This section provides a brief description of wound characteristics commonly included in wound assessment instruments. More comprehensive descriptions of wound characteristics are found in Chapter 3. The precise characteristics included in any given tool vary according to the purpose of the instrument (prediction of healing, assessment of wound status, prescription of treat- ment, etc.) and the philosophy of the instrument developers.
Location
Assess the location of the wound by identifying where the lesion occurs on the patient’s anatomy. As discussed in Chapter 3, body diagrams are typically used to document wound location.
Location may also be identifi ed by choosing the anatomic site from a list. Specifi c wound locations benefi cial or detrimental to healing are still to be determined.
Shape
Some assessment tools measure wound shape. Wound shape, which also helps to determine the overall size of the wound, is determined by evaluating the perimeter of the wound. Shape of the wound is related to wound contraction: as wounds heal, they often change shape and may begin to assume a more regu- lar, circular/oval shape. Compare Figures 5.1 to 5.3 to see the onset and progression of contraction and epithelialization.
It is identifi ed by a change in wound open area size as well as a change in wound shape (e.g., from irregular to symmetric, such as the circular or oval formation and rounding off of the edges of the wound). One wound shape deserves mention, the butterfl y shape or mirror image pressure ulcer on the sacrum.
This shape is important because it has been associated with rapid evolution and mortality. The butterfl y shape as seen in Figure 5.4 has been suggested as a characteristic of terminal pressure ulcers related to skin failure.12,13
Size
Most tools include some measure of size. Size can be deter- mined by measuring (in cm) the longest and perpendicularly widest aspect of the wound surface that is visible. Determine surface area by multiplying the length by the width. It can be diffi cult to determine where to measure size on some wounds, because the edge of the wound may be hard to visualize or the edge may be irregular. This is a skill that takes practice. Use of the same reference points for determining size improves the reliability and meaningfulness of the measures. In clinical prac- tice, one of two reference points are used; the longest aspect of
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FIGURE 5.1 Stage IV pressure ulcer on sacrum with stringy yellow slough evident. Note the epidermal ridge formation. (Copyright © C. Sussman.)
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FIGURE 5.2 Same wound as in Figure 5.1. The wound shows evidence of contraction with a smaller surface area. Healthy granulation tissue present throughout wound bed. (Copyright © C. Sussman.)
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FIGURE 5.3 Same wound as in Figures 5.1 and 5.2. The wound is now 100% fi lled with healthy granulation tissue. Note sustained wound con- traction and evidence of epithelialization. (Copyright © C. Sussman.)
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depth. Edges that are not attached to the base of the wound imply a wound with some depth of tissue involvement (see Fig. 5.5). The wound that is a crater or has a bowl/boat shape is a wound with edges that are not attached to the wound base as shown in Figure 5.6. The wound has walls or sides. There is depth to the wound.
• Thickness. As the wound ages, the edges become rolled under and thickened to palpation. Wounds of long duration may continue to thicken, with scar tissue and fi brosis developing in the wound edge, causing the edge to feel hard, rigid, and indurated. Hyperkeratosis is the callus-like tissue that may form around the wound edges, especially with diabetic ulcers (see Chapters 3 and 12).
• Color. The edge achieves a unique coloring with time. The pig- ment turns a grayish hue in both dark- and light-skinned persons.
Evaluate the wound edges by visual inspection and palpation.
Figures 5.5 to 5.7 show wounds with different edges.
Undermining/Tunneling
Some wound assessment tools include an evaluation of undermin- ing or pocketing and tunneling. As explained in Chapters 3 and 4, the wound and perpendicular widest aspect of the wound or
the length of the wound from head to toe (or using a clock face to represent the body, 12 o’clock—the head to 6 o’clock—the feet) and the width of the wound from side to side (or 3 o’clock to 9 o’clock). (Chapter 4 has step-by-step procedures for measuring size, depth, and undermining.)
Depth
Measure the depth of the wound as explained in Chapter 4.
Multiple measures of depth within the wound can increase reliabil- ity of depth evaluation. Some tools evaluate wound depth using description of tissues involved instead of numeric measurements.
Edges
The edges of the wound refl ect some of the most important characteristics of the wound. When assessing edges, consider the following qualities:
• Distinctness. Look for how clear and distinct the wound out- line appears. If the edges are indistinct and diffuse, there are areas where the normal tissues blend into the wound bed.
Well-defi ned edges are clear and distinct and can be outlined easily on a transparent piece of plastic.
• Attachment. Edges that are even with the skin surface and the wound base are edges that are attached to the base of the wound. This means that the wound is fl at, with no appreciable FIGURE 5.4 Butterfl y-shaped pressure ulcer on the sacrum. Note also soft, soggy black eschar present. (Copyright © B.M. Bates-Jensen.)
FIGURE 5.5 Full-thickness pressure ulcer with wound edges that are not attached to the base of the wound. The edges are rolled and thick- ened. (Copyright © B. M. Bates-Jensen.)
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FIGURE 5.6 Full-thickness pressure ulcer that is bowl or crater- shaped. The wound has edges that are not attached to the wound base.
(Copyright © C. Sussman.)
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FIGURE 5.7 Pressure ulcer with chronic fi brosis and scarring at the wound edge. The edge is rolled and thickened and indurated to palpa- tion. (Copyright © B.M. Bates-Jensen.)
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undermining and tunneling represent the loss of tissue under- neath an intact skin surface. Typically, instruments measure undermining and tunneling as either present or absent or with measurements of the extent of the processes. If measurements are used, the percent of the wound edge involved in the process and the distance the process extends from the edge are evaluated.
Necrosis
Necrosis is dead, devitalized tissue. Characteristics of necrotic tissue included in most wound healing measurement tools include presence, amount, color, consistency or moisture content, and adherence to the wound bed. In most cases, the clinician is asked to choose the predominant characteristic present in the wound. For additional information on necrosis, see Chapters 3 and 17 and Figures 5.4 and 5.8.
The amount of necrotic tissue present in the wound is evaluated by one of two methods. One method involves using clinical judgment to estimate the percentage of the wound cov- ered with necrosis. Picture the wound as a pie and divide it into four (25%) quadrants. Look at each quadrant and judge how much necrosis is present. Add up the total percentage from judgments of each quadrant; this determines the percentage of the wound involved. A second method involves actual linear measurements of the necrotic tissue. Measure the length and width of the necrosis and multiply to determine surface area of necrosis.
Exudate/Drainage
Most wound healing measurement tools require evaluation of exudate or drainage type and amount. Evaluating exudate type can be tricky because of the moist wound healing dressings used on most wounds. Some dressings interact with wound drainage to produce a gel or fl uid, and others may trap liq- uid and drainage at the wound site. Before assessing exudate type, gently cleanse the wound with normal saline or water and evaluate fresh exudate. Additionally, observe the wound dressing for exudate prior to discarding it. Pick the exudate type that is predominant in the wound, according to color and consistency.
CLINICAL WISDOM
Tips for Assessing Wound Edges
Defi nitions for help in assessing wound edges:
● Indistinct, diffuse—unable to distinguish wound outline clearly
● Attached—even or fl ush with wound base, no sides or walls present, fl at
● Not attached—sides or walls are present; fl oor or base of wound is deeper than edge
● Rolled under, thickened—soft to fi rm and fl exible to touch
● Hyperkeratosis—callus-like tissue formation around wound and at edges
● Color—intensifi ed color, increased pigmentation with grey hue at edge
To judge the amount of exudate in the wound, observe two areas: the wound itself and the dressing used on the wound.
Observe the wound for the moisture present. Are the tissues dry and desiccated? Are they swimming in exudate? Is the drain- age spread throughout the wound? Use clinical judgment to determine how wet the wound is. Evaluate the dressing used on the wound for how much it interacts with exudate. (See also Chapter 18 for management of exudate and infection.) Figures 5.9 to 5.12 show different characteristics of exudate.
Surrounding Skin Characteristics
The tissues surrounding the wound are often the fi rst indica- tion of impending further tissue damage. Some wound healing assessment tools include evaluation for
• Color, including erythema
• Edema
• Induration
• Maceration
• Hemorrhage or hematoma
Information on assessing for these characteristics of surround- ing skin was provided in Chapter 3.
Granulation Tissue
Most wound-measurement tools include assessment of the wound bed for granulation tissue. As presented in Chapter 2, the presence of granulation tissue signals the proliferative phase FIGURE 5.8 Sacral pressure ulcer with yellow slough and black necrotic areas present. Large amount of serosanguineous exudate present, the dressing is saturated. (Copyright © B.M. Bates-Jensen.)
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from the edges only. Use of a transparent measuring guide can be helpful to determine percentage of the wound involved in resurfacing and to measure the distance that the epithelial tis- sue extends into the wound from proliferative edges.
Use of Wound Characteristics Assessment in Specifi c Measurement Tools
The wound healing measurement tools discussed in this chap- ter include assessments of some combination of the forego- ing characteristics. All evaluate tissue attributes of the wound, and several evaluate surrounding skin. Methods of assessment, of wound healing. It is present in full-thickness wounds only.
Partial-thickness wounds do not require granulation tissue for- mation for wound healing. Granulation tissue is healthy when it is bright, beefy red, shiny, and granular with a velvety appear- ance. The tissue looks bumpy and may bleed. Well-vascularized granulation tissue can be seen in Figures 5.13 and 5.14.
Epithelialization
As discussed in Chapter 2, epithelialization is the process of epidermal resurfacing and appears as pink or red skin.
Figures 5.15 to 5.17A–D show the process of epidermal resur- facing. In partial-thickness wounds, the epithelial cells migrate from islands on the wound surface as well as from the wound edges. In full-thickness wounds, epidermal resurfacing occurs
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FIGURE 5.10 Wound with packing still present, note the moderate amount of serous exudate on dressing. The green color suggests pos- sible infection. (Copyright © C. Sussman.)
FIGURE 5.11 Full-thickness stage IV pressure ulcer with moderate amount of serous exudate. (Copyright © B.M. Bates-Jensen.)
FIGURE 5.12 Wound with moderate amount of purulent exudate.
(Copyright © B.M. Bates-Jensen.) FIGURE 5.9 Wound with bleeding or sanguineous exudate. (Copy-
right © B.M. Bates-Jensen.)
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format, and scoring differ. Copies of the SWHT, PUSH, and BWAT tools and instructions for their use are found in this chapter’s appendixes.