Assessing a wound is never just about the ‘Polaroid’ picture. The skin being the largest organ, doesn’t fail on its own. It is affected by other factors. Thus, when treating a wound, you need to start with
1.
Four examples can occur on the perineal/sacral/trunk area of the body and can be confused when assigning etiology.
- Comfort is the usual goal at end of life. Focus on goals for palliative care, and keep wound care simple.
- Maintenance is the goal when healing is unlikely because we are unable to correct the etiology. Focus on preventing infection and monitor wound presentation. Manage wound exudate. Use passive dressings such as alginates, foams, gels, etc.
- Healing is the usual goal with a comprehensive approach of etiology, systemic support, and topical therapy per wound presentation. Measure weekly and consider active therapies that change the tissue, add a matrix, or promote angiogenesis if wound size doesn’t progress by 30-40% in 3-4 weeks.
Of course there are more questions in the assessment of a wound and the etiology work-up. However, these three questions are foundational in the next steps of diagnostics, topical and/or systemic treatment, and possible referrals.
CASE EXAMPLE: A 76 year-old man with a sacral stage IV pressure ulcer is a full code. Diagnostics reveal he has sacral osteomyelitis. The patient does not desire surgery or antibiotics intravenously. He is not palliative care. His wound goals are maintenance because wound healing is unlikely due to the inability to correct/treat the osteomyelitis. Thus, our goals are to prevent symptomatic infection (pain, induration, fluctuance, odor) through passive dressings that manage drainage and address local bacterial count as needed (methylene blue/gentian violet dressings, silvers, manuka honey). Contraindicated active/adjunct therapies include negative pressure wound therapy (angiogenesis), bioengineered skin grafts, or collagen products (matrix and tissue changes). Monitor wound presentation and alter topical wound dressing as needed.
Always remember...Skin and wound assessment can be challenging and rewarding at the same time. The wound bed and skin presentation will give you hints as to its needs; You just have to be able to interpret the presentation and know the products that will help you achieve wound bed homeostasis.
This blog was brought to life by PESI speaker and author
Kim Saunders, MSN/ED, RN, CWON®, CFN. Kim Saunders has 18 years as a wound, ostomy, and continence expert in home health, acute care, hospice, and outpatient settings. Kim consults for patients related to wounds, ostomy, and incontinence-associated dermatitis. Her experience includes healthcare system-projects related to bed, stretcher, and wheelchair surfaces as well as system processes for skin and wound issues. She also is a co-owner of WOC Consulting, LLC.
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