Wound Assessment & Documentation Terms WOUND LEVEL Pressure Ulcers: Stage I o An observable pressure-related alteration of intact skin

n with indicators, as compared to an adjacent or opposite area on the body, which may include changes in one or more of the following: Skin temperature (warmth or coolness) Tissue consistency (firm or boggy feel) &/or Sensation (pain, itching). o The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. Stage II-Partial thickness skin loss involving the epidermis &/or dermis. Stage III-Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Stage IV-Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Deep tissue injury o A pressure-related injury to subcutaneous tissues under intact skin. o Initially, these lesions have the appearance of a deep bruise & may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment. Other Wounds: Partial thickness-Tissue damage confined to the epidermis and/or dermis layers only. Full thickness-Tissue damage extending through the dermis & superficial fascia to involve subcutaneous tissue & possibly muscle/bone. WOUND TYPE Abscess-A cavity containing pus & surrounded by inflamed tissue. Ischemic/Arterial-A decreased supply of blood to a body part which typically leads to atrophy & in severe cases necrosis of the affected part. Neuropathic/diabetic foot ulcer o An ulcer typically occurring on the plantar aspect of the foot in areas prone to excessive pressure. o Generally presents as a symmetrically round, puncture-appearing wound cavity with a clean bed & heavily calloused periwound tissue. Pressure Ulcer-Localized injury to the skin &/or underlying tissue, usually over a bony prominence, & as a result of shear, friction, &/or pressure. Shearo The mechanical force that is parallel rather than perpendicular to an area. o It may play a role in triangularly shaped or tunneled sacral pressure ulcers. o This parameter is affected by pressure, the coefficient of friction between materials contacting each other, & how much the body interlocks with the support surface. Skin Tear-Traumatic peeling away of the epidermis from the dermis. Traumatic-Abrupt, acute tissue damage from physical or mechanical means external to the body. Venous insufficiency/stasis ulcer o A typically partial-thickness wound resulting from chronic venous insufficiency. o It is usually located between mid-calf & malleolus & has shaggy, irregular borders & often heavy exudate. Skin graft donor site-The area where the epidermis has been purposely removed so that free tissue can be moved to another part of the body where tissue coverage is needed. Page 1 of 4

Skin graft host site-The area where the skin graft is placed over a full-thickness wound. Surgical incision-A cut produced surgically that creates a partial thickness wound (if it does not penetrate the superficial fascia) or a full-thickness wound (if it penetrates to muscle tissue or deeper). Perineal Dermatitiso Moisture-associated skin damage resulting from prolonged exposure to urine &/or stool. o This exposure results in the release of inflammatory cytokines which causes redness, edema, blistering, skin erosion, weeping, itching, pain.

LOCATION Left or Right Bilateral-Occurring or appearing on two sides of the body Lateral-Away from the midline of the body Medial-Toward the midline of the body Anterior-Near to or at the front of the body Posterior-Near to or at the back of the body Dorsal-Pertaining to the back of an appendage, i.e. the back of the hand or top of the foot Plantar-The bottom of the foot Palmar-The palm of the hand Upper or Lower DIMENSIONS Length (cm)-Wound measurement along the vertical axis (head to toe is from 12:00 to 6:00) of the body. Width (cm)-Wound measurement along the horizontal axis (side to side is 3:00 to 9:00) of the body. Depth (cm)-Measurement from the top of the intact epidermis to the deepest part of a wound. Tunneling (cm) o A linear tract extending several times deeper than the wound opening. o Use clock positions to establish location within the wound. Undermining o Separation of the superficial or deep fascia from underlying tissues. o Separation of tissues creates a pocket that can collect wound exudate & prevents efficient removal. o Use clock positions to establish location around the wound. Clock positions-Use of the hour hands of a clock to denote locations of undermining; the head is 12:00, the foot is 6:00, & 9:00 & 3:00 are the lateral aspects. WOUND BED-The area of the wound contained within the borders of the viable epidermis. Granulation tissue (%) o Pink/red, moist tissue composed of new blood vessels, connective tissue, fibroblasts, & inflammatory cells, which fills an open, healing wound o Typically appears deep pink or red with an irregular, granular (bumpy) surface. Necrotic fibrous tissue/slough (%) o Soft, moist, devitalized, dead tissue; may be white, yellow, tan, brown, or green. o It may be loose or firmly adherent & has a stringy or fibrous texture & appearance. Eschar (%) o Black, brown, or gray necrotic, devitalized tissue. o It can be firmly adherent or separated from surrounding viable wound margins. o Eschar may be hard, soft or boggy. Hypertrophic o Excessive granulation tissue formation above the plane of surrounding healthy epidermis. Page 2 of 4

It prevents expedient reepithelialization of the wound bed.

WOUND MARGINS-The area immediately adjacent to the wound bed where epithelialization typically occurs. Wound length & width are measured from the margins. Epithelialized-complete-Total coverage of wound bed with epithelial cells. Epithelializing o The process of becoming covered with epithelial cells. o The new epithelial cells advance across the wound until they eventually meet epithelial cells moving in from the opposite direction. Rolled epithelium-Chronic, excessive epidermal growth along the wound border that does not extend into the wound bed. Callous-Typically painless thickening of the stratum corneum at locations of external pressure or friction. PERIWOUND-The tissues within 3 cm. of the wound Bruise (ecchymosis)-Black/blue/purple discoloration of skin caused by blood extravasation into subcutaneous tissues as a result of trauma to underlying vessels or fragility of vessel walls. Excoriation-Injury to epidermis or dermis caused by scratching, abrasion, or chemical/thermal burning. Induration-Hardening of tissue, especially the skin & superficial fascia, caused by edema, inflammation, &/or granulation. Inflammation o A protective response of the body to irritation or injury. o Cardinal signs of inflammation include redness, heat, swelling & pain. Intact-Epidermis & dermis without damage. Maceration-The softening or breaking down of skin resulting from prolonged exposure to moisture. Tape-skin tearing o Removal of epithelium caused by tape. o This is separate from epidermis removal related to shearing or pressure. EXUDATE-Fluid from a variety of sources that is discharged from the wound Type: Serous o Clear watery wound drainage. o Can be composed of blood plasma, intracellular or extracellular fluids, or a variety of other fluids. Sanguinous-Mostly bloody drainage with little, if any, serous fluid. Serosanguinous-A combination of serous & bloody drainage. Purulent (pus) o Creamy, viscous fluid primarily composed of polymorphonuclear leukocytes. o It is usually pale yellow to yellow green, sometimes whitish, bloody & is typically associated with infection. Amount: No drainage-Wound drainage that does not stain the dressing during routine dressing changes. Minimal-Wound drainage that mildly stains the dressing during routine dressing changes. Moderate-Wound drainage that has met the limit of the dressing's absorptive ability without saturating or leaking during routine & appropriate dressing change intervals. Heavy-Wound exudate that saturates a dressing during routine & appropriate dressing change intervals. IMPEDIMENTS TO HEALING Active tobacco use Page 3 of 4

 PAIN

Blood glucose consistently above 200 mg/dL End of life Steroid use Limb ischemia Heavy disease burden-Multiple medical comorbidities that delay/stop wound healing. Infection-The invasion of body tissues by pathogenic organisms that reproduce & multiply, causing disease by local cellular injury, secretion of toxins, or antigen-antibody host reaction. Malnutrition-Nutritional status below what is needed for optimal wound healing. Noncompliance-Patient is unwilling or unable to make lifestyle changes that maximize wound healing.

Continuous-Pain at some level is always present. Episodic-Pain in response to some stimulus such as movement, dressing changes, or procedures. Level-Rating on a scale of 1 to 10.

DRESSING Dry-No strikethrough or leakage of wound exudate. Intact-Dressing is well-secured to the body. Leaking-Exudate is not contained within the dressing. Strikethrough-Exudate has penetrated the outermost level of the dressing but is not actively leaking. CURRENT GOAL OF THERAPY Compete resolution-Complete epithelialization of the wound with no drainage. Infection control-To prevent or lessen the damage of pathogenic organisms that invade the host tissues. Palliative care-Interventions designed to relieve/reduce the negative effects of a wound but not necessarily with the goal of complete healing. DEBRIDEMENT Autolytic-Removal of devitalized tissue accomplished by use of moisture-retentive dressings to accelerate the body's natural proteolytic debridement processes. Biologic-Removal of devitalized tissue by the external application of maggots. Enzymatic-Removal of devitalized tissue by the external application of proteolytic enzymes. Mechanical-Removal of devitalized tissue by physical forces (whirlpool, pulsatile lavage, wet/dry gauze). Sharp-Removal of devitalized tissue by a sharp instrument (scalpel, scissors). IMPRESSION Healed-Fully epithelialized wound or fully approximated incision with no discernible drainage. Improved-Overall wound characteristics have changed for the better. Initial assessment-First comprehensive assessment of the wound when a plan of care is formulated. Unchanged-No significant change in wound characteristics since the last comprehensive exam. Worsening-Deterioration of several wound aspects since the last comprehensive exam. Brown, G. (April 2006). Wound documentation: Managing risk. Advances in Skin & Wound Care, 159-162.

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