uting conditions can be altered, e.g., by reperfusion, application of moisture-retentive dressings, or stimulation with biophysical agents, as described in Part IV of this text.
ASSESSING WOUNDS IN THE INFLAMMATORY PHASE
Assessment of the periwound and wound tissues during the infl ammatory phase includes four categories of wound attributes:
• Adjacent and periwound tissue appearance
• Wound bed tissue appearance (color and texture)
• Wound edges
• Exudate characteristics (odor, type, and quantity)
In this section, the attributes of the wound and the peri- wound tissues that serve as benchmarks of the phase are described during acute infl ammation, chronic infl ammation, and absence of infl ammation. Figures 3.30 and 3.41A,B show a wound that went from the chronic infl ammatory phase to the
acute infl ammatory phase and subsequently progressed to the proliferative and then to epithelialization and remodeling phase.
Acute Infl ammation
Signs of acute infl ammation (e.g., erythema, pain, edema, heat, loss of function) often extend well beyond the imme- diate wound and periwound tissues into adjacent tissues.
Initially, they indicate a healthy response and are a prerequi- site to normal healing. Use the characteristics observed during acute infl ammation as a reference point for the evaluation of impaired responses.
Adjacent and Periwound Tissue Assessment
The major attributes of adjacent and periwound tissues that are observed and palpated in the infl ammatory phase are color, fi rmness/texture, temperature, and pain.
Skin Color
Erythema is one of the classic characteristics of the acute infl am- matory phase. Initially, the adjacent skin can be erythematous due to reactive hyperemia. Erythema may not be evident in individuals with darkly pigmented skin (see previous discus- sion on skin color attributes). Reddened skin with streaks lead- ing away from the area can indicate cellulitis, a skin infection. If observed, check the patient’s history for fever, chills, history of recurrent cellulitis, or medications being used to treat the con- dition. If no treatment has been initiated, these fi ndings should be reported immediately to a physician.
Edema and Induration
The edema of the acute infl ammatory phase is localized and brawny. It feels fi rm and distorts the swollen tissues, causing the skin to become taut, shiny, and raised from the contours of the surrounding tissues. This edema results from trauma (e.g., pres- sure ulcers, burns, and surgical debridement) and is related to the release of histamines. Histamines cause vasodilation and increase vascular permeability, resulting in the movement of fl uid in the interstitial spaces. Edema is usually accompanied by pain.
Induration is abnormal hardening of the tissue at the wound margin from consolidation of edema in the tissues. To test for induration, attempt to pinch the tissues gently; if induration is present, the tissues cannot be pinched. Induration follows refl ex hyperemia or chronic venous congestion.74
Skin Temperature
Skin temperature should be tested as previously described.
During acute infl ammation, expect the temperature of the wound and adjacent tissues to be the same. As healing pro- gresses, the temperature of the adjacent wound tissue will gradu- ally decline, and the area of increased temperature will narrow.109 Pain
Chapter 22 is devoted to wound pain with specifi c assessment guidelines. Therefore, this discussion is very limited. Assess spontaneous or induced pain in the adjacent tissues by pal- pation or patient/family report, or both. Quantify using an accepted pain scale like the visual analog scale. Pain can indi- cate infection or subcutaneous tissue damage that is not visible, such as in pressure ulcers or vascular disease. Report of the sud- den onset of pain accompanied by edema in a leg is a common 5
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FIGURE 3.30 Traumatic wound in acute infl ammatory phase. Note:
(1) Adjacent tissue erythema, (2) Periwound erythema, (3) Hemor- rhagic tissue, (4) Sanguinous drainage, (5) Location over anterior tibia, (6) Classifi cation: full thickness. (Copyright © A. Myer.)
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10/2 – AL
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11/20 – AL
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FIGURE 3.31 A: Chronic wound: converted to acute infl ammatory phase. This is a sacral wound with stringy, yellow slough evident. Note example of epidermal ridge formation of wound edges. Predominant wound healing phase diagnosis:
acute infl ammatory/proliferative phase. Wound severity diagnosis: impaired integumentary integrity secondary to skin involvement extending into fascia, muscle, and bone (Stage IV pressure ulcer). B: Same wound as in (A), progressing through the proliferative phase. The wound is contracting and proliferating. Note changes in size, shape, and depth, as well as new healthy granulation tissue compared with (A). C: Note sustained wound contraction. Note epithelialization and proliferative phases. D: The wound is completely resurfaced and is in the remodeling phase. (Copyright © C. Sussman.)
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FIGURE 3.32 Full-thickness skin resected from calf. Note: (1) Vascularized dermis; (2) Yellow, healthy fat tissue; (3) White fi brous fascia; (4) Dark red muscle tissue; (5) Tendon covered with peritenon; (6) Blood vessel. (Copyright © J. Wethe.)
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indicator of deep vein thrombosis and wound infection. Pain in the calf or during palpation over a vein accompanied by unilat- eral edema is an indicator of thrombophlebitis, and immediate referral is required. The absence of pain in an obviously infected or infl amed wound should be investigated as an indication of neuropathy and the need for further assessment of sensation.
Wound Bed Tissue Assessment
Assess the wound bed for depth, undermining and tunneling, and exposure of subcutaneous and deeper tissues.
Depth
A partial-thickness skin loss creates a shallow crater that looks red or pink, or shows the yellow reticular layer—a thin, yellow, mesh-like covering that constitutes the deep layer of the dermis (Fig. 3.12). If the crater is bright and shiny, it is healthy and viable and should be left intact. Refer back to Chapter 2 and Figure 3.38 to view the anatomy of the tissues deep to the skin. If the wound penetrates through the dermis into the subcutaneous tissue, it will appear as though it contains yellow fat (such as chicken fat) or white connective tissue, called fascia. Fascia covers and wraps around all muscles, tendons, blood vessels, and nerves.
Wounds that extend through the subcutaneous tissue into the muscle can have a pink or dark red appearance with a shiny layer of fascia on top.
Undermining and Tunneling
Excavation of the subcutaneous tissues during debride- ment creates a “cave,” or undermining, of the wound edges.
Undermining can lead to separation of fascial planes (Figs. 3.4A,B and 3.33). Muscles lie together in bundles that are held together by fascia; when the fascia is cut, the muscle bundles separate. Separation of the fascial layers opens tun- nels along the fascial planes between the muscles under the skin. Tunnels can join together and form sinus tracts (Fig.
3.16B). Infection can travel through these tunnels, leading to abscess.
Exposure of Subcutaneous and Deeper Tissues
When debriding or treating deep or undermined wounds, it is likely that muscle tissue or tendons will be exposed. Muscle tis- sue can be identifi ed by appearance (striated) and by activity (it jumps or twitches when palpated). Muscles are connected to bones by tendons. These are rope-like structures covered with a sheath of white fascia called peritenon. Sparing the peritenon during wound care procedures facilitates the growth of new granulation tissue over the intact peritenon.
Penetration of a wound into a joint can expose several ana- tomic structures, including ligaments, which are white and striated; joint capsule, which is white and shiny; and cartilage,
which is white, hard, and smooth, and is located on the ends of bones. Bone is white and hard, and covered with a clear or white membrane called periosteum. Loss of peritenon or periosteum will compromise a skin graft. Wounds that can be probed to bone are considered to have osteomyelitis, and immediate refer- ral is warranted.
Assessment of Wound Edges
Palpate wound edges for fi rmness and texture. Observe the mar- gins for curling. During acute infl ammation, the wound edges are often indistinct or diffuse as in Fig. 3.30, and they change shape as wound contraction and epithelialization begins to cover the wound surface. Wound edges can be attached to the wound base or separated from it, forming walls with the base of the wound at a depth from the skin surface as in Fig. 3.33. This is considered a key factor in wound resurfacing. When undermining occurs, the wound edge is not attached, and epithelialization cannot advance, because the keratinocytes are unable to advance across the gap.
Repetitive injury to the wound edges can cause them to become fi rm, fi brotic, and indurated; this in turn can affect the ability of epithelialization to progress.68 Figure 3.35A–D shows examples of wound edges. Chapter 5 has detailed descriptions of different types of wound edges.
Assessment of Wound Drainage
Wound drainage during the acute infl ammatory phase is an indication of the status of the clotting mechanisms and infec- tion. During assessment, record the presence or absence, color, odor, quantity, and quality of the wound drainage.
Wound drainage that contains proteins, dead cells, and debris is called exudate and is typically brown or grey, although it may be viscous and look like pus (Fig. 3.36A,F). Bloody exu- date is called sanguineous drainage. Sanguineous wounds may have impaired clotting due to anticoagulant or antiplatelet pharmaceutical products (e.g., aspirin or Plavix) or disease processes such as hemophilia. A medical history, including a pharmacologic history, and systems review are indicated to determine the causes of the sanguineous drainage (Fig. 3.36F).
CLINICAL WISDOM
Excessive Infl ammatory Signs and Infection
Excessive signs of acute infl ammation should be considered a signal of impending wound infection.127
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FIGURE 3.33 Cave, or undermining, of the wound edges. Note the shelf. (Copyright © C. Sussman.)
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Wound Bed Tissue Assessment
In wounds in the chronic infl ammatory phase, necrotic tissue usually covers all or part of the wound surface. Necrotic tissue varies in color and may be black, yellow, tan, brown, or gray.
Soft necrotic tissue, such as fi brin or slough, can be present in the wound bed. Fibrin forms on the wound surface of venous ulcers. Slough is necrotic fat and fascia adhering to the layer beneath it. See Figures 3.17, 3.26B, 3.28C, 3.38, and 3.39 for different appearances of necrotic tissue.
During assessment, record the presence and color of necrotic tissue. Wounds that are in the chronic infl ammatory phase of healing often have a combination of several attributes. For example, a wound can have black and yellow necrotic tissue, as well as pink granulation tissue or healthy muscle tissue (Fig. 3.34) and sanguinous drainage.
In wounds that are chronically infl amed, a portion of the wound surface is often in the proliferative phase with granula- tion tissue present, but the proliferation fails to progress pos- sibly due to infection. Not all pink tissue is granulation tissue:
muscle tissue that lies beneath newly removed necrotic tissue is pink or dark red.
Signs of acute infl ammation may be absent. If, however, cellulitis or other infection is present, streaks of redness will often be seen in the periwound and adjacent skin extending away from the wound, and pain can become intense (Fig. 3.37).
Signs and symptoms of systemic infection that can lead to sep- sis include fever of 101°F (39.4°C) or higher; chills; manifesta- tion of shock, including restlessness, lethargy, and confusion;
and decreased systolic blood pressure.89 These are red fl ags that require immediate medical follow-up.
Chronic Wound Drainage
Prolonged, chronic infl ammation is the result of a bacteria- fi lled wound.128 When there is a high bacterial count (>105), signs of active infection are seen. Wound drainage characteris- tics, including color, odor, and volume, are often used as indi- cators of active wound infection. During assessment, record the presence or absence, color, odor, and quantity of exudate. The BWAT includes a nominal Likert scale to rate each one of these aspects. (See Chapter 5).
Exudate Color
Exudate color can suggest the type of infection. Normally, wound exudate is serous—a clear or light-yellow fluid.
Exudate from an infected wound can be yellow, tan, brown, or green. Wound drainage that has a yellow/gray or green color, has a foul odor, and/or is viscous, is commonly referred to as pus. Pus is a result of the demise of neutro- phils after they have phagocytosed debris and excessive bacterial loads. Green exudates are usually associated with an anaerobic infection. The wound dressing should be examined after removal for evidence of the attributes of the wound exudate (Fig. 3.36A–F).
Exudate Odor
Not all malodorous exudate signifi es infection. The odor can result from solubilization of necrotic tissue by enzymatic debriding agents or autolysis. In assessing exudate odor, begin by cleansing exudate from the wound to determine whether the Copious or persistent sanguineous drainage should be reported
to a physician immediately, as it may be a sign of internal bleeding.
In contrast, clear fl uid drainage is called transudate. The presence of transudate indicates diffusion of plasma fl uid from the blood into the surrounding tissues. Serous transudate is a clear yellow fl uid that exudes from the wound. It is usually odorless, and is present in varying amounts during the infl am- matory phase (Fig. 3.36B,E).
Chronic Infl ammation
Infl ammation that persists for weeks or months is referred to as chronic (or persistent). Chronic infl ammation occurs when the macrophages and neutrophils fail to phagocytose necrotic matter, ingest foreign debris, and fi ght infection.128 Therefore, necrotic matter and foreign debris is typically found in the wound bed. Chronic infl ammation is also related to the release of histamine from the mast cells and refl ex hyperemia associated with vasodilation of the surrounding vasculature.
Repeated trauma to a wound can also develop into chronic infl ammation.
Adjacent and Periwound Tissue Assessment
Chronic infl ammation in the periwound area appears as a halo of erythema in lightly pigmented skin and a dark halo in darkly pigmented skin. The latter may be easily mistaken because of its similar appearance to hemosiderin staining. Arterial ulcers over the malleolus and pressure ulcers are frequently seen with a halo of erythema, but they lack the blood fl ow to progress the wound (Fig. 3.37).
There is minimal temperature change or cooling, compared with adjacent uninjured tissues. Edema may prompt some minimal fi rmness in the periwound tissues. Usually, the pain response is minimal. Intense pain may be associated with arte- rial vascular disease or infection.
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FIGURE 3.34 Chronic infl ammatory phase. Note the following wound characteristics: (1) Sanguineous drainage, (2) Muscle exposure, (3) Hemosiderin staining surrounding the wound. (Copyright © B.M.
Bates-Jensen.)
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FIGURE 3.35 Wound edges. A: Absence of proliferative phase. Wound with no epithelialization present. The wound is clean, but nonprolif- erating. B: Same wound as in Figure 3.41A. Wound is in acute pro- liferative phase with evidence of new epithelial migration. indicating wound improvement. C: There is an absence of the epithelialization phase due to chronic fi brosis and scarring at the wound edge. Edges achieve a unique, grayish hue in both dark and lightly pigmented skin.
Note rolled and thickened attributes. Chronic proliferative phase. D:
Example of knowledge gained from careful examination of the wound edge. This is a chronic, deep ulcer that does not bleed easily. Wound is in chronic proliferative phase. Note: (1) New pressure-induced dam- age (hemorrhage), (2) Maceration from wound fl uid, (3) Friction injury with signs of infl ammation. (Copyright © B.M. Bates-Jensen.)
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FIGURE 3.36 Assesment of wound Drainage. A: Wound appears “clean,” but it is in the chronic proliferative phase.
The quantity of exudate is determined by the amount of dressing saturated by the drainage. Note: (1) Moderate to large amount of sanguineous exudate, (2) Moderate to large amount of purulent exudate. Evaluate for infection. B: Wound with packing still present. Note: (1) Moderate amount of serous exudate on dressing, (2) Green color of exudate sug- gests possible infection. C: Wound with composite dressing shows scant amount of serous exudate. Wound is in chronic infl ammatory phase. There is an absence of proliferative phase. Wound is stage III pressure ulcer. D: Wound with com- posite dressing. Dressing shows scant amount of serosanguineous exudate. The wound bed shows a gelatinous mass that may be gelatinous edema. Bright pink skin is scar tissue. Evaluate for trauma. (Copyright © C. Sussman.)
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