Wound Assessment Using Your Senses


We use typically 3 out of 5 senses when assessing the wound:

See: What does it look like? What color is the wound bed? Is there necrotic tissue? Are underlying structures exposed (bone, muscle, tendon)? Is there tunneling or undermining? What are the wound measurements (length x width x depth)? What color is the drainage? How much drainage? Is there peri-wound maceration (from moisture)? Epibole? Do you have photos or a prior assessment for comparison with the current assessment?


Smell: Is there an odor? Is the odor related to chronic wound drainage, autolytic debridement, infection, contamination (stool or urine), the treatment being used? Is the odor present after cleansing the wound?

Touch: Is there crepitus, induration, firmness, erythema? Can you palpate bone? Is purulent drainage expressed? Is the peri-wound warm?

In particular case, our wound is ~6cm x 6cm x 2cm, with no tunneling or undermining, moderate serosanguinous evacuation, no signs or indications of active infection, present over the sacrum. No bone, tendon, and muscle are presently exposed; but, they need to be exposed to the past per the report you received. this can be a chronic wound, present >1 year. The wound has been treated for osteomyelitis (OM) within the past, however, has nothing happening presently to create us assume active infection. Our goal is healing. However, would you stage this wound, and what would your treatment be? Current treatment: dry gauze TID.

Stage: chronic/healing stage IV (because of past bone exposure)—remember, you can’t backstage, once an IV, perpetually an IV!

Wound Treatment Planning

Drainage is moderate and serosanguinous, however, the dressing is being modified TID… therefore, evacuation is probably going progressing to be an oversized quantity. Why is that the wound draining so much? Is there underlying infection? Involve your knowledge domain team here, as needed—determine whether or not imaging is required, laboratory tests, etc. Remember, the gold normal for diagnosis OM could be a bone biopsy… however, would this be necessary if we all know that the wound was already positive for and treated for OM? Involve infectious disease, providers, and alternative disciplines as required.

Some Treatment Choices:

  • Alginate
  • Hydrofiber
  • Foam
  • Composite dressing (think dressings that contain an absorptive layer, cover layer, and adhesive border)
  • NPWT (negative-pressure wound therapy)

Given the number of wound evacuation described within the situation, we tend to wouldn’t be thinking along the lines of hydrocolloids, hydrogels, transparent films, or contact layers.

Because there isn’t tunneling or undermining in our wound, we tend to in all probability don’t want a rope or a ribbon dressing.

Because there aren’t signs or symptoms of active infection, we are able, to begin with, a non-antimicrobial dressing. If the wound doesn’t improve or evacuation isn’t managed or if it will increase, we are able to modification our dressing to incorporate antimicrobial properties like silver pro re nata once we assess.

This narrows our choice down to plain alginate, plain Hydrofiber, NPWT, plain foam, or presumably composite dressing. If we are able to complete occasional dressing changes we are able to seemingly use a foam-bordered dressing to cover versus gauze. If we want frequent dressing changes, we’ll like gauze and tape.

When deciding between Hydrofiber and alginate there are some vital things to seem at… you’ll be able to additionally refer back to my comparison chart in earlier blogs. Gelling fiber dressings are plain-woven dressing with absorptive properties, gelling fluid on contact with the dressing. Alginates are absorptive however usually absorb less than gelling fiber dressings; they’re additionally not plain-woven. each is available in plain and antimicrobial formats, usually.

We need a wound filler given the depth; we tend to can’t simply cover with a foam dressing.

NPWT could be an additional aggressive treatment. Typically, we will be able, to begin with less aggressive or invasive treatments and move to additional aggressive or invasive as required. in addition, it’s vital to seem at and monitor laboratory results, particularly nutritionary markers and weight trends.

Finally, before selecting and applying our dressing, we’ll decide what we’ll clean the wound with… plain saline versus an antiseptic or cytotoxic solution? Given our current wound description, saline appears as an acceptable alternative.

Because there aren’t any peri-wound problems (maceration, epibole, erythema, etc.), we tend to seemingly won’t apply a treatment to the peri-wound at this point.

Monitoring and Follow-Up

So, we’ll cleanse the wound, pat dry, and apply our product of choice… what do you think is the best treatment? Do you have any other suggestions? What things should we be monitoring and how often? What do you expect to happen in a week? What other things do we need to put into place? Think bed or seating surfaces, nutrition, managing friction, shear, moisture—is the patient continent? Remember the tools available to you, especially if in an inpatient setting: physical therapy, occupational therapy, dietitians, providers, general surgery, infectious disease, plastic surgery, attending providers, etc. Think of all of the categories in the Braden Scale, and be sure that you have appropriate interventions in place to meet each of this patient’s deficiencies (look back at the previous Braden mini-series for suggestions).

Stay tuned for the next blog to see how this wound progresses. And remember, there’s always more than one way to treat a wound!

International Conference on Wound Care, Tissue Repair and Regenerative Medicine
Date & venue: June 14-15, 2018 | London, UK

Website: https://goo.gl/eLcFyZ


Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s