Wound Assessment

Purpose of a wound assessment?

Determine etiology and assist with determining outcomes (treatment)

What allergies could be part of a wound assessment?

Latex

Adhesives

Sulfa

Animal Products

How does pain determine etiology?

Elevation, dependency, activity related

Hematocrit values and significance

Women 37-47%

Men 42-52%

Low = anemia, blood loss, malnutrition

High = dehydration or clots

Hemoglobin values and significance

Women 12-16 g/dL
Men 14-18 g/dL
Low = anemia, blood loss

High = dehydration, blood clot

Total WBC values and significance

5-10 10^9/L

Low = infection risk

High = infection, inflammation, anemia

Platelet values and significance

150-400k/uL

Low = delayed clotting

High = blood clots

Total lymphocyte count values and significance

71800 cells/mm

Low = decreased immune function, protein deficiency, delayed wound healing

Serum albumin values and significance

3.5-5 g/dL (plasma protein produced by the liver)

Low = malnourished (edema), metabolic stress, inflammation

High = dehydrated

Serum prealbumin values and significance

15-45 mg/dL (transport protein)

Low = malnourished, mortality risk increases

Blood glucose values and significance

70-110 mg/dL

Signs of hyperglycemia: increased thirst, fatigue, blurred vision, slow healing infections

HbA1C values and significance

<5.7%

>6.5% is DM

BUN values and significance

10-20 mg/dL

High = kidney disease/dehydrated; delayed wound healing

Creatinine values and significance

0.6-1.2 mg/dL (slightly lower in females)

High = kidney disease

Low = malnutrition

Fasting glucose blood test precautions for exercise

<100 mg/dL too low (carb up)

>250 mg/dL too high (test urine for ketones, hold therapy until insulin)

What characteristics should be looked at in wounds?

Drainage (min/mod/max; serosanguinous, serous, purulent; milky)

Odor (min/mod/max; foul, ammonia-like)

Exposed structures (bone, tendon, muscle, hardware, nerves)

Periwound skin (erythema, edema, hemosiderin deposition, macerated, scaly, absensce of hair)

Wound border (regular, irregular, epiboly, contracted, callus, macerated)

Temperature and pain profile

What does color indicate in wounds?

Red - healthy with good BF

Pink - poor BF

Purple - wound is engorged

Black - necrotic, nonviable (eschar)

Yellow - slough/stringy, nonviable

Gray - nonviable

Green - infection

White - maceration

Signs of infection

Drainage, erythema, heat, odor, swelling, tenderness