Kim Saunders, MSN/ED, RN, CWON®, CFN
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 3 important questions
1. What is the wound etiology?
Four examples can occur on the perineal/sacral/trunk area of the body and can be confused when assigning etiology.
- Pressure ulcers present as well-defined edges caused by an ischemic injury to the tissue over the bone or under a medical device. They are bottom up tissue injuries that usually take longer to heal than superficial top-down injuries.
- Moisture-associated skin damage occurs peri-stomal, peri-wound, incontinence-associated, or intertriginous dermatitis (skin folds). This top-down, irregular-edge skin damage occurs from hyper-hydrated skin. Primary goals including moisture containment and prevention/treatment of skin.
- Friction is top-down superficial skin damage caused by the skin rubbing against something else. It can present like a blister from a shoe, or it can present initially like a patchy, irregular-edge appearance on the fleshy part of the buttocks as they rub on the bed-sheet.
- Shearing is bottom-up damage caused by blood vessel distortion. It presents with irregular edges, often linear in the direction of the damage, and is the culprit of undermining in pressure ulcers.
2. The next question should focus on the patient as a person: What are the ‘life goals’?
- Is the patient palliative care or hospice? If so, your goals should focus on quality of life: minimize trauma, control odor, manage excess exudate, prevent deterioration & infection, and optimize pain management.
- There are many topical wound products that can assist in this management to support any systemic medication needed.
3. Thirdly, what are the wound healing goals (comfort, maintenance, healing)?
- 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.
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.
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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