Wound assessment and reporting

Wound healing is determined by the general health of your patient, so a comprehensive assessment of your patient is crucial when planning and evaluating treatment.

Patient report

When assessing and reporting on a patient, be sure to note the following:

Full medical history such as diabetes, vascular diseases, compromised immune system, connective tissue disorders and allergies
Medication
Nutritional status
Lifestyle, for example tobacco and alcohol habits or impaired mobility
Psychological problems
Quality of life

Wound assessment

Diagnosing the underlying cause of a wound is an essential part of wound assessment – and you can only treat the wound once this has been determined. You’ll also need to assess the wound bed and the surrounding skin. After you’ve made these assessments, you can select the best dressing.

Wound report

When assessing and reporting on a wound, you’ll want to note the following:

Wound location, size and type
Characteristics of the wound bed, such as necrotic tissue, granulation tissue and infection
Odor and exudate (none, low, moderate, high)
Condition of the surrounding skin (normal, white, shiny, warm, red, dry, scaling, thin)
Clinical signs of wound infection (delayed healing, odor, abnormal granulation tissue, increased wound pain and/or excessive exudate)
Wound pain (location of the pain, pain duration, pain intensity, nociceptive or neuropathic).

In many countries Coloplast offers training in wound assessment and management for health care professionals.

Leg Ulcers

Four out of ten chronic wounds are venous leg ulcers. Read more

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References

1. Fogh et al. Wound Repair and Regeneration 2012;20: 815-821

2. Gottrup et al. Wound Repair and Regeneration 2008;6:615-25

3. Palao I Domenech et al. Journal of Wound Care 2008;17(8):342-48

The three most common types of leg ulcers are:

Venous leg ulcers (70%)
Arterial leg ulcers (10%)
Mixed venous and arterial leg ulcers (10–15%)

Venous leg ulcers

Venous leg ulcers are caused either by dysfunction of the venous valves or an inadequate calf muscle pump. In both cases, blood isn’t sufficiently returned to the heart. This leads to higher venous pressure, which can cause edema. And an increased fluid level between cells can result in cell death, leading to ulcers. This is why compression therapy is an essential part of treating venous leg ulcers.

Venous leg ulcers are often located in the gaiter area of the leg and characterized by:

Irregular shape
Brown pigmentation in the peri-ulcer skin area (often with eczema)
Normal foot pulse

Venous leg ulcers are often painful, especially during daytime. Elevation of the leg can relieve some of the pain.

Arterial Ulcers

Arterial leg ulcers are caused by insufficient blood supply to the leg or feet due to arteriosclerosis. The condition reduces the supply of oxygen and nutrients to the cells, resulting in tissue death and, eventually, ulcers.
Patients with arterial ulcers should not be treated with compression therapy, but will often need vascular surgery.

Arterial ulcers are often located in the gaiter area and on the feet, and are characterized by:

Fairly regular shape
Atrophic, pale periwound skin
Weak foot pulse

Arterial ulcers can be very painful, especially at rest.

Mixed Venous And Arterial Leg Ulcers

Mixed venous and arterial leg ulcers are ulcers caused by both venous and arterial disease. The majority of patients diagnosed with mixed venous ulcers have ulcers of venous origin and develop arterial insufficiency over time.

Treatment Needs

Venous leg ulcers should normally be treated with graduated compression therapy. However, not all patients can tolerate full compression. Mixed etiology ulcers are likely to require a reduced level of compression. Arterial leg ulcers should not be treated with compression therapy.

Wound dressings for leg ulcers should offer superior absorption and exudate management properties that enable them to absorb and retain exudate under compression bandages (venous leg ulcers). Suitable dressings include Biatain Silicone, Biatain Non-Adhesive.

A silver-releasing dressing, such as Biatain Ag or Biatain Silicone Ag, can help prevent or resolve wound infection.

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Diabetic Foot Ulcers

Diabetic foot ulcer infections increase the risk of amputation 155 times (1). Read more

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References

1. Lavery et al. Diabetes Care 2006;29(6):1288–93 2

Up to 15% of diabetics are likely to develop a foot ulcer at some stage in their lives. Diabetic ulcers have a considerable negative impact on patients’ lives, and are highly susceptible to infection that all too often leads to amputation. This makes infection control of paramount importance in diabetic foot ulcer management.

Successfully managing a diabetic foot ulcer requires a comprehensive understanding of the wound: its cause, progression, risk, and treatment.

The main causes of diabetic foot ulcers are:

Neuropathy
Poor blood supply (ischemia)

Neuropathy

Diabetes can change the body’s ability to combat infection. Not only are the feet more prone to infection, it’s also harder to get rid of an infection once it’s there. So it’s crucial that you assess the patient regularly to prevent and react quickly to infections.

Treatment Needs

Treat the underlying causes of a diabetic foot ulcer if possible
To support the healing process, use appropriate moist wound healing dressings with superior absorption and exudate management properties, such as Biatain Non-Adhesive foam dressing or Biatain Alginate dressing
A silver-releasing moist wound healing dressing, such as Biatain Ag, can help prevent or resolve wound infection

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Pressure Ulcers

Responsible for a two-fold increase in mortality rates (1), pressure ulcers demand timely, effective treatment. Read more

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References

1. Brem and Lyder. The American Journal of Surgery 2004;188:9S–17S

2. NPUAP-EPUAP Pressure Ulcer Prevention, Quick Reference Guide, 2010 (pdf)

3. NPUAP-EPUAP Pressure Ulcer Treatment, Quick reference guide, 2009 (pdf)

4. Gottrup et al. Wound Repair and Regeneration 2008;6:615-25

5. Palao I Domenech et al. Journal of Wound Care 2008;17(8):342-48

6. Fogh et al. Wound Repair and Regeneration 2012;20: 815-821

A pressure ulcer (decubitus ulcer) is a localized injury to the skin and/or underlying tissue, usually over a bony prominence. This type of ulcer is the result of pressure, or pressure in combination with shear (2). The pressure prevents the blood from circulating properly, and causes cell death, tissue necrosis and the development of ulcers. Wheelchair users or people confined to a bed (for example, after surgery or an injury) are especially at risk.

Major Cause Of Morbidity

Pressure ulcers are a major cause of morbidity and mortality, especially for people with impaired sensation, prolonged immobility, or advanced age. The most common places for pressure ulcers are over a bony prominence, such as elbows, heels, hips, ankles, shoulders, the back, and the back of the head.

Classification

Pressure ulcers are classified according to the degree of tissue damage observed. In 2009 the EPUAP-NPUAP advisory panel agreed upon four levels of injury (3):

Category/Stage I: Non-Blanchable Redness Of Intact Skin

Full thickness skin or tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Treatment needs (2,3)

Pressure must be relieved or removed by appropriate measures.
Wound care must be optimized by:

Debridement of necrotic tissue
Appropriate cleansing of wound and surrounding skin
Use of appropriate moist wound healing dressings

Suitable wound dressings for pressure ulcers are foam or alginate dressings with superior absorption and exudate management properties, such as Biatain Silicone or Biatain Adhesive foam dressing or Biatain Alginate dressing. A silver-releasing dressing such as Biatain Ag can help prevent or resolve wound infection.

Download Our Tips For Preventing, Assessing And Treating Pressure Ulcers:

Pressure ulcers – prevention and treatment: A Coloplast quick guide (pdf)

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Acute Wounds

Acute wounds must be treated promptly to stop bleeding and protect tissue. Read more

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Acute Wounds – Signs And Symptoms

A cut or tear in the skin
Bleeding, swelling, pain, and/or difficulty moving the affected area
There may be dirt or foreign objects inside the wound
Exudate is normally clear
Large or deep, acute wounds with heavy bleeding need acute medical attention to stop bleeding and check for damage to vital organs or tissue.

Treatment Needs

Foreign objects should be removed from the wound and necrotic tissue debrided, as it can function as a base for infection and delay wound healing. Wound cleansing with Sea-Clens Wound Cleanser, may be appropriate.

Exudate production is part of the natural wound healing process (1), but the exudate needs to be managed appropriately. Exudate levels are often high during the inflammatory phase of wound healing, and leakage of exudate under the dressing can damage the surrounding skin. Wound exudate must be absorbed and managed by a dressing with moist wound healing properties. This supports the healing process and reduces scar formation. (2-3)

With appropriate care, smaller acute wounds will normally close within days or weeks depending on the size, depth and position of the wound.

Suitable dressings for acute wounds are dressings with superior absorption and exudate management properties that support a moist wound healing environment. These include Biatain Silicone, Biatain Adhesive or Comfeel. Where infection is present, Biatain Silicone Ag and Biatain Ag are appropriate choices.

Why Do Some Acute Wounds Become Chronic?

If a person has a condition affecting the circulation system and/or immune response, normal wound healing processes may be impaired, and the wound may become chronic. Chronic wounds are often defined by the underlying condition that prevents wound healing, such as venous leg ulcers, arterial leg ulcers, diabetic foot ulcers or pressure ulcers.

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Necrosis

If a wound contains dead (necrotic) tissue, it’s a sign that the wound is not healing normally. Read more

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Necrotic tissue is often black or yellow. It may be soft or it may form a scab (eschar). Necrotic tissue can contain bacteria – and if the bacteria grow, the wound will become infected.

Necrosis

Removal of necrotic tissue (debridement)

Necrotic tissue must be removed in order to support wound healing. Removal can be surgical, mechanical, enzymatic (such as maggot therapy), or it can be achieved by supplementing the body’s own ability to break down necrotic tissue (autolytic debridement).

Choice of dressing

The autolytic debridement process is optimised when the wound is moist. Coloplast has a range of dressings that support moist wound healing. For optimal moisture balance in the wound, the hydrocolloid Comfeel dressing and the unique properties of the Biatain foam dressing both support the natural autolytic debridement process.

Purilon gel is ideal for gentle and effective autolytic debridement of tissue in both dry and moist necrotic wounds, when used in combination with a secondary dressing such as Comfeel or Biatain.

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Periwound Skin

The skin surrounding an wound is vulnerable. This may be associated with age, disease processes or exposure of the skin to wound exudate or dressing adhesives. Read more

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Maceration

Exudate leaked from ulcers can cause maceration, a softening or sogginess and breakdown of the skin that results from on-going contact with excessive moisture. Maceration can lead to skin breakdown, causing the ulcer to grow or creating satellite ulcers. Macerated tissue is white in colour.

macerated skin

Erythema

Erythema is an abnormal redness of the skin caused by dilation of blood vessels. Redness of the peri-ulcer skin may be a sign of inflammation or wound infection.

Fragile skin

As we grow older, the texture of our skin changes and our skin becomes thinner, weaker and less protective. If a wound is surrounded by fragile skin, dressings are more likely to cause skin irritation. You must examine the skin carefully before deciding to use either an adhesive or a non-adhesive dressing.

Fragile skin

Choice of dressing

The Biatain dressing range offers dressings with superior absorption and exudate management properties for all types of skin conditions.

Normal, healthy skin has a smooth and resilient structure. With proper wound treatment and use of dressings with superior absorption and exudate management, the skin surrounding a wound may be perfectly healthy and suitable for adhesive dressings such as Biatain Adhesive or Biatain Super, Adhesive.

If the skin is very fragile, consider using a non-adhesive dressing such as Biatain Non-adhesive or Biatain Alginate.

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Wound Exudate

Whether a wound is low-, medium- or high-exuding, superior absorption and control of exudate are essential for optimal healing. Read more

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References

1. White RJ and Cutting KF. British Journal of Nursing 2003;12(20):1186-1201

2. Adderly UJ. Wound Care, March 2010:15-20

3. Colwell JC et al. Wound Ostomy Continence Nursing 2011;38(5):541-53

4. Enoch B and Harding K. Wounds: A Compendium of Clinical Research and Practice 2003;15(7):213-29

5. Andersen et al. Ostomy/Wound Management 2002;(48)8:34-41

6. Thomas et al. http://www.dressings.org/TechnicalPublications/PDF/Coloplast-Dressings-Testing-2003-2004.pdf

7. White R and Cutting KF. http://www.worldwidewounds.com/2006/september/White/Modern-Exudate-Mgt.html

8. Romanelli et al. Exudate management made easy. Wounds International 2010;1(2).

In the inflammatory phase of wound healing, exudate levels are usually high. Non-healing, or chronic, wounds are often stuck in the inflammatory phase and may produce large amounts of exudate. Increased exudate levels can be a symptom of infection and increased oedema.

Wound exudate is a fluid composed of plasma, blood cells and platelets. Most of the wound exudate filters from the blood and/or lymph system into the wound area, but red blood cells and platelets leak from injured capillaries. Composition and viscosity varies, from thin and clear plasma fluid to thick yellow secretion containing high concentrations of white blood cells and bacteria.

Controlling exudate

If wound exudate is not properly controlled, it can leak from the dressing and result in the peri-ulcer skin being exposed to the exudate (1). This causes over-hydration maceration of the skin and can ultimately delay healing (2,3).

Maceration is a softening or sogginess and breakdown of the skin caused by on-going contact with excessive moisture. Macerated tissue looks white and maceration can cause an ulcer to grow or create satellite ulcers.

Macerated skin(2,3)

Delays healing
Increases risk of infection
Increases friction risk
Can result in wound enlargement

macerated skin

It is therefore very important that excess exudate is removed from the wound by an absorbent dressing. (4)

Control of exudate, removal of unhealthy tissue by debridement and management of bacterial load are all part of good wound bed preparation. The optimal wound dressing keeps the wound moist and absorbs exudate, locking it inside the dressing to prevent maceration.

Dressings for exuding wounds

We recommend the Biatain dressing range, which provides superior absorption - faster healing (5,6) of low to high exuding wounds. Biatain dressings effectively absorb and retain wound exudate, ensuring a moisture balance that is optimal for healing of exuding wounds.(7,8)

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Wound infection

All wounds contain bacteria – even wounds that are healing normally. But if the bacteria count rises the wound may become infected. Read more

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References

1. Jørgensen et al. International Wound Journal 2005;2(1):64-73

2. Münter et al. Journal of Wound Care 2006;15(5):199-206

3. Reitzel & Marburger. EWMA 2009

4. Ip et al. Antimicrobial activities of silver dressings: an in vitro comparison. Journal of Medical Microbiology 2006;(55):59-63.

5. Basterzi et al. In-vitro comparison of antimicrobial efficacy of various wound dressings. Wounds 2010; July.

6. Data on file (Independent laboratory testing performed by Wickham Laboratories).

7. Thomas et al. www.dressings.org/TechnicalPublications/PDF/ Coloplast-Dressings-Testing-2003-2004.pdf

Wounds that are not healing normally may have a bacterial imbalance resulting in local infection of the wound.

Likely signs of wound infection are one or more of the following:

Delayed or stalled healing
Odour
Increased wound exudate
Absent/abnormal/discoloured granulation tissue
Increased pain at wound site

infected wound

Other symptoms

Additional clinical symptoms may arise if the infection spreads to the healthy tissue surrounding the wound. Depending on the type of bacteria, the wound exudate may become more pus-like, and the peri-ulcer skin may be tender, red and painful. The patient may also have a fever.

Please remember that diabetic foot ulcers do not always present with the classical signs of local infection.

Dressings for infected wounds and wounds at risk of infection

If a wound is healing normally, a foam dressing with superior absorption such as Biatain is ideal. If the wound is infected or there is risk of wound infection, we recommend silver dressings such as Biatain Ag, or Biatain Alginate Ag. These provide superior absorption for faster healing of infected wounds (1-7). If the infection is spreading beyond the wound, the silver dressing must be combined with systemic antibiotic treatment at the discretion of a physician.

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Treatment of a venous leg ulcer

See how the use of Biatain® Non-Adhesive foam dressings led to a 95% reduction in ulcer area after four weeks’ treatment of a venous leg ulcer. Read more

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The patient

The patient – an 85-year-old woman – had been suffering from a venous leg ulcer on the lateral part of her lower left leg. The skin on her leg was fragile. The ulcer had persisted for five months at inclusion.

Previous treatment

Prior to inclusion, the ulcer had been treated with alginate dressings and compression therapy for ten weeks. Ulcer healing was delayed compared to the normally expected healing rate.

Biatain Non-Adhesive introduced

When the patient began treatment with Biatain Non-Adhesive, the ulcer area was 4.9 cm². The ulcer contained 20% fibrinous tissue and 80% healthy granulation tissue. During the four-week treatment period, long-stretch compression bandages were applied.

This picture shows the ulcer at inclusion after cleansing:

Ulcer area was reduced by 73% after two weeks of treatment with Biatain Non-Adhesive:

The ulcer area was reduced by 95% after 4 weeks of treatment with Biatain Non-Adhesive:
After four weeks treatment the ulcer area was reduced by 95%.

Conclusion

During the four weeks treatment period:

Biatain Non-Adhesive demonstrated remarkable reduction in ulcer size.
Biatain Non-Adhesive caused no leakage or maceration, even under compression therapy.
Biatain Non-Adhesive minimised pressure marks.
Biatain Non-Adhesive was comfortable and easy to use.

Download full case description (PDF)

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Treatment of an infected diabetic foot ulcer

See how treatment of a heavily infected ulcer with Biatain® Ag Non-Adhesive foam dressing and Biatain Alginate® Ag prevented amputation of a foot. Read more

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The patient

This patient suffered from heart failure, coronary heart disease, arterial hypertension and venous insufficiency in both lower limbs, as well as Alzheimer’s.

Deep foot ulcer

For four months, she had a very deep diabetic foot ulcer on the right foot with erythema, oedema, crepitation and heat in the surrounding tissues. She was referred to the A&E department and after examination by Vascular Surgery, her family was informed that the immediate treatment would involved supracondylar amputation since she was suffering from a grade 4–5 diabetic foot based on the Wagner scale.

Biatain Ag introduced

The family was opposed to this treatment, and the patient was returned to her home for monitoring by her family doctor and out-patient care and dressing by home nursing. Biatain Alginate Ag and Biatain Ag were used in combination with debridement and oral antibiotics.

This picture shows the ulcer at inclusion:
The ulcer at inclusion.

This picture shows the ulcer after five weeks of treatment with first Biatain Alginate Ag and then Biatain Ag Non-Adhesive:
The ulcer after 5 weeks treatment with first seasorb Ag and then Biatain Ag.

Here we see the ulcer after four months’ treatment:
The ulcer after 4 months treatment.

The ulcer was closed after 10 months’ treatment:
Closed ulcer after 10 months treatment

Conclusion

The objective set was to prevent amputation of the foot, ensure the well being and comfort of the patient and of the family. The method used began to bear fruit already seven days after the treatment started, with visible changes in the development of the wound.The wound closed ten months after the treatment was started.

Download full case description (PDF)

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Treatment of a Stage III sacral pressure ulcer

See how a one-month treatment of a heavily exuding sacral pressure ulcer with Biatain® Ag effectively eliminated signs of local infection. Read more

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The patient

The patient was an 88-year-old woman with a highly exuding Stage III sacral pressure ulcer. The ulcer had persisted for two months and had previously been treated with standard moist wound healing products.

The ulcer

The ulcer had several signs of local infection, a significant odour, and was heavily exuding. A small undermining was present at the top of the ulcer and there was approximately 50% unhealthy necrotic tissue in the wound bed.

The first picture shows the infected, highly exuding pressure ulcer before Biatain Ag treatment:

Biatain Ag Adhesive introduced

Odour was eliminated after just one week of treatment:

The ulcer after one week of treatment.

This picture shows that the wound bed is clean and healing is progressing after four weeks of treatment:

The ulcer after four weeks of treatment.

Conclusion

During the one-month treatment period Biatain Ag effectively eliminated signs of local infection and supported healing of this heavily exuding sacral pressure ulcer. Elimination of odour and a significant increase in healthy granulation tissue was observed already after one week.

Download full case description (PDF)

Tips for prevention, assessment and treatment of pressure ulcers are available in:

Pressure ulcers – prevention and treatment: A Coloplast quick guide

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For more information about Wound Care, you can contact the resources below. Read more

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American Academy of Dermatology

The academy members include practicing dermatologists who are committed to excellence in patient care, medical and public education, research, professionalism and member services support . Learn more about this academy at www.aad.org.

Association for Professionals in Infection Control and Epidemiology

APIC is a professional association dedicated to improving health and patient safety by reducing risks of infection and other adverse outcomes. Learn more about this association at www.apic.org.

Association for the Advancement of Wound Care

AAWC is a non-profit association for anyone involved in wound care. Join in to learn more about wound care at www.aawconline.org.

Diabetic Foot Study Group

The aim of the DFSG is to promote improvements in diabetic foot care. Read more about this group at www.dfsg.org.

European Pressure Ulcer Advisory Panel

EPUAP works to lead and support all European countries in the efforts to prevent and treat pressure ulcers. You can learn more about their activities at www.epuap.org.

European Wound Management Association

The EWMA deals with all clinical and scientific issues related to wound healing. Each year, EWMA hosts one of the largest international events within wound management and wound healing in Europe. Learn more about this association at www.ewma.org.

International Working Group on the Diabetic Foot

IWGDF works to improve outcomes of diabetic foot problems and strengthen the communication between healthcare professionals. Learn more about their work at www.iwgdf.org.

International Association for the Study of Pain

IASP is the world's largest multidisciplinary organization working to support the study of pain and to translate that knowledge into improved pain relief worldwide. Read more about them at www.iasp-pain.org.

National Pressure Ulcer Advisory Panel

NPUAP is an American organization working for the prevention and improved treatment of pressure ulcers. Read more at www.npuap.org.

Strategic Marketplace Initiative (SMI)

A consortium of executives representing healthcare providers; medical products, pharmaceuticals and supply chain distribution companies; and service businesses united to reengineer and advance the future of the healthcare supply chain for the purpose of improving the overall healthcare marketplace in the United States. Learn more by visiting www.smisupplychain.com.

World Wide Wounds

World Wide Wounds is an electronic wound management journal dedicated to providing practical guidance and information on all aspects of wound management to healthcare professionals worldwide. Read the journal at www.worldwidewounds.com.

Wound Healing Society

The Wound Healing Society is a non-profit organization for clinical and basic scientists dedicated to improve the area of wound healing. Learn more about their activities at www.woundheal.org.

Wound, Ostomy and Continence Nurses Society

The WOCN Society is a professional nursing society. It supports its members by promoting educational, clinical and research opportunities to advance the practice of expert healthcare to individuals with wounds, ostomies and incontinence. Read more about this society at www.wocn.org.

World Union of Wound Healing Societies

WUWHS is an international organization dedicated to improving the wound care standards for patients and the healthcare performance of professionals. It also works to ensure universal access in all healthcare systems. For more information go to www.wuwhs.org

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Headline

Wound assessment and reporting

Patient report

Wound assessment

Wound report

Wound Types

Leg Ulcers

References

The three most common types of leg ulcers are:

Venous leg ulcers

Arterial Ulcers

Mixed Venous And Arterial Leg Ulcers

Treatment Needs

Diabetic Foot Ulcers

References

Neuropathy

Poor Blood Supply (Ischemia)

Infection

Treatment Needs

Pressure Ulcers

References

Major Cause Of Morbidity

Classification

Category/Stage I: Non-Blanchable Redness Of Intact Skin

Category/Stage II: Partial Thickness Skin Loss Or Blister

Category/Stage III: Full Thickness Skin Loss (Fat Visible)

Category/Stage IV: Full Thickness Tissue Loss (Muscle/Bone Visible)

Category/Stage: Unstageable

Treatment needs (2,3)

Download Our Tips For Preventing, Assessing And Treating Pressure Ulcers:

Acute Wounds

References

Acute Wounds – Signs And Symptoms

Treatment Needs

Why Do Some Acute Wounds Become Chronic?

Wound and skin condition

Necrosis

Removal of necrotic tissue (debridement)

Choice of dressing

Periwound Skin

Maceration

Erythema

Fragile skin

Choice of dressing

Wound Exudate

References

Controlling exudate

Macerated skin(2,3)

Dressings for exuding wounds

Wound infection

References

Other symptoms

Dressings for infected wounds and wounds at risk of infection

Case studies

Treatment of a venous leg ulcer

The patient

Previous treatment

Biatain Non-Adhesive introduced

Conclusion

Treatment of an infected diabetic foot ulcer

The patient

Deep foot ulcer

Biatain Ag introduced

Conclusion

Treatment of a Stage III sacral pressure ulcer

The patient

The ulcer

Biatain Ag Adhesive introduced

Conclusion

External Resources

Get in touch

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