Question

82 year old John is admitted to your care from a nursing home for management of chest infection. John is bed bound due to septicaemia affecting his general functioning. You find on admission that John came in with a sacral pressure injury and has an existing care plan. Johns vital signs are stable. Wound management plan states 3rd daily dressing of wound. You find that the dressing is soaked with exudate. Complete a wound assessment and management plan. What dressings would you apply to the wound?

Answer 1

Ans)

An assessment of the wound should be done weekly and be used to drive treatment decisions. Wound assessment includes: location, class/stage, size, base tissues, exudates, odor, edge/perimeter, pain and an evaluation for infection.

Location
Documentation of location indicating which extremity, nearest bony prominence or anatomical landmark is necessary for appropriate monitoring of wounds. (Hess 2005)

Class/Stage
Pressure ulcers are classified by stages as defined by the National Pressure Ulcer Advisory Panel (NPUAP). Originally there were four stages (I-IV) but in February 2007 these stages were revised and two more categories were added, deep tissue injury and unstageable.

Pressure Ulcer Staging
Stage I - Intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister.

Stage III - Full thickness skin loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining/tunneling.

Stage IV - Full thickness skin loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

(Suspected Deep) Tissue Injury - Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. (NPUAP 2/07)

Class
There are a number of classification and grading systems used in wound care but the simplest method uses the terms partial thickness or full thickness
• Partial thickness wound (PTW): damage to epidermis and/or dermis only
• Full thickness wound (FTW): damage to subcutaneous layer or deeper

Size
Measurement

Length – from top edge to the bottom edge (head to toe) at longest point
Width – from edge to edge perpendicular to the length at widest point
Depth – straight in, perpendicular to the base, at deepest point

Undermining/Tunneling

Using the “clock concept” (12 o’clock is in the direction of the patient’s head and 6 o’clock is toward the feet)
Where does it start and where does it end (clockwise direction)
Tunnel depth is at it’s deepest point
Location of deepest point
Base Tissues
Assessing the appearance of tissue in the wound bed is critical for determining appropriate treatment strategies and to evaluate progress toward healing. (Keast et al. 2004)

Necrosis/Eschar - Black, brown or tan devitalized tissue that adheres to the wound bed or edges and may be firmer or softer than the surrounding skin.
Slough - Soft, moist avascular tissue that adheres to the wound bed in strings or thick clumps; may be white, yellow, tan or green.
Granulation - Pink/red moist tissue comprised of new blood vessels, collagen fibers and fibroblasts. Typically the surface is shiny and moist with a granular appearance.
Epithelium - New pink and shin tissue/skin that grows in from the edges or as islands on the wound surface.

Exudates
Amount

None – base and dressing dry
Slight – small amount in center of dressing
Moderate – contained within the dressing
Copious – extends beyond dressing onto clothing or bed linen
Type

Serous – thin, watery, clear or straw colored
Serosanguineous – thin, pale red to pink
Purulent – thick, opaque, tan, yellow to green and may have an offensive odor
Consider treatment modality and frequency of dressing changes
Odor
Assess after cleansing (Garcia & Thomas 2006). Extreme malodor, especially if accompanied by purulent exudates is suggestive of infection. Most wounds do have an odor. The type of dressing can affect odor as well as hygiene and the presence of nonviable tissue (Keast et al. 2004).

Edge/Perimeter

Describe wound edges (approximated, rolled, calloused)
Describe periwound skin (indurated, erythematous, macerated, healthy)
Describe presence of excoriation, denudement, erosion, papules, pustules or other lesions
Induration - Abnormal hardening of the tissue caused by consolidation of edema,
this may be a sign of underlying infection.
Erythema - Redness of surrounding tissue may be normal in the inflammatory stage of healing. However, if accompanied by an increase in temperature of tissue, exudates or pain may also be a sign of infection.
Maceration - Caused by excessive moisture, Tissue loses its pigmentation (appears lucid or turns white) and becomes soft and friable.

Management:

- Decrease pressure- 2 nd hourly position changing.

- Protect the red area w/ occlusive dsg or thick cream.

- Correct incontinence- bladder/bowel training, or catheter, rectal tube.

- Frequent skin/incontinence care.

- Protect entire area w/ cream.

- Comfeel dressing change every week or sis if soiled, cavilon spray to be applied as it creates a thin film & calendula over redness sights.