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Wound Assessment andManagement
247
Wound Assessment
Assessment of the patient’s living and personal environment is also important.
Frequency of repositioning, surfaces, turning schedules, transferring techniques,
and durable medical equipment (such as assistive devices, trapeze, bed rails, and
padding) can all impact wound development and healing. Use of risk assessment
scales may increase awareness, but have limited predictability and effectiveness in
pressure injury prevention [17]. A meta-analysis of 33 studies demonstrated a lack
of evidence for risk assessment scales in decreasing pressure injury incidence, but
the scales did increase preventive interventions [18]. The two most commonly used
tools are the Braden and Norton scales. No conclusive evidence demonstrates that
one is superior to the other.
• The Braden scale evaluates six categories: sensory perception, moisture, activ-
ity, mobility, nutrition, friction, and shear for predicting pressure injury develop-
ment. Research has shown that patients with scores of 18 or less are at risk for
the development of pressure sores [19].
• The Norton Score is another commonly used tool for assessing pressure injury
risk that evaluates ve categories: physical condition, mental condition, activity,
mobility, and incontinence.
Most nursing facilities use a pressure injury report to document identified
wounds: location, stage, measurement, and description. Pressure injury reports
fulfill standardized documentation as mandated by both state and federal
(F686) regulations. Practitioners should document the number, location, and
size (length, width, and depth in centimeters) of wounds and assess for the
presence of an exudate, odor, sinus tracts, necrosis or eschar formation, tunneling/undermining, infection, healing signs (granulation and epithelialization),
and wound margins. For a pressure injury, determine the stage of the ulcer
according to the National Pressure Injury Advisory Panel (NPIAP) Staging
System (Table2).
Risk of developing a pressure injury is signicantly high within the rst 4weeks
after admission to a long-term care facility [20]. After the initial assessment, a
weekly reassessment should occur during the rst 4weeks, followed by at least a
quarterly assessment and when there is a change in patient status [21]. The patient’s
overall clinical condition should be reassessed whenever a pressure injury fails to
show evidence of healing within 2–4weeks of any intervention. Every nursing facility is required to develop and implement its own comprehensive wound care plan in
accordance with CMS regulations.
Some patients develop a pressure injury 2–3days before death. These are
referred to as Kennedy terminal ulcers and are markers of imminent death.
The Kennedy ulcer develops suddenly over the sacrum as a blister or Stage 2
and rapidly progress to Stage 3 or 4. These ulcers can be pear-, horseshoe-, or
buttery-shaped with irregular borders. Kennedy terminal ulcers are initially
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Table 2 National Pressure Injury Advisory Panel Staging System
Stage Denition Comment
Suspected deep
tissue injury
(SDTI)
Stage I Localized nonblanchable erythema. Skin
Stage II Exposed dermis characterized as either a
Stage III Full thickness skin loss. Adipose tissue
Stage IV Full thickness skin and tissue loss
Unstageable Full thickness skin and tissue loss which
Adapted from Edsberg, L.E. etal J Wound Ostomy Continence Nurse 2016:43(6):585–597
Pressure-related necrosis of soft tissue
with intact overlying skin
intact. Compressed between bony
prominence and external surface
shallow ulcer with a crimson wound bed
(without slough or bruising) or as an
intact or ruptured uid-lled blister
may be visible, but bone, tendon, or
muscle not exposed
characterized by exposed bone, tendon, or
muscle. Rolled edges, undermining and/or
tunneling often occur
cannot be staged until slough or eschar is
removed from the ulcer bed
Discoloration (crimson→purple),
changes in temperature, texture,
tenderness. May progress rapidly
Clinically similar to SDTI.May be
difcult to detect with deepened
skin pigmentation
Do not use to describe skin tears,
tape burns, dermatitis, maceration,
or excoriation
Tunneling or undermining may
occur. Depth may vary by location
Slough or eschar if present may
obscure the extent of tissue loss
Do not remove eschar present on
heels
R. G. Stefanacci
red/purple, then turn to yellow, and nally turn black. The etiology is unclear,
but is thought to be part of multiorgan failure. Treatment is the same as that for
pressure injuries.
Types ofWounds
There are four main categories of wounds (pressure injury, diabetic, arterial, and
venous), and those of mixed etiology. The type of wound can usually be determined by
its location, inspection of the wound, and the patient’s clinical history. If the wound
type remains uncertain, laboratory and/or radiographic studies may help. For example,
with a lower extremity wound, an ankle-brachial index or a Doppler arterial study can
help determine whether the ulcer is caused by vascular insufciency, pressure or both.
Pressure Injury
• 95% of wounds develop on the lower body, 65% over the sacrum and pelvic area,
and 30% in the lower extremities. Other common pressure sites include the coc-
cyx, heels, ischium, iliac crest, lateral foot, lateral malleolus, and greater trochanter.
• There are three mechanical factors that can produce tissue damage: pressure,
friction, and shear. Shearing occurs between shifting of tissue plains beneath the
Wound Assessment andManagement
skin. A friction (or rubbing) injury is supercial and easily discernible (e.g., as
may occur with a Parkinson tremor). Shear and friction usually occur together to
cause skin injuries.
• A pressure injury is a localized area of damaged or necrotic tissue that develops
when soft tissue is compressed between a bony prominence and an external sur-
face for a prolonged period of time.
• In 2009, NPUAP-EPUAP redened a pressure “ulcer” as “a compressive tissue
injury” that is caused by pressure alone or by pressure combined with shearing.
Friction alone is not a direct cause of a pressure injury, but it does contribute
shear strain in tissue.
• Pressure injuries can range from nonblanchable erythema of intact skin (Stage 1)
(or in dark-skinned persons, the skin may have a deep blue or purple hue), to
deep ulcers extending down to the bone (Stage IV).
• The skin failure at the end of life is not considered to be a pressure injury. Skin
tears, abrasions, or lacerations are not pressure injuries.
249
Diabetic Wounds
• Commonly occur over the metatarsal heads.
• Due to vascular compromise of the lower extremities coupled with a decreased
potential for healing and peripheral neuropathy.
• Typically painless, thus the wound is often not noticed until symptoms of infec-
tion occur (malodor, fever or chills).
• When examining the wound it should be probed with a sterile implement to
assess its depth and to determine whether undermining or osteomyelitis could be
present [22].
Ischemic Wounds
• Typically occur in the lower extremities, but can also occur in the upper
extremities.
• Diabetes mellitus and smoking have been implicated as contributing factors due
to their decreasing arterial blood ow causing peripheral vascular disease.
• Clinical signs of arterial insufciency often precede development of an ischemic
wound. These include a cold, pale or cyanotic foot, absence of digital and lower
extremity hair, and thin atrophic skin of the legs.
• Present either as a painful wound with discrete borders (a “punched out” appear-
ance), or “wet” or “dry” gangrene.
• The base of the ulcer may be covered with a dry black or brown eschar, or appear
pale pink and brous.
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R. G. Stefanacci
Venous Wounds
• Commonly seen in the lower extremities.
• Caused by peripheral edema due to venous insufciency/stasis, and may be asso-
ciated with organ dysfunction (i.e., heart, liver, and kidney) [23].
• Less painful than ischemic wounds.
• Have irregular borders and often seen with hyperpigmented changes of the sur-
rounding skin.
Prevention ofWounds
Paramount to wound care management is prevention. In 2014 the Agency for Health
Care Policy and Research (AHCP) had developed guidelines and recommendations
on the prediction, prevention and early treatment of pressure injuries in adults [24],
that are still widely utilized today as they remain applicable in many health care
settings. The rst step recommended for the prevention of pressure injuries by the
Institute for Healthcare Improvement (IHI) is to identify patients at risk, and then
implement prevention strategies in these patients [25]. The “six essential elements
of pressure injury prevention” include:
• “Conduct” a pressure injury assessment on admission for all patients.
• “Reassess risk” for all patients daily
• “Inspect” skin daily
• “Manage” moisture
• “Optimize” nutrition and hydration
• “Minimize” pressure
The IHI recommends that prevention measures include a comprehensive treatment plan with risk factor reduction, multidisciplinary interventions, functional
adaptation, environmental modications, and a psychosocial evaluation. Evaluating
and optimizing residents’ predisposing conditions and comorbidities can help prevent the development of wounds. Inspecting the skin daily during bathing or personal care, as well as scheduled turning and positioning of patients, has been shown
to help prevent wounds. Provide support surfaces with special mattresses and overlays to help eliminate friction, shear, and moisture. Minimize pressure over bony
prominences. Seats should be padded with air, foam, or gel cushioning and avoid
use of donut-shaped devices. Residents at highest risk (those who completely compress a static surface, or have pressure injuries that fail to heal), should be placed on
a dynamic surface. A patient should never be directly positioned on the greater
trochanter for more than momentary positioning. Use padding (i.e., heel or “bunny”
boots, egg crates, heel lifts, suspension devices, etc.) for off-loading of heels and
elbows. Patients should have a static support surface such as a foam overlay or gel
Wound Assessment andManagement
251
mattress placed on their standard mattress. A supine patient should be maintained
at the lowest head elevation below 30° as tolerated; head elevation ≥30° provides
as much pressure as being in a seated position. Repositioning every 4h has been
shown to be as effective as 2-h intervals in wound healing, but this repositioning or
partial turning does not always remove pressure from the sacrum or heels. Care
should be taken to minimize shearing or friction during repositioning. If necessary,
lift devices should be used to prevent soft tissue injury. Slow gradual turns should
be used in patients with hemodynamic instability.
The 2-h turning schedule was established through research done in 1946 on spinal cord injury patients [26]. However, the actual interval for optimal turning in
prevention has not been established. This interval can be shortened or lengthened by
a host of intrinsic and extrinsic factors. For example, in a study using healthy volunteers, intervals of 1–1.5h rather than the traditional 2-h schedule were required to
prevent skin erythema on a standard mattress [27].
Nutritional and hydration status are intrinsic factors that affect pressure wound
development and healing. Hospitalized patients who are undernourished are twice
as likely to develop pressure injuries as compared to non-undernourished patients
[28]. Inadequate hydration and nutrition predispose to pressure injury development
[16]. The daily caloric intake of 30–35kcal/kg and daily protein intake of 1.2–1.5g/
kg of body weight is recommended for nutritionally compromised patients who
either have or are at risk of pressure injuries. Adequate uid hydration is provided
by 30–35mL of uid per kg body weight per day, or 1mL of uid per calorie for
persons receiving enteral tube feeding. Enteral nutritional support can signicantly
reduce the risk of developing pressure injuries in selected patients by up to 25% in
some studies. The benet of nutritional support in promoting wound healing is still
debated [29]. Use of vitamin C supplementation in wound healing is disputed. Two
well-designed randomized controlled trials compared high dose vitamin C with
either low dose vitamin C or placebo and had contradictory results [30]. (For a more
in-depth discussion on nutrition refer to the Chapter on “Weight and Nutrition in
Post-Acute and Long-Term Care.”)
Under clinical circumstances such as metastatic cancer, multiple organ failure,
cachexia, severe vascular compromise, and terminal illness, unavoidable wounds
may develop [31]. The clinician should judiciously document the reasons why preventive interventions were not appropriate, untreatable, or unsuccessful, such as
frequent repositioning causing discomfort or severe pain.
Unavoidable Pressure Ulcers/Injuries
Pressure ulcers/injuries are considered to be a quality measure of care in LTC.There
are many factors that are responsible for “unavoidable” pressure injuries. According
to the National Pressure Ulcer Advisory Panel (NPUAP) a pressure injury is considered to be unavoidable if it developed despite the following interventions.
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1. The patient’s clinical condition and risk for pressure injuries were evaluated.
2. Interventions were consistent with the patient’s needs and goals, as well as rec-
ognized standards of practice that were assessed and implemented.
3. The impact of the interventions was monitored, evaluated, and revised as
necessary.
A pressure injury is considered to be avoidable if the facility failed to implement
these interventions. Many LTC residents are either bed or chair-bound, which signicantly limits pressure off-loading and places them at risk for pressure injury.
Residents with hemodynamic instability can make turning or repositioning at risk to
develop bradycardia, hypotension, or hypoxemia. In addition, some patients are
comfortable in a particular body position and may move themselves back into the
previous position after being turned. Vasoconstrictive medication to counter low
blood pressure can predispose to skin ischemia. An advanced directive for health
care that defers articial nutrition and hydration can put the patient at risk for malnutrition and skin ulcer development. Refusal of basic personal care is a common
issue, especially in residents who are confused and cognitively impaired. This can
frustrate staff who are attempting to ofoad tissue pressure.
Staging ofPressure Ulcers/Injuries
AMDA—The Society for Post-Acute and Long-Term Care Medicine follows the
guidelines set forth by the National Pressure Ulcer Advisory Panel (NPUAP) that
dene, classify, and stage pressure injuries as summarized in Table 2. Staging is
based on the extent of observable tissue damage [32]. The latest version of these
guidelines describe Stages I–IV along with two adjunctive terms, “suspected deep
tissue injury and “unstageable,” utilized to more accurately classify these wounds
(see website http://www.npuap.org). Reverse staging should not be used. For exam-
ple, a lesion may be referred to as a, “healing stage IV” but it cannot be described
as progressing from a Stage IV to a Stage III.If a healed Stage IV pressure injury
reopens at the same anatomical site, it is always considered as Stage IV.A wound
covered by eschar should be categorized as a Stage IV until the eschar has been
debrided or self-debrides. Do not debride wounds over the heal as this can expose
the calcaneum and result in osteomyelitis.
Serialized staging of wounds can help monitor wound progression and healing.
The Pressure Ulcer Scale for Healing (PUSH) tool was developed by the NPUAP
to help monitor pressure wound healing over time. It evaluates wound surface area,
exudate, and the type of tissue seen in the wound bed. This scale has been adopted
by many institutions [33]. Despite the theoretical simplicity of the PUSH tool, confusion regarding its use and interpretation still exists leading to inter-practitioner
variability in staging ulcers [34]. The NPUAP guidelines have been used (at times
inappropriately) as “quality of care” indicators or to identify suboptimal wound
management.
Wound Assessment andManagement
253
Management ofWounds
The burden of wound care treatment should be weighed against its intended benet.
Communication with the patient and family/caregivers is important and concerns
should be claried and discussed. However, it is imperative to establish realistic
expectations for wound healing. As with any medical treatment, if a patient with
decision-making capacity declines or does not adhere to the recommended plan of
treatment, the practitioners should offer alternatives and document them in the medical record. A palliative approach should always be considered when wound healing
is unlikely. With good care many Stage 1 or 2 wounds can heal in persons on
hospice.
Treatment ofWounds
Numerous factors impede healing. An interdisciplinary team approach is essential.
Table3 provides commonly encountered challenges to optimal wound care.
Principles of Treatment for Wound Care in Long-Term Care [35].
1. Assess risk factors, preexisting wounds, pain, and quality of life.
2. Consider an analgesic medication prior to and after wound care/dressing
changes and, if needed, prescribe scheduled pain medicine for chronic
wound pain.
3. Clean the wound surface with an isotonic solution (normal saline) to remove
debris and to decrease bacterial load.
4. Debride necrotic tissue—sharp, autolytic, mechanical, biologic, and enzymatic
debridement.
Table 3 Wound care challenges
Wound
type
Pressure Excess pressure and
Ischemic Inadequate blood ow Revascularization or
Venous Venous insufciency
Diabetic Peripheral neuropathy
Challenge to wound
care Standard approach Treatment
Pressure relief Topical: packing with
shear/friction forces
surgical removal/
correction
Correct incompetent
causing edema
causing pressure points
on feet
valves, reduce edema
Ofoad pressure, careful
routine evaluation of feet
hydrogel or saline.
Devices: Pressure reduction
mattresses, padding overlying
bony prominences
Topical: dry or antimicrobial
Topical: moist environment
Topical: pack with
antimicrobial solution or
hydrogel
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5. Fill dead space (undermining, tunnels) with loose absorbent wound packing.
6. Decrease bacterial load/infection.
7. Keep the wound moist to promote granulation with appropriate dressings—
lms, foams, alginates, hydroactives, hydrogels, and hydrocolloids.
8. Support the wound healing process with adjunctive treatments—vacuum-
assisted closure, electric stimulation, skin grafts, and growth factor treatment.
9. Prevent further injury by relieving pressure and providing proper surface sup-
port to protect the surrounding skin.
10. Improve the patient’s overall condition with proper nutrition and hydration.
11. Manage risk factors and comorbidities—diabetes, ESRD, anemia, PVD,
malnutrition.
12. Address complications—psychosocial issues, malodor, exudates.
13. Accurately track wound-healing progress using tools—PUSH, Sussman
Assessment Tool.
Causal factors should continue to be identied and addressed, including systemic
factors and comorbidities. Optimize nutritional status. Address psychosocial issues.
Manage pain and infection; both are crucial for effective wound care. If necrotic
tissue exists, it should be debrided in order to allow viable granulation and wound
healing to occur. Wounds should be cleansed and irrigated to remove necrotic debris
at each dressing change. Necrotic tissue impedes the healing process and may represent a nidus for infection. Saline should be chosen for wound irrigation rather than
cytotoxic antiseptic agents such as Dakin’s solution, iodine, and acid- and alcoholbased solutions that can retard healing.
There are ve methods of debridement—sharp or surgical, autolytic, mechanical, biologic, and enzymatic debridement. Any dry black eschar on the heels should
not be debrided unless it is tender, uctuant, erythematous, or suppurative. Wounds
with no surrounding local infection can have an occlusive hydrocolloid dressing
placed over them, allowing the eschar to autodigest itself via autolytic debridement.
Hydrocolloids and hydrogels are used as autolytic debridement and help to maintain
moisture in the dressing. Enzymatic debridement involves applying a topical debriding agent such as collagenase or papain-urea to devitalized tissue. This may cause
some degree of pain but is more tolerable than surgical debridement. Biological
debridement uses live, disinfected larvae, or maggots. Mechanical debridement uses
dressings that are allowed to dry and then removed, peeling off nonviable adherent
tissue. This mode of debridement has fallen into disfavor as it also removes new
healing tissue!
When a wound is exceptionally large, malodorous, or has a large amount of
necrotic tissue, more aggressive measures may be required. If all other methods of
debridement have failed and/or timing is critical because of worsening infection and
imminent sepsis, surgical debridement may be necessary. Obviously, the risks of an
invasive procedure with sharp debridement, albeit relatively low, must be weighed
against the intended benets.
Major categories of dressings that cover wounds include lms, foams, alginates, hydroactives, hydrogels, and hydrocolloids. Many products exist in
Wound Assessment andManagement
255
combinations. A chosen dressing must be able to maintain a moist wound bed, keep
surrounding skin dry, and limit contamination of the wound. The ideal wound bed
is not too moist or dry. The wound characteristics as well as the wound coverings’
cost, ease of use, and made of action should be considered when choosing a product.
Wound care also includes the use of transparent, impermeable lms on wounds that
could be contaminated by urinary or fecal incontinence. These dressings need to be
attached with waterproof tape to intact skin. Deep wounds and wounds with tunneling or undermining should be lightly packed with moist gauze or other ller. Packing
should be changed regularly to avoid contamination with bacteria. Hydrogels are
useful for deep wounds with little exudate whereas alginates help absorb tissue uid
and signicant exudate. Overly dry intact skin should be protected with moisturizers. Silver impregnated dressings provide broad-spectrum antimicrobial coverage in
lesions that are colonized or particularly susceptible to becoming infected based on
location, mechanism, or clinical context. Collagen dressings promote the development of new granulation tissue.
Several novel modalities have recently been developed with mixed. These
include growth factors (broblast growth factor, platelet-derived growth factor, and
nerve growth factor); electrotherapy; and negative pressure wound therapy. One
type of negative pressure therapy is vacuum-assisted closure (VAC). A wound VAC
is a closed system that uses negative pressure to drain wound uid and approximate
wound edges, thereby promoting wound healing. Although this therapy may
improve healing, it has not been shown to be cost effective [36]. Hyperbaric oxygen
therapy increases oxygen tension at the wound site and has demonstrated improved
healing rates in selected patients. Its use has been limited by high cost and lack of
availability. Other novel therapies that have proven successful are noncontact normothermic wound therapy, ultrasound/ultrasonic misting, as well as infrared and
ultraviolet light therapy.
Complications ofWounds
Pressure injuries are associated with a multitude of short- and long-term medical
and psychosocial complications [37]. These may have a signicant and damaging
impact on a person’s sense of well-being by worsening quality of life with isolation,
increased dependence, pain, and disgurement [38]. Odor, drainage, and pain from
the wound are common. Infection is a major complication that spans the spectrum
from clinically insignicant bacterial colonization to cellulitis, deep tissue infection, osteomyelitis, and sepsis. Treating infected wounds can be difcult because
they may be chronically contaminated and/or colonized and topical antibiotic agents
are often caustic to cells and growth factors required for healing. Osteomyelitis is
more common in this population as pressure sores frequently occur over bony
prominences [39].
Wound odor and heavy exudates can distress patients and result in signicant
feelings of embarrassment and/or depression. This can then lead to decreased social
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R. G. Stefanacci
interaction and poor quality of life. Adequate wound cleaning, debridement, and
proper disposal of used dressings can signicantly control odor. Topical metronidazole can help control odor by eradicating anaerobic bacteria. Other products to
decrease bacterial count and odor include cadexomer iodine, Dakin solution,
medical- grade honey, and silver dressings. Excessive wound exudates can lead to
maceration, breakdown, and itching. Foams and alginate dressings are good choices
to reduce these exudates. However, excessive dryness in a wound causes delayed
wound healing by inhibiting epithelialization. An absorptive dressing should not
excessively dry the wound.
Pressure injuries in long-term care residents have been shown to increase
morbidity and mortality especially from sepsis. Osteomyelitis is associated with
high levels of morbidity related to the need for several weeks of IV antibiotics,
extra radiographic imaging, and surgical debridement. These occurrences contribute to side effects, discomfort, and immobility. Because skin breakdown can
be a portal for bacteremia, nursing facility residents have been shown to have a
high risk of sepsis with mortality rates as high as 50% [40]. In one study, nursing
facility residents with pressure injuries were shown to be two to three times
more likely to die (as compared to their cohort who have no pressure injuries)
with a 1-year mortality rate of 50%. The length of hospitalization for nursing
facility residents with pressure injuries is two to three times greater than those
without [41]. Anyone with a large wound or large amount of drainage should be
monitored for dehydration and metabolic derangements. Any nonhealing wound
should be evaluated for stula formation, heterotopic calcication, and squamous cell carcinoma.
Wound prevention and management have nancial implications. Estimates have
shown that the cost of care triples for a nursing home resident with a pressure injury.
The Centers for Medicare and Medicaid Services (CMS) periodically revises the
Interpretive guidance and investigative protocol for Surveyors for use in assessing
wound care in nursing facilities. As of 2014 the CMS guidelines under Federal Tag
F686 state that a nursing facility may be cited if they fail to prevent new pressure
injury development; fail to promote healing of previously identied injury; fail to
prevent ulcer progression; fail to treat an infectious complication of a pressure
injury; or there is development of a Stage 4 ulcer, unless the wound is deemed
unavoidable [42].
Accurate and complete documentation of wound care is vital. Wound parameter
and description are reviewed in Table 4. For optimal wound care, AMDA The
Society for PA and LTC Medicine recommends standardized timelines for assessment, descriptions, care plans, and treatments of wounds. A timeline should include
reevaluations based on the severity of the wound. As previously discussed, a thorough skin examination should occur on admission to LTC that identies and documents any existing wounds. Scheduled 2–3week reevaluations should be performed
by trained staff members that know how to follow a consistent approach to wound
care and its documentation. In community-based home care or in assisted living
wound care can be improved when the physician and facility engage the services of
a home health care agency.
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