Wound assessment

Wound assessment is a component of wound management. As far as may be practical, the assessment is to be accomplished before prescribing any treatment plan. The objective is to collect information about the patient and about the wound, that may be relevant to planning and implementing the treatment.

Wound assessment principles

Wound assessment includes observation of the wound, surveying the patient, as well as identifying relevant clinical data from physical examination and patient's health history. Clinical data recorded during an initial assessment serves as a baseline for prescribing the appropriate treatment.

TIME framework and Triangle of Wound Assessment (TWA)

To assist clinicians in standardizing the wound assessment and preparation of wound bed for treatment, the TIME framework has been developed in 2002 by a group of wound care experts.[1][2] The TIME acronym stands for Tissue, Infection/Inflammation, Moisture, and Edge – components that, per the TIME recommendation, should be thoroughly assessed to optimize the treatment. Depending on the clinical findings for each component, TIME recommends certain clinical actions aimed at correcting the issues and facilitating the healing.

A recent global anthropological study has prompted clinicians to review the TIME framework[3] and resulted in a 2016 development of a new comprehensive tool for wound assessment – the Triangle of Wound Assessment (TWA).[4] Based on the study's findings, TWA identifies three zones (wound bed, wound edge, and periwound skin) that must be included in wound assessment to arrive at clinical decisions that will help heal the wound in the most efficient way. TIME framework components are integrated into the assessment of each zone.

The introduction of periwound skin as a component of wound assessment identifies a significant departure from traditional methods; it emphasizes the importance of addressing periwound skin during treatment in the same measure as wound bed and wound edge.[5]

Wound assessment is a holistic process that considers the patient's current state of health, the factors that may impede wound healing, and the cause, duration and state of the wound.[6] As such, this process is applicable to any wound.

Wound assessment components

Health history

Patient's health history may include disorders that affect the body's ability to heal itself. These disorders are called comorbidities and may interfere with circulatory and metabolic body functions, levels of various physiological assessment components (sugar, albumin, etc.), and induce other factors that negatively affect the healing.[7] Common co-morbidities are: diabetes, venous insufficiency or peripheral arterial disease, respiratory and cardiovascular disorders, malignancies and autoimmune disorders.

Impeding factors

Among other factors that may impede the healing of a wound are:[8][9]

Wound

Wound cause

If the wound is chronic, is it the result of: an underlying illness (diabetic, venous and arterial ulcers), poor handling of the patient (pressure injuries, deep tissue injuries, wounds with cavities and undermining), poor previous treatment choices that slowed down the healing (untreated infection, inappropriate wound care product choice, lack of necessary procedures).[20] If the wound is acute, is it the result of: traumatic injury, burn, or surgery.[21]

Wound duration

For chronic wounds: time the current wound has been present, is it a recurring wound, how many times it has recurred in the past, how long it took to heal each time. For acute wounds: when the wound was first acquired before the clinician visit.

Wound state

Wound bed, wound edge and periwound skin should be examined before the initial treatment plan is devised. It should also be re-assessed at each visit or each dressing change.

For wound bed, the following parameters are assessed:

  • Tissue type; presence and percentage of non-viable tissue covering the wound bed
  • Level of exudate
  • Presence of infection

Wound edge must be examined to detect:[22]

  • Maceration
  • Desiccation
  • Undermining
  • Elevation above surrounding tissue (raised edge)
  • Epibole (rolled edge)

For periwound skin, the following conditions should be diagnosed or ruled out:[23][24]

  • Maceration
  • Dry, scaly skin
  • Desiccation
  • Excoriation and skin stripping
  • Hypergranulation and hyperkeratosis
  • Eczema
  • Callus build-up and epibole
  • Infection and inflammation

References
  1. Schultz, GS; Sibbald, RG; Falanga, V; Ayello, EA; Dowsett, C; Harding, K; Romanelli, M; Stacey, MC; Teot, L; Vanscheidt, W (March 2003). "Wound bed preparation: a systematic approach to wound management". Wound Repair and Regeneration. 11 (s1): S1–28. doi:10.1046/j.1524-475X.11.s2.1.x. PMID 12654015.
  2. Fletcher, J (April–May 2007). "Wound assessment and the TIME framework". British Journal of Nursing. 16 (8): 462–4, 446. doi:10.12968/bjon.2007.16.8.23415. PMID 17551428.
  3. Dowsett, C; Gronemann, M; Harding, K (2015). "Taking wound assessment beyond the edge". Wounds International. 6 (1).
  4. Dowsett, C; Protz, K; Drouard, M; Harding, K (May 2015). "Triangle of wound assessment made easy" (PDF). Wounds International.
  5. Lawton, S; Langøen, A (October 2009). "Assessing and managing vulnerable periwound skin". World Wide Wounds. SMTL. Retrieved May 9, 2017.
  6. Cornforth, A (December 2013). "Holistic wound assessment in primary care". British Journal of Community Nursing. 18 (12): S28, S30, S32–4. doi:10.12968/bjcn.2013.18.Sup12.S28. PMID 24796082.
  7. Ackermann, PW; Hart, DA (October 2013). "Influence of Comorbidities: Neuropathy, Vasculopathy, and Diabetes on Healing Response Quality". Advances in Wound Care. 2 (8): 410–421. doi:10.1089/wound.2012.0437. PMC 3842870. PMID 24688829.
  8. Anderson, K; Hamm, R (December 2012). "Factors That Impair Wound Healing". Advances in Wound Care. 4 (4): 84–91. doi:10.1016/j.jccw.2014.03.001. PMC 4495737. PMID 26199879.
  9. Guo, S; Dipietro, LA (March 2010). "Factors affecting wound healing". Journal of Dental Research. 89 (3): 219–29. doi:10.1177/0022034509359125. PMC 2903966. PMID 20139336.
  10. Gosain, A; Dipietro, L (March 2004). "Aging and wound healing". World Journal of Surgery. 28 (3): 321–6. doi:10.1007/s00268-003-7397-6. PMID 14961191.
  11. Wilson, JA; Clark, JJ (April–June 2003). "Obesity: impediment to wound healing". Critical Care Nursing Quarterly. 26 (2): 119–32. doi:10.1097/00002727-200304000-00006. PMID 12744592.
  12. Arnold, M; Barbul, A (June 2006). "Nutrition and wound healing". Plastic & Reconstructive Surgery. 117 (7S): 42S–58S. doi:10.1097/01.prs.0000225432.17501.6c. PMID 16799374.
  13. Russell, L (March 2001). "The importance of patients' nutritional status in wound healing". British Journal of Nursing. 10 (6S): S42, S44–9. doi:10.12968/bjon.2001.10.Sup1.5336. PMID 12070399.
  14. "Drugs that delay wound healing". Prescrire International. 22 (137): 94–8. April 2013. PMID 23662318.
  15. Silverstein, P (July 1992). "Smoking and wound healing". American Journal of Medicine. 93 (1A): 22S–24S. doi:10.1016/0002-9343(92)90623-J. PMID 1323208.
  16. Finnie, A; Nicolson, P (March 2002). "Injecting drug use: implications for skin and wound management". British Journal of Nursing. 11 (6S): S17–28. doi:10.12968/bjon.2002.11.Sup1.12246. PMID 11979188.
  17. Price, P; Krasner, DL (August 2014). "Health-related quality of life & chronic wounds". Today's Wound Clinic. 8 (6).
  18. Faria, E; Blanes, L; Hochman, B; Filho, MM; Ferreira, L (January 2011). "Health-related quality of life, self-esteem, and functional status of patients with leg ulcers". Wounds: A Compendium of Clinical Research and Practice. 23 (1).
  19. Herber, OR; Schnepp, W; Rieger, MA (July 2007). "A systematic review on the impact of leg ulceration on patients' quality of life". Health and Quality of Life Outcomes. 5: 44. doi:10.1186/1477-7525-5-44. PMC 1947954. PMID 17651490.
  20. Frykberg, RG; Banks, J (September 2015). "Challenges in the treatment of chronic wounds". Advances in Wound Care. 4 (9): 560–582. doi:10.1089/wound.2015.0635. PMC 4528992. PMID 26339534.
  21. Nicks, BA; Ayello, EA; Woo, K; Nitzki-George, D; Sibbald, RG (December 2010). "Acute wound management: revisiting the approach to assessment, irrigation, and closure considerations". International Journal of Emergency Medicine. 3 (4): 399–407. doi:10.1007/s12245-010-0217-5. PMC 3047833. PMID 21373312.
  22. Benbow, M (March 2016). "Best practice in wound assessment". Nursing Standard. 30 (27): 40–7. doi:10.7748/ns.30.27.40.s45. PMID 26932649.
  23. Hollinworth, H (October 2009). "Challenges in protecting peri-wound skin". Nursing Standard. 24 (7): 53–4, 56, 58 passim. doi:10.7748/ns2009.10.24.7.53.c7330. PMID 19927560.
  24. Woo, KY; Ayello, EA; Sibbald, G. (2009). "The skin and periwound skin disorders and management". Wound Healing Southern Africa. 2 (2).
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