Developing a ‘Cheat Sheet’ for Wound Assessment

I’ve had the pleasure of meeting more people this year alone than at any other time in my life who’ve shared more remarkable stories about how they’ve overcome adversity.

One such story comes from Captain Charles Plumb, a United States Navy jet pilot veteran who during the Vietnam War his plane was shot down over enemy territory. He ejected and was captured after parachuting to the ground. He spent six years as a prisoner of war (POW), but what really caught my attention was how thankful he is to this day that his parachute actually opened despite the nightmare that he endured. As a POW, he had to form his own method of communication although he spent most of his time alone inside an 8-by-8 cell.

This made me struggle with disbelief to think that we as providers might resort to claiming that we have difficulty communicating with some of our patients. When communicating with a new patient, we must listen first and give them our input later. We must ask pertinent questions and refrain from interrupting in order to understand the full scope of their issues. Only then can we comfortably devise a “cheat sheet” of sorts for the assessment of their chronic wounds as a means to care for patients in the context of our busy and challenging schedules. 

Starting the Assessment

We are always racing against time to close chronic wounds, and sometimes we must refer patients to other providers if we are not making progress. When I created this cheat sheet, I wanted the ability to focus on key factors related to chronic wounds while addressing findings in a comprehensive approach. The following steps can be performed on initial visit and periodically. If what I’ve listed here is not inclusive enough for you, I encourage you to create one that meets your needs. First, I’ve established a set of steps for approaching the cheat sheet:

Step 1: Concentrate on the patient.
Step 2: Concentrate on the wound.
Step 3: Concentrate on the periwound tissue.
Step 4: Consider key elements.
Step 5: Develop an action plan, re-assess periodically, and refer appropriately.

The Cheat Sheet

1.    Review the patient’s history

a.    Onset, cause, and timeline
       b.    Intrinsic factors
              i.         Age
              ii.         Perfusion
              iii.        Comorbidities
                          1.    Diabetes
                          2.    Heart related conditions (congestive heart failure, ejection fraction, high blood pressure, symptoms)
                          3.    Cerebrovascular accident/transient ischemic attack
                          4.    Cancer
                          5.    Markers of autoimmune disease
              iv.         Mobility
              v.         Obesity
       c.    Extrinsic factors
              i.         Nutrition
              ii.        Smoking
              iii.        Bacteria
              iv.        Stress
              v.         Medications
              vi.        Pressure
              vii.       Gait
       d.     Other:
              i.         Family support?
              ii.        Home environment—steps? Accessibility? Assistive devices?
              iii.       Joint range of motion?
              iv.       Current and past wound care treatment
              v.        Ability to adhere to program

2.    Wound

My first lesson in wound care prior to seeing a patient was to pick up the patient’s chart and get a mental picture of what the wound looked like by reviewing the prior note. With technology advancements and the utilization of electronic health records, this imaginary exercise is now easily accomplished.
 
It is recommended to have a working wound etiology assessment/diagnosis while looking at wound characteristics to determine which phase of healing the wound is in.
 
An open wound will either be on the inflammatory or proliferative phase based on the wound characteristics noted. Capturing this valuable information yields clinical decisions to select appropriately interventions.
 
a.    Etiology (brief description)
              i.         Venous
                          1.    Moderate drainage, shallow wound bed with irregular borders, medially located gaiter area, no pain with elevation. Approximately 70–80% of outpatient wounds
              ii.         Arterial
                          1.    Distally located/dorsum/toes, maybe painful, punched out lesions, tend to be deeper, granulation maybe absent, hair loss on legs, pain with elevation, intermittent claudication. Approximately 10% of wounds
              iii.         Mixed
                          1.    Venous wounds with an arterial component—20% of the 70–80% venous-related wounds
              iv.         Pressure Injury
                          1.    Wounds caused by prolonged pressure over bony prominences or by medical devices. 
              v.         Neuropathic/Diabetic
                          1.    Challenging wounds typically located on the plantar aspect/distal/lateral foot often preceded with neuropathy/loss of protective sensation, callus, deformities with/without the presence of peripheral arterial disease, dry skin. 
              vi.         Lymphedema
                          1.    Asymmetrical extremity swelling unilaterally or bilaterally that maybe caused congenitally or from cancer-related surgeries, infections, chronic venous insufficiency, trauma, obesity, filariasis. This is a progressive disease ending with skin changes, wounds, and frequent infections.
              vii.         Atypical
                          1.    Wounds not in typical appearance or locations as above ones. Approximately 10% of wounds.
b.    Determine which phase of healing the wound is currently in:
              i.         Inflammatory
                          1.    Drainage greater than minimal?
                          2.    Is there nonviable tissue/slough?
                          3.    Is the tissue red in color with no granulation?
                          4.    Is there hypergranulation?
              ii.         Proliferative
                          1.    Is there beefy red granulation tissue?
                          2.    Is the wound drainage decreasing?
              iii.         Maturation
                          1.    Is the defect closed with no drainage nor scabs?
c.    Assessment:
              i.         Wound bed characteristics:
                          1.    Size
                                 a.    Length and width (cm)
                          2.    Depth
                                 a.    Deepest aspect perpendicular to where skin was located and measured (cm)
                          3.    Color of tissue
                                 a.    Describe colors found in percentage
                          4.    Type of tissue
                                 a.    Describe tissue found in wound—red nongranular, granulation, hypergranulation, slough, bone, tendon, fibrin, eschar
                          5.    Drainage
                                 a.    Amount
                                        i.     Minimal
                                        ii.     Moderate
                                        iii.     Maximal
                                 b.    Type
                                        i.     Serous
                                        ii.     Bloody
                                        iii.     Serosanguinous
                                        iv.     Purulent
                          6.    Undermining
                                 a.    Describe location using the clock method, measured (cm)
                          7.    Tracts
                          8.    Odor
                          9.    Pain

3.    Periwound

The skin can guide clinicians in determining the health of the area being inspected. It can establish if the patient is experiencing an acute or chronic wound infection. If you maintain and compare serial periwound objective measurements, then clinical decisions can be made to select interventions such as antibiotics and/or surgical interventions. These characteristics should resolve as the wound moves to the proliferative phase of healing. Long wave infrared thermography and Near infrared spectroscopy has changed how I view periwound tissue especially on finding deeper problems or even on darker pigmented individuals.
a.    Characteristics
              i.         Redness
              ii.         Warmth
              iii.         Swelling
              iv.         Induration
              v.         Maceration
              vi.         Deep tissue injury?
              vii.         Sensation
              viii.         Pain
b.    Periwound characteristics can help guide which phase of healing the wound is in.
              i.         Is the periwound indicating an inflammatory response or an infectious process?
              ii.         Is the wound progressing to the proliferative phase by a decrease of inflammatory markers?

4.    Key elements to address:

a.    Arterial perfusion
              i.         Macrovascular noninvasive
                          1.    ankle-brachial index/toe-brachial index
              ii.         Microvascular noninvasive
                          1.    skin perfusion pressure vs. transcutaneous oxygen
              iii.         Intermittent claudication?
              iv.         Perfusion invasive
                          1.    Computed tomography angiography if good kidney function
b.    Swelling
              i.         General
              ii.         Bilateral symmetrical?
                          1.    Chronic heart failure?
                          2.    Ejection fraction?
                          3.    Kidneys?
                          4.    Hypoprotenemia?
                          5.    Lipedema?
              iii.         Localized edema (assess wound but also entire extremity)
              iv.         Asymmetrical extremity swelling
                          1.    Chronic venous insufficiency
                          2.    Lymphedema
                          3.    Phlebolymphedema
                          4.    Lipolymphedema
c.    Infection
               i.         Clinical assessment
                          1.    Acute infection—planktonic bacteria?
                          2.    Chronic infection – biofilm?
                          3.    Sepsis
                          4.    Osteomyelitis
                                 a.    Probe to bone
                                 b.    MRI
              ii.         Culture
                          1.    Swab
                          2.    Biopsy (recommended if no contraindications)
                          3.    DNA sequencing
d.    Nutrition
              i.         Hydration status?
              ii.         Malnutrition?
              iii.         Albumin/prealbumin to measure nutritional support
              iv.         Vitamin D, vitamin C, protein, deficiency?
              v.         Homocysteine
e.    Labs (based on working diagnosis selection may differ)
              i.         WBC/Comp
              ii.         CRP/ESR
              iii.         HA1C
f.      Range of motion and strength deficits

5.    Action based regarding findings steps 1–4

a.    Revascularization
b.    Wound Bed Preparation
              i.         Debridement
              ii.         Bacteria control
              iii.         Exudate management
              iv.         Edge of wound
c.    Wound Hygiene
              i.         Cleanse
              ii.         Debride
              iii.         Refashion the edge
              iv.         Dress
d.    Culture
              i.         Biopsy considered the gold standard (adequate perfusion)
              ii.         Tissue culture
              iii.         Swab
              iv.         DNA sequencing
e.    Compression
              i.         Unna’s boot
              ii.         “Duke” boot
              iii.         Multilayer compression
              iv.         Short-stretch bandaging
              v.         Garments
              vi.         Devices
              vii.         Velcro alternative
              viii.         Others
f.      Complete decongestive therapy (all components below need to be addressed for successful management of lymphedema)
              i.         Skin care
              ii.         Manual lymph drainage
              iii.         Compression/bandaging
              iv.         Exercise
              v.         Education
g.    Offloading
              i.         Total contact casting, removable devices
              ii.         Positional pressure offloading
              iii.         Post-offloading assess balance, muscle atrophy, gait
              iv.         Others:
h.    Antibiotics/local antimicrobials
i.      Nutritional supplementation/hydration/glycemic control
j.      Advanced modalities
              i.         Electrical stimulation
              ii.         Low frequency ultrasound
              iii.         Topical oxygen therapy
              iv.         Hyperbaric oxygen therapy
              v.         Others
k.    Exercise/strengthening/flexibility
l.      Surgical interventions

Consider PAINE, a short mnemonic to remind us of the important considerations to make when evaluating wounds.
P—Patient, perfusion, pressure
A—A1c
I—Inflammation, infection
N—Nutrition
E—Edge, exudate, edema

Conclusion

We also must consider the advantages of technology to help validate our assessments. There’s equipment that can help detect bacteria, thermal imaging for hypoperfusion or an increased thermal change, and taking tissue oxygenation measurements. Currently I utilize my cheat sheet along with these handheld technologies to provide real-time assessment of patients and their wounds while minimizing distractions. My one-page guidance to assessments (download here) could also be a helpful tool. Remember that in our field not all wounds heal with time, but what we do during the wounded time matters most.
 
Frank Aviles Jr. is Wound Care Coordinator for Natchitoches (LA) Regional Medical Center; wound care and lymphedema instructor at the Academy of Lymphatic Studies, Sebastian, FL; physical therapy (PT)/wound care consultant at Louisiana Extended Care Hospital, Natchitoches; and PT/wound care consultant at Cane River Therapy Services LLC, Natchitoches.

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