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Wound assessment in primary care

Wound assessment is a commonly encountered clinical responsibility for nurses in many healthcare settings and is primarily intended to describe the state of a wound at a given point in time.1 Accurate wound assessment and an understanding of the complexities of wound management is essential in ensuring that cost-effective and evidence-based interventions are used.2 The results of the wound assessment will determine the treatment prescribed, and practitioners need to ensure they have the essential skills required  to plan, implement and evaluate care on an individual basis.3 This article will explore the importance of wound assessment; provide guidance on how to undertake wound assessments and discuss the role of the nurse in ensuring high quality of care is received by all.

Patient assessment

Wound bed preparation is a fundamental aspect of effective wound management4 but wound assessment should not be performed in isolation. Complete holistic assessment of the patient and the wound needs to be performed to highlight the underlying aetiology and other factors that could delay wound healing. To ensure successful treatment of the wound, the World Union of Wound Healing Societies5 stressed the importance of effective assessment and recommended the following diagnostic process:

  • Determine the cause of the wound.
  • Identify any comorbidities/complications that may contribute to the wound or delay healing.
  • Assess the wound status.
  • Help to develop the management plan.

Wound assessment needs to start by obtaining a patient full medical history in the context of the patients overall wellbeing.6 This needs to include assessment of the patient's past medical history, medication record, pain assessment, nutritional assessment and psychological wellbeing. Most wounds, whatever the aetiology, heal without difficulty, however some wounds are subject to factors that can impede healing. It is these factors that need to be appropriately managed to help aid healing.7

Wound assessment

There are many factors to take into account when assessing wounds. These include:

History of the wound. It is important to take into account the duration of the wound, whether the wound originally occurred spontaneously or occurred as a result of trauma, injury or surgery and whether the wound is currently healing, deteriorating or is static in nature.

Size of the wound. Every wound should have measurements documented; this should include measurement of the length, width and depth. The use of wound tracing or clinical photography can provide useful visual documentation and it is important to remember if medical photography is used, that appropriate patient consent is obtained and local guidance is adhered to. 

Wound site. The location of the wound needs to be assessed and documented as it can hold clues as to the original cause of the wound. For example wounds on the feet of a patient with diabetes may be a result of pressure, neuropathy or peripheral arterial disease; a wound on a patient's sacrum may be a result of unrelieved pressure. Additionally the position of the wound can influence the choice of dressing treatment; for example dressing choice for a wound on the toe may be different to that on the abdomen. 

Wound bed assessment. Assessment of the current condition of the wound bed is vital to ensure realistic and meaningful aims are set and that the most appropriate dressings are recommended to optimise wound healing. Using a wound assessment tool in combination with complete holistic assessment assists the practitioner in ensuring that they focus systematically on all of the critical components of wound healing.3

Wound bed assessment tools

Wound assessment tools have been produced to aid clinicians with wound assessment. The most commonly used wound assessment tool is 'TIME,' originally produced by the International Advisory Board on Wound Bed Preparation.4 The acronym TIME stands for:

T = Tissue - is it viable or non-viable?

I = Infection or inflammation - is there evidence of infection or chronic inflammation?

M = Moisture balance - is there an imbalance of moisture levels, and is the wound bed too wet or too dry?

E = Edge of wound - whether the wound edges or advancing or non-advancing, is there any evidence of undermining?

Tissue 

Assessment of the wound bed will help distinguish between viable and non-viable tissue. Viable tissue includes granulation and epithelial tissue, non-viable tissue such as slough, necrotic tissue and eschar is thought to impede wound healing and therefore should be debrided using an appropriate method. Figure 1 shows a venous leg ulcer - the wound bed is covered with 90% dried-out slough/necrotic tissue. Wound healing will not occur until this non-viable tissue has been debrided. Treating this venous ulcer with the required compression therapy in combination with a wound dressing that provides a moist wound environment will facilitate autolytic debridement, progressing this wound towards healing. Prior to commencing wound debridement it is important that the underlying diagnosis of the wound is established, as in some circumstances debridement may not be appropriate. Figure 2, for example, shows a toe affected by peripheral arterial disease which is being allowed to auto-amputate, so requires to be left in a dry condition rather than being actively debrided. 

Infection/inflammation

Significantly increased bacterial loads in the wound bed can delay wound healing. Signs and symptoms of increased bacterial load include:

  • New or increasing pain.
  • Erythema.
  • Local warmth.
  • Swelling/peri-wound oedema.
  • Purulent discharge/increased exudate levels.
  • Pyrexia.
  • Delayed healing.
  • Abscess formation.
  • Malodour.
  • Bleeding or fragile granulation tissue.5

It is important to remember that all wounds will contain some evidence of bacteria. Wounds that are contaminated or colonised, will not delay healing. Whereas wounds that are critically colonised or clinically infected will delay wound healing. In wounds where there are signs of local infection (critical colonisation) but no signs of spreading infection the use of topical antiseptic/antimicrobial agents may be helpful.8 It is important to remember that currently there is no clear research evidence to support the use of antimicrobial dressings therefore the practitioner needs to consider the risk of bacterial resistance and cost implications.8 Patients with evidence of spreading infection should be treated with appropriate systemic antibiotic therapy. It is important to note that wound swabs should not be routinely taken to 'diagnose' infection; microbial swabs should only be taken to assist in deciding the most appropriate antibiotic therapy.5 In the case of diabetic foot ulceration, the presence of infection (see Figure 3) needs to be treated as a medical emergency, as 'time equals tissue'. Foot emergencies include new ulceration, swelling, discolouration and infection, and these should be referred to the diabetic foot multidisciplinary team within 24 hours of presentation.9

Moisture

Creating a moist wound interface is essential for wound healing to occur; exudate is produced as part of the body's response to tissue damage.10 A moist wound environment aids the autolytic process and acts as a transport medium for essential growth factors during epithelisation.11 If the wound becomes too dry this will slow epithelial migration, but if the wound is too wet, the exudate may damage the periwound skin and cause maceration.2 The levels of moisture in the wound bed and the amount of exudate will inform dressing product choice - wound dressings should provide a moist wound environment but in wounds where exudate levels are increased the wound dressing needs to be able to manage the level of exudate, prevent leakage and minimise maceration. Figure 4 shows a highly exudating venous leg ulcer - there are significant amounts of oedema around the lower limb and this is resulting in high exudate levels from the sloughy venous ulcer. The wound needs to be managed with dressings that have the capacity to hold high volumes of exudate, but this needs to be in combination with treatment of the underlying disease process, which in the case of venous ulceration would be compression therapy. 

Edges

Wound edge assessment refers to whether the epidermal margins of the wound are advancing or non-advancing across the wound bed, whether there is any evidence of undermining, rolling, thickening or callus formation. Lack of epithelialisation together with no improvement in the wound dimensions can be a sign that the wound is failing to heal.2 The regular measurement of the wound will enable assessment as to whether epithelisation is occurring and whether the wound is healing. If the wound fails to reduce in size, repeated consideration should be given to tissue, infection and moisture and ensure that all aspects of wound bed preparation are addressed.10 The underlying diseases and the causation of the wound needs to be considered and managed/treated wherever possible. Figure 5 shows a neuropathic ulcer in a patient with diabetes. Using the principles of TIME, the tissue appears viable, there are no signs of infection or chronic inflammation and moisture levels appear balanced, but the wound edges are non-advancing. The reason for the wound failing to heal is continued pressure being applied due to inappropriate footwear.

 Every patient with a wound has a right to expect a good minimum standard of care regardless of the aetiology of their wound, where the care is being delivered or by who.12 Therefore every practitioner that is involved in wound care needs to ensure they have the knowledge and skills to undertake assessment of the patient and the wound, making certain that the most appropriate wound product is used. Accurate wound assessment and timely interventions will optimise wound healing, leading to improved healing rates, improved patient satisfaction, reduction in cost and overall improvement of quality of care delivered.

 

References

1. Flanagan M. Improving accuracy of wound measurement in clinical practice. Ostomy Wound Management 2003;49:28-40.

2. Ousey K, Cook L. Understanding the importance of holistic wound assessment. Practice Nursing 2011;22(6):308-14.

3. Cook L. Wound Assessment: Exploring competency and current practice. British Journal of Community Nursing 2011;16(12):S34-40.

4. Schultz GS, et al, The Wound Bed Advisory Members. Wound bed preparation and a brief history of TIME. Int J Wound 2004;1(1):19-2.

5. World Union of Wound Healing Societies. Principles of Best Practice:  Diagnostics and Wounds. London: MEP Ltd; 2008.

6. International Consensus. Optimising wellbeing in people living with a wound. Wounds International 2012. 

7. Grey J, Enoch S, Harding K. Wound Assessment. British Medical Journal 2006;332(7536):285-88.

8. Wounds UK. Best Practice Statement: The use of topical antiseptic/antimicrobial agents in wound care. 2010.  Available at: www.wounds-uk.com/pdf/content_9627.pdf.

9. NICE. National Institute of Clinical Excellence: Type 2 diabetes - Prevention and management of foot problems. 2004. 

10. Dowsett C, Newton H. Wound Bed Preparation: TIME in practice Wounds UK 1(3):60-70.

11. Cutting K, Tong A. Wound physiology and moist wound healing. Holsworthy: Medical Communications Ltd; 2003.

12. Wound UK. Best Practice Statement: Optimising wound care. Aberdeen; Wound UK: 2008.