Wound Care Intro

What are seven aspects of wound examination?

- Systems review

- Location: provides insight as to the type of wound and problems that may be encountered

- Age of wound: acute vs. chronic

- Size: photograph with calculation, volumetrics, tracings, total body surface area (burns), direct measurement/ruler method

- Depth: probe with cotton-tipped applicator, document deepest area, multiple locations if necessary

- Tunneling (sinus tracts)/undermining: measure using probe and paper tape measure, document locations on the clock

- Photography: provides supplemental info about tissue type and condition of surrounding skin

What are two methods of direct measurement?

- Longest and widest areas

- Clock with 12:00 at the head of the patient

What is the rule of 9s used for?

Measurement of total body surface area used in assessment of burn wounds (percentage of the body affected by the burn)

What does a red wound bed indicate?

Granulation, bleeding

Why is a red wound bed typically good?

Because it indicates that there is adequate blood

What does a yellow wound bed indicate?

Slough (fibrinous); not healthy and needs to be removed to encourage healing

What is slough?

Mix of WBCs, bacteria, foreign debris, denatured collaged, etc.

What does a black wound bed indicate?

Eschar (necrotic); ischemic, completely dead

What do white wound edges indicate?

Maceration

What do red wound edges indicate?

Inflammation

What do purple wound edges indicate?

Bruising or trauma

What do pink wound edges indicate?

Epithelialization (good sign, new epithelial tissues)

What do raised wound edges indicate?

Hyperkeratosis, callus, scar (too much skin, can cause pressure and cause a wound to get bigger)

How is amount of wound drainage measured?

- None

- Scant

- Minimal

- Moderate

- Copious

What are five colors that wound drainage might be?

- Clear

- Pale yellow

- Red

- Brown

- Blue-green

What might the consistency of wound drainage be?

- Thin/watery

- Thick

What are four types of drainage/exudate?

- Serous (light yellow)

- Sanguineous (red)

- Serosanguinous (pink)

- Purulent (brown, green, dark yellow)

What is undermining?

Tissue under wound edge becomes eroded separated from surrounding tissue; must be measured and documented

What is tunneling?

- Narrow passageway

- Defect in fascial plane

- Extends from wound bed into soft tissue

- Must be measured and documented

- High potential for abscess formation

What do patients with tunneling have a high potential for?

Abscess formation

When is wound odor assessed?

After wound has been debrided and rinsed

What will cause an increased odor from a wound?

Infection

How mind wound odor be described?

- None

- Strong

- Foul

- Pungent

- Fecal

- Musty

- Sweet

What are pseudomonas and proteus?

Types of bacteria

How do pseudomonas affect wound odor?

Sweet, fruity smelling with green drainage or tissue

How does proteus bacteria affect wound odor?

Ammonia-like

What is the bioburden?

The number of microorganisms with which an object is contaminated

What are six other components of evaluation?

- Circulation

- Sensation

- ROM and strength

- Mobility

- BMI

- Lab values (WBC, sedimentation rate, hgb, glucose, albumin/pre-albumin/total protein

What is involved in the neuropathic foot exam?

- Monofilament testing

- Loss of protective sensation (inability to feel at one or more sites)

What monofilament determines if the patient has protective sensation?

5.07 (bends at 10 g pressure)

Even if the patient does not have a wound, what is the main focus for a patient with a loss of protective sensation?

Educating them on wound care

What are the grades of the Wagner System for classification of neuropathic ulcers?

- 0: no open lesion; deformity or cellulitis

- 1: superficial ulcer

- 2: deep ulcer to tendon, bone, capsule

- 3: deep ulcer with abscess, osteo, or joint infection

- 4: partial-foot/localized gangrene

- 5: gangrene of entire foot

Which grades in the Wagner System require some level of amputation?

4 and 5

What are the grades of the UT Staging System for classification of neuropathic ulcers?

- 0: pre- or post-ulcerative site

- 1: superficial wound, not involving tendon/capsule/bone

- 2: wound penetrating to tendon or capsule

- 3: wound penetrating to bone or joint

What are the stages of the UT Staging System for classification of neuropathic ulcers?

- A: clean wound (no infection, no ischemia)

- B: non-ischemic, infected wound

- C: ischemic, non-infected wound

- D: ischemic and infected wound