Wound Assessment

SKIN OR INTEGUMENT

● Largest organ in the human body

● 15% of total body weight

● External covering of the body

● Consists of 3 layers:

○ Epidermis

○ Dermis

○ Subcutaneous tissue/Hypodermis

● Wound care is important to avoid potential systemic

problems

Acid mantle

suppresses bacterial growth

(4-6.5 pH)

Mainly because of sweat and oil glands

Defensins

■ Antimicrobial peptides/proteins

■ Exert an immunomodulatory &

chemotactic function (movement of

cells)

■ Produced by skin

■ Affect skin inflammation, infection,

and would healing

■ Capable of killing or inhibiting

bacterial growth through direct

membrane destruction

■ Help neutralizing secreted toxins

from bacteria

Moisture barrier/Water retention

Prevents evaporation of fluids from

within

■ Keeps the homeostasis of fluids

inside our body

Cells of Langerhans

■ Unique population of tissue

resident macrophages (WBC) that

form a network of cells across

epidermis of skin

■ Ability to migrate from epidermis to

draining lymph nodes

■ Dense network of immune system

cells that reside in epidermis and

help determine appropriate

adaptive immune response or

interpreting the microenvironmental

contexts in which we encounter

substances

■ First line of defense at the chance

there is a wound

Keratin cells

besides producing keratin (toughens our skin), it secretes Interleukin 1

Interleukin 1

one of the parts of

cytokines that has a central role in

the regulation of immunity and

inflammatory responses or due to

sterility of wound

■ E.g., septic shock – the interleukin 1

acts directly on blood vessels to

induce vasodilation and rapid

production of platelet-activating

factor and nitric oxide

■ Aids in the inflammatory process

through vasodilation for blood flow

in the wound area; rapid production

of platelets to clot the wound;

nitric oxide production to

vasodilate blood vessels and bring

nutrients and inflammatory

responders to the area.

Thermoregulation

○ Excretion of sweat

■ Evaporation of sweat helps cool

down the body (e.g., during

exercise)

○ Vasodilation or vasoconstriction of blood

vessels

■ If our body needs to conserve heat,

there would be vasoconstriction to

prevent diffusion of heat from the

surface of the skin if there is not

much blood flow in the area.

Sensation

Pertinent how we sense our surroundings

Sweat production

○ Releases toxins from our body and excess fluid from our skin

Storage and synthesis

Excretions/absorption/synthesis of Vitamin D

Converts sunlight into vitamin D

which is important for absorption of

calcium in our body

Epidermis, Dermis, Subcutaneous Tissue

Layers of the skin

Epidermis

outermost layer and initial protection of

the skin

Cant Look Good Saying Bitching

Stratum Corneum, Lucidum, granulosum, spinosum, basale

Stratum corneum

contains the dead keratinocytes, flakes, and sheds; provides waterproofing of the skin

Stratum lucidum

contains translucent cells that are only found on the palms and soles

Stratum granulosum

contains the cells of Langerhans; responsible for water retention

Stratum spinosum

contains cells of Langerhans and keratinocytes; provides additional protective layer

Stratum basale

single layer of epidermal cells; contains melanocytes that can regeneration

Dermis

composed of collagen and elastin fibers; contains the nerve endings (sensory receptors), blood vessels (capillaries), lymphatics, and sweat and sebacious glands; supports structure of the skin, providing mechanical strength

Papillary Layer

extensive layer of ridges, increasing the surface area of the skin; makes up the stretchy area of the skin

Reticular Layer

attaches to the subcutaneous tissue in the means of connective tissue

Subcutaneous fatty tissue

the hypodermis (adipose); where major blood vessels are located; for thermoregulation and storage of calories; also a mechanical shock absorber

WOUND ASSESSMENT

● Interdisciplinary approach to healthcare

● We help the doctors and the nurses in updating the

status of wounds of our patients

WOUND

● A breakdown in the protective function of the skin

○ E.g., mechanical wound, skin breakdown,

problems in circulation

● The loss of continuity of epithelium, with or

without loss of underlying connective tissue (i.e.

muscle, bone, nerves)

○ There are different depths of wound

● Following injury to the skin or underlying tissues/

organs caused by surgery, a blow, a cut,

chemicals, heat/ cold, friction/ shear force,

pressure or as a result of disease, such as leg

ulcers or carcinomas

● Classified as either acute or chronic

WOUND HEALING

● Natural physiologic reaction to tissue injury

● Interplay between numerous cell types, cytokines,

mediators, and the vascular system

○ Cytokines & mediators help with the

inflammatory process – increases amount of

cells & blood flow to the area

○ Initial stage: Hemostasis

○ Inflammatory phase

○ Proliferative phase

○ Maturation and Remodeling

Phases of wound healing

IMMEDIATELY AFTER THE INJURY

● Outpouring of lymphatic fluid and blood

● Goal is to achieve adequate hemostasis

● Aggregation of platelets follows the arterial

vasoconstriction to the damaged endothelial lining

○ To mitigate blood loss

● Vasoconstriction is a short-lived process that is

soon followed by vasodilation, which allows the

influx of white cells and more thrombocytes

○ Vasodilation brings nutrients and

inflammatory mediators to start the healing

process

● TLDR: stop bleeding (vasoconstriction) → plug

wound (platelets) → begin inflammatory process

(vasodilation)

Thrombin time test –

average time (10-30 sec) for

blood to clot

○ Longer time = clotting is not working well

INFLAMMATORY PHASE (0-25 DAYS)

● Hemostasis and chemotaxis

● WBC (kill bacteria) and thrombocytes (clotting) speed

up the inflammatory process

● Mediators and cytokines

○ Promote collagen degradation,

transformation of fibroblasts,

neovascularization, and re-epithelialization

Destroys damaged collagen → creation of new blood vessels → healing of the skin

Interleukins (IL1, IL6)

inflammatory mediators

tumor necrosis factor-α (TNFα),

for formation of new tissue; monocyte-derived cytokines; for pathogenesis and gram-negative shock

platelet-derived growth factor (PDGF)

released from platelets; help heal wounds and damaged walls of blood vessels; help in angiogenesis or revasculation

FGF2

fibroblast aids in repair and regeneration of tissue; fibrosis proliferation

Serotonin

– promotes cellular viability and proliferation and migration of both fibroblasts and keratinocytes

Histamine

vasodilator; enhances blood flow to the wound and inflammation

Platelet-derived growth factor

○ Attracts, enhances the multiplication and division of fibroblasts

Neutrophils, monocytes, and endothelial cells adhere to a fibrin scaffold

○ Initial scaffolding after injury

○ Phagocytosis of (foreign) debris and bacteria

○ Allows for the decontamination of the

wound

PROLIFERATIVE OR GRANULATION PHASE (2-25 DAYS)

● Day 2 of healing up to 25 days.

● Fibroblasts have laid new collagen and

glycosaminoglycans

Glycosaminoglycans

body’s natural moisturizer; hydrophilic molecules that draw out water into your skin and keeps it moisturized; maintains skin integrity by providing volume, elasticity, and firmness

Reepithelialization

○ Migration of cells from the wound periphery

○ From epithelium around the wound to the

center

Neovascularization

From endothelial progenitor cells

Wound Contraction

○ Facilitated by the continued deposition of

fibroblasts and myofibroblasts

○ To close the wound to the center

MATURATION OR REMODELING PHASE (15 DAYS TO 1 YEAR)

● Excess collagen degrades (Type 3 - Type 1)

● Wound contraction peaks at week 3

● Maximal tensile strength of the wound occurs

about 11-14 weeks

● Ultimate scar will have only about 80% maximum

strength of the initial skin in the area.

○ Original tensile strength of the skin is not

fully restored

Type I Collagen

The organic part of the bone, membranes for guided tissue regeneration Skin, bone, teeth, tendon, ligament, vascular ligature

Type II Collagen

The main constituent of cartilage, cartilage repair, and arthritis treatment Cartilage

Type III Collagen

The main constituent of reticular fibers, hemostats, and tissue sealants Muscle, blood vessels

Type IV Collagen

The major component of the basement membrane, attachment enhancer of cell culture, and diabetic nephropathy indicator Basal lamina, the epithelium-secreted layer of the basement membrane

Hemeostasis

• Blood coagulation

• Platelet accumulation

  • Release of growth factor

Inflammation

• Cleanse debris and bacteria invasions

  • Migrations of epithelial cells toward wound bed

Proliferation

• Formulation of granulation tissue by epithelium to cover wounds bed

Remodelling

• Fibroblasts completely recover wound to the wound bed

  • Formation of scar

● Hypoxia/Ischemia

○ Common in areas with poor blood flow

○ E.g., Pts with arterial insufficiency

● Bacterial colonization/Infection

● Reperfusion injuries

○ Damage after restoration of blood flow

● Altered cellular responses

○ E.g., cancer

● Tissue edema

○ Due to lack of blood flow in the area

● Maceration

○ Yung kulubot sa finger pads natin after

swimming → prone for wounding

○ Too much hydration

● Dehydration

○ Skin breakdown due to lack of moisture

● Collagen synthesis defects

○ Since collagen is the building blocks, this is

a problem

FACTORS LEADING TO IMPAIRED HEALING

Partial Thickness

○ Destruction of both the epidermis and

dermis

○ Pink, painful, NO yellow tissue/adipose

tissue

Full Thickness

○ Destruction of the dermis, epidermis, and

subcutaneous tissue

○ May expose the muscles and bones

ACUTE WOUND

● An injury to the skin that occurs suddenly rather than

over time

● It heals at the predictable and expected rate of the

normal wound healing process

● Can occur anywhere on the body and vary from

superficial scratches to deep wounds damaging

blood vessels, nerves and muscles

● Less than 12 weeks

CHRONIC WOUND

● A wound that does NOT heal in an orderly set of

stages and in a predictable amount of time

● Slow to heal are often = chronic (>12 weeks)

● Stuck in one or more of the phases of wound

healing

● Chronic wounds often remain in the inflammatory

stage for too long

● Venous and arterial ulcers, diabetic ulcers (most

common), and pressure ulcers are only a few

examples

● Cause patients severe emotional and physical stress

and pain

Wound base

Bottom of the wound (deepest)

Wound depth

Vertical distance from the visible surface

to the deepest area

Distance between top of the periwound

area to the deepest area of the wound

Wound edges/margin

Inside the perimeter of the wound

Periwound area

● Skin surrounding the wound

● Minimum of 4cm

Epibole

● Rolled edge

● Wound edge is curled under,

preventing wound closure

● (+) Epibole

Callused

● Fibrotic, hyper-keratotic

● Constantly exposed to repeated

injuries

Macerated

Skin is exposed to moisture for a

prolonged period of time

Erythema (Red)

Infection, trauma, inflammation

White

Moisture (maceration)

Blue/Purple (cyanotic)

● Poor blood flow, trauma

● (+) blue discoloration on periwound

area

Warm

Possible infection in the area

Cold

Poor blood flow in the area

Macerated

Soft or mushy

“Parang cereal na nababad na sa gatas”

Induration

Hardening, firm or hard

Denuded

○ Loss of epidermis, caused by exposure to

urine, feces, body fluids, wound exudate

and friction

○ May be maceration intially, progresses to

denudation

■ Pag natanggal/scraped off yung

white part (maceration) sa ibabaw

ng wound, nagiging denudation

○ (+) denuded wound on ___________

Excoriated

○ Linear erosion

■ Loss of epidermis

○ Destruction of skin by mechanical means

○ Scratch

○ (+) Excoriated wounds on

___________________

Tunneling

○ Channel or pathway that extends in any

direction from the wound through the

subcutaneous tissue

○ Has an exit point

Undermining

○ Tissue destruction underlying intact skin

along the wound margins

○ Caused by shearing forces

○ NO exit point

NECROTIC TISSUE

● Non-viable, dead tissue

○ Better removed since it can impede healing

○ Eschar is sometimes not removed

(depending on the case)

Slough

○ Yellow, green, grey

○ Lighter, thin, wet

○ Stringy

Eschar

○ Black, brown grey

○ Darker, thicker

○ Hard

EPITHELIAL TISSUE

● Epithelialization

● Outer most layer of skin

● Deep pink to pearly pink

● Closure of the wound, healing

● (+) epithelialization of wound on ________________

GRANULATION TISSUE

● New tissue that replaces dead tissue

○ Usually seen over sloughs or eschars

● Beefy, red color

● Puffy and mounded

● Grows from the base of the wound

HYPERGRANULATION TISSUE

● Forms above the surface of the wound

● Delays epithelialization

MUSCLE TISSUE

● Pink to dark red

● Highly vascularized

● Striated, grooved, or ridged

TENDON

● Attaches muscle to bone

● Shiny when healthy

FASCIA

● Hypodermal area

● Covering over the muscles

● Shiny and white

● Great organizer

BONE

● Shiny

● Smooth

Beefy red

○ Healthy tissue, good blood flow

Pale pink

○ Poor blood flow, anemia

Purple

○ Engorged, swelling, high bacterial levels,

trauma

○ Cyanotic; low oxygen areas

Black/Brown

○ Non-viable, necrotic tissue

Yellow

○ Non-viable tissue, slough

Green

○ Non-viable tissue, Active infection

White

○ Macerated, poor blood flow

Serious

Clear, straw-coloured Thin watery Normal

Fibrinous

Cloudy Thin watery May indicate fibrin strands present.

This is normal.

Serosanguinous

Opaque/ pink Thin watery May indicate the presence of red blood cells and capillary damage from, e.g. traumatic dressing removal or surgery

Sanguinous

Red Thin watery May indicate trauma to blood vessels.

May indicate low protein content due

to malnutrition. Venous or congestive

cardiac failure. May indicate the

presence of a fistula.

● Fistula is commonly seen in

dialysis

Seropurulent

Murky yellow/ cream/ coffee Thicker/ sticky/ creamy May indicate a bacterial infection

and/or the presence of necrotic liquid

or tissue.

Purulent

Yellow/ grey/ green Thick/ sticky

● Thicker than seropurulent

May indicate infection. Contains

pyogenic (pus-generating) organisms

and other inflammatory cells.

Haemopurulent

Dark, blood-stained Viscous/ sticky Will indicate an infection and will contain neutrophils, dead/ dying bacteria and inflammatory cells. Consequent damage to dermal capillaries leads to blood leakage.

Haemorrhagic

Dark red Thick/ sticky Indicates infection and/or trauma.

Capillaries are so friable they readily

break down and spontaneous

bleeding occurs. Not to be confused

with bloody exudate produced by

over-enthusiastic debridement.