the wound edge from deeper tissue

Tunnelling:

Channel extending beyond open wound bed

 
Measure the degree of each incidence in centimetres. Document areas of undermining and tunnelling using clock face orientation (head = 12 o’clock).

Assessment of the skin surrounding the wound is an important component of wound assessment. Assess for:

  • Colour:
    • Redness (erythema)
    • Bruised (purple)
    • Hemosiderin staining (brown staining from long-standing venous insufficiency)
  • Temperature:
    • Compare to non-wounded area of body (opposite side of body)
  • Maceration (moist, soft):
    • Typically white looking
  • Induration
    • Firm or edematous skin
  • Further breakdown (i.e., tape injury, blisters, excoriation, etc.)
Peri-wound Terminology Description
1. Erythema
  • Redness surrounding the wound on the peri-wound skin
2. Hemosiderin staining
  • Brown discolouration due to chronic venous insufficiency
3. Macerated
  • Moist around wound, skin looks wet and soft
4. Indurated
  • Swelling or edema around wound, firm to touch

Sussman (2012)

  • Local infection: Micro-organisms are moving deeper into the wound, proliferating at a rate that causes a host response and delays healing. Local infection is limited to one location, system or structure. Signs and symptoms of infection include subtle or overt signs of infection.  
  • Spreading: Micro-organisms are proliferating at a rate such that they invade the tissue surrounding the wound. Signs and symptoms of infection spread to outside of wound border. Infection can invade deep tissue, fascia, muscle, organs or body cavities.
  • Systemic: Micro-organisms spread through the body via the lymphatic or vascular system. Systemic inflammatory response (sepsis) and organ dysfunction occurs.

1. Orsted HL, Keast DH, Forest-Lelande L, Kuhnke JL, O’Sullivan-Drombolis D, Jin S, et al. Best practice recommendations for the prevention and management of wounds. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada; 2017 [cited 2018 Jan 23]. 73p. Available from: https://www.woundscanada.ca/health-care-professional/education-health-care-professional/advanced-education/12-healthcare-professional/110-supplements.

2. British Columbia Provincial Nursing Skin and Wound Committee. Guideline: wound bed preparation for healable and non-healable wounds in adults and children. June 2015. [cited 2018 Jan 23]. Available from: https://www.clwk.ca/communities-of-practice/skin-wound-community-of-practice/buddydrive/

3. Sibbald G, et al. (2011). Special considerations in wound bed preparation 2011: An update. Advances in Skin and Wound Care, 24(9), 415-436.

4. British Columbia Provincial Nursing Skin and Wound Committee. (2018). Guideline: Wound Management for Adults & Children. [cited 2018 Nov 7]. Available from: https://www.clwk.ca/buddydrive/file/guideline-wound-management-2018-august/

5. Sussman C. (2012). Assessment of the patient, skin and wound. In: C. Sussman and BM Bates-Jensen (Ed.), Wound Care A Collaborative Practice Manual for Health Professionals (4th ed.). pp. 53-109. Philadelphia, PA: Lippincott, Williams & Wilkins

6. Van Rijswijk L & Eisenberg M. (2010). Wound assessment and documentation. In: Krasner DL, Rodeheaver GT, Sibbald G, Woo K (Ed.), Chronic Wound Care A Clinical Source Book for Health Care Professionals (5th ed.). pp. 99-116. Malvern PA: HMP Communications.

7. Lampe KE. (2010). The general evaluation. In McCulloch JM & Kloth LC (Ed.), Wound Healing Evidence-Based Management (4th ed.). pp 65-93. Philadelphia PA: F.A Davis Company.

8. Ennis WJ & Menses P. (2010). Complications in repair. In McCulloch JM & Kloth LC (Ed.), Wound Healing Evidence-Based Management (4th ed.). pp 51-64. Philadelphia PA: F.A Davis Company.

9. Registered Nurses Association of Ontario (2004). Assessment and Management of Venous Leg Ulcers. Toronto, Canada: Registered Nurses Association of Ontario

10. British Columbia Provincial Nursing Skin and Wound Committee. Guideline summary - wound infection. Jan 2017. [cited 2018 July 11]. Available from: https://www.clwk.ca/communities-of-practice/skin-wound-community-of-practice/buddydrive/

11. British Columbia Provincial Nursing Skin and Wound Committee. Prevention of pressure injury in adults & children: guideline 2017 November. [cited 2018 July 11]. Available from: https://www.clwk.ca/communities-of-practice/skin-wound-community-of-practice/buddydrive/

12. Norton L, Parslow N, Johnston D, Ho C, Afalavi A, Mark M, O’Sullivan-Drombolis D, Moffat S. Best practice recommendations for the prevention and management of pressure injuries. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada; 2017 [cited 2018 July 11]. Available from: https://www.woundscanada.ca/health-care-professional/education-health-care-professional/advanced-education/12-healthcare-professional/110-supplements.

13. National Pressure Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emilt Haesler (Ed.). Cambridge Media: Perth, Australia; 2014.

14. Sibbald RG, Elliott JA, Ayello EA, Somayaji R. Optimizing the moisture management tightrope with wound bed preparation 2015. Adv Skin Wound Care. 2015; (10):466-76

15. International Wound Infection Institute (IWII) Wound infection in clinical practice. Wounds International 2016. Retrieved from: http://www.woundinfection-institute.com/2016/11/wound-infection-in-clinical-practice-update2016/

16. British Columbia Provincial Nursing Skin and Wound Committee. (2014). Guideline: Assessment and Treatment of Lower Leg Ulcers (Arterial, Venous & Mixed) in Adults. [cited 2018 Nov 7]. Available from: https://www.clwk.ca/buddydrive/file/guideline-lower-limb-venous-arterial/

17. Registered Nurses’ Association of Ontario (2013). Assessment and Management of Foot Ulcers for People with Diabetes (2nd ed.). Toronto, ON: Registered Nurses’ Association of Ontario.

18. British Columbia Provincial Nursing Skin and Wound Committee. (2018). Guideline: Assessment and Treatment of Diabetic and Neuropathic Ulcers in Adults. [cited 2018 Nov 7]. Available from: https://www.clwk.ca/buddydrive/file/guideline-diabetic-neuropathic-ulcers/

19. LeBlanc K, Woo K, Christensen D, Forest-Lalande L, O’Drea J, Varga M, McSwiggen J, van Inevald C. (2017). Best practice recommendations for the prevention and management of skin tears. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada; 2017 [cited 2018 Nov 07]. 45p. Available from: https://www.woundscanada.ca/health-care-professional/education-health-care-professional/advanced-education/12-healthcare-professional/110-supplements.

20. Harris C, Kuhnke J, Haley J, Cross K, Somayaji R, Dubois J, Bishop R, Lewis K. (2017). Best practice recommendations for the prevention and management of surgical wound complications. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada; 2017 [cited 2018 Nov 07]. 63p. Available from: https://www.woundscanada.ca/health-care-professional/education-health-care-professional/advanced-education/12-healthcare-professional/110-supplements.

21. Botros M, Kuhnke J, Embil J, Goettl K, Morin C, Parsons L, Scharfstein B, Somayaji R, Evans R. (2017) Best practice recommendations for the prevention and management of diabetic foot ulcers. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada; 2017 [cited 2018 Nov 07]. 67p. Available from: https://www.woundscanada.ca/health-care-professional/education-health-care-professional/advanced-education/12-healthcare-professional/110-supplements.

22. Posthauer ME, Banks M, Dorner B, Schols JM. The role of nutrition for pressure ulcer management: national pressure ulcer advisory panel, European pressure ulcer advisory panel, and pan pacific pressure injury alliance white paper. Advances in skin & wound care. 2015 Apr 1;28(4):175-88.

23. Sibbald G, et al. (2006). Increased bacterial burden and infection: The story of NERDS and STONES. Advances in Skin and Wound Care, 19(8), 447-461.

24. Posthauer ME. (2012). Assessment and treatment of nutrition. In: C. Sussman and BM Bates-Jensen (Ed.), Wound Care A Collaborative Practice Manual for Health Professionals (4th ed.). pp. 187-211. Philadelphia, PA: Lippincott, Williams & Wilkins

25. Medical Council of Canada (2018). Clinical Laboratory Tests- Normal Values. Retrieved from: https://mcc.ca/objectives/normal-values/ . (November 24, 2018).