Lesson 6: Wound Assessment + Pressure Injury Staging

Question 1

Initial Wound Assessment

Answer 1

Etiological factors
- Location of wound
- Depth and contours
- Patient’s history

Assessment of systemic factors
- Nutrition status
— Weight loss? Dehydrated? Malnutrition?
- Perfusion status
- Glucose control
- Medications
- Comorbidities

Question 2

Comprehensive Wound Assessment

Answer 2

• location
• onset and duration
• prior treatment and response
• dimensions
• tunnelling or undermining
• status of wound bed
• status of wound edges
• exudate
• status of surrounding tissue
• indicators of infection
• wound-related pain

Question 3

Pressure Injuries

Answer 3

Location: over bone or under medical device

Characteristics
- Partial or full thickness
- Round or oval with defined edges

Patient history
- Immobility
- Sliding down in bed
- Medical device in place

Question 4

Friction Injury

Answer 4

Location: fleshy areas exposed to rubbing

Characteristics
- Superficial
- Round or irregular borders
- Wound bed pink/red with no necrosis

Patient history
- Restlessness
- Rubbing against underlying surface

Question 5

Incontinence-Associated Dermatitis

Answer 5

Location: areas exposed to urine and stool

Characteristics
- Superficial
- Irregular borders
- Pink/red + moist wound bed

Patient history
- Fecal or urinary incontinence

Question 6

Intertriginous Dermatitis

Answer 6

Location: base of body fold on opposing sides

Characteristics
- Superficial
- Linear crack on opposing sides
- Wound bed pink or red

Patient history
- Diaphoresis
- Trapped moisture

Question 7

Pressure Injury - Stage 1

Answer 7

Non-blanchable erythema

Treatment
- Pressure relief + offloading

Question 8

Pressure Injury - Deep Tissue Injury

Answer 8

Intact or nonintact skin with localized areas of persistent non-blanchable, deep discolouration
OR
epidermal separation revealing a dark wound bed or blood-filled blister

Caused by intense or prolonged pressure/shear forces

Classify wound as DTI until:
- Wound resolves → no action
- Wound is covered with eschar → now unstageable
- Viable tissue is exposed → stage 1-4, depending on depth

Question 9

Pressure Injury - Stage 2

Answer 9

• Partial thickness skin loss with exposed dermis
• Wound bed is pink/red and moist
• Superficial with no exposed fat, muscle, granulation, or slough/eschar

Question 10

Pressure Injury - Stage 3

Answer 10

• Full thickness skin loss with visible fat in wound base
• No exposed muscle, bone, or joint
• Slough/eschar may be present but cannot obscure wound depth
• Cannot have stage 3 on areas of body with no fat

Question 11

Pressure Injury - Stage 4

Answer 11

• Full thickness skin loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone
• Base has necrotic tissue with tunneling/undermining

Question 12

Pressure Injury - Unstageable

Answer 12

• Full thickness skin loss obscured by slough and eschar
• Cannot confirm depth or injury

Question 13

DIWAMOPI

Answer 13

D: debride necrotic tissue
I: identify and treat infection
W: wick fluid from tunneling/undermining
A: absorb excess exudate
M: maintain moist wound surface
O: open wound edges
P: protect healing wound
I: insulate healing wound

Question 14

D: debride necrotic tissue

Answer 14

Indications (yes to at least 1)
- When goal is repair
- When wound is already open and necrotic tissue is present
- When wound is clinically infected

Options
- surgical/instrumental
- conservative sharp wound debridement
- enzymatic
- autolytic
- chemical
- hydrotherapy
- ultrasonic
- larval / maggot therapy

Question 15

Surgical Debridement

Answer 15

• Sterile excision of all necrotic tissue
• Good for wounds with large amount of necrotic tissue or with bone/joint involvement

Risks of the OR
- Overall patient condition
- Coagulation disorders
- Active infection

Question 16

Conservative Sharp Wound Debridement (CSWD)

Answer 16

• Removal of loose + avascular tissue at bedside
• Good for uninfected wounds with loose necrotic tissue
• Need to identify viable structures to avoid
• Need to establish plane of dissection between viable and nonviable

Question 17

Enzymatic Debridement

Answer 17

• Collagenase/Santyl
• Selective + non-invasive but is slow
• Need to cross-hatch large areas of dry necrosis prior to application
• Nickel-thick application with moist cover dressing

Question 18

Autolytic Debridement

Answer 18

• Uses patient’s own WBC to debride
• Requires moist wound bed with adequate perfusion

Indications
- Limited necrotic tissue
- Dry and adherent eschar

Options
- Dry = hydrogel or medihoney
- Wet = alginates or hydrofibers

Question 19

Chemical Debridement

Answer 19

• Antimicrobial, odor elimination, breakdown of necrotic tissue
• Good choice for infected and necrotic wounds
• Cheap but must be changed frequently (q12-24h)

Options
- Dakins solution, Anasept

Question 20

Hydrotherapy Debridement

Answer 20

• Used to soften + loosen necrotic tissue via pulsed lavage

Contraindications
- Exposed blood vessels
- Graft sites

Question 21

Ultrasonic Debridement

Answer 21

• Uses ultrasound-powered NS mist
• Good to remove slough, thin fibrous exudate, and bacteria

Question 22

Larval + Maggot Debridement

Answer 22

• Used for complex + difficult wounds
• Action is restricted to necrotic tissue
• Very fast acting; in 1-2 dressing changes

Question 23

Contamination

Answer 23

bacteria present on wound surface but not replicating and not impairing wound healing

Question 24

Colonization

Answer 24

bacteria present, are reproducing slowly, but low numbers so not interfering with repair process

Question 25

Critical Colonization

Answer 25

number of bacteria are high enough to interfere with wound repair →now WOCN intervenes topically

Question 26

Invasive Infection

Answer 26

bacteria numbers are so high that they migrate into the periwound skin and triggers a systemic response

Question 27

Antiseptic Solutions

Answer 27

- Dakins or Anasept (both sodium hypochlorite) 0.025-0.0125%) - Iodine 1% - Acetic Acid 0.25 %

Question 28

AMD Dressings

Answer 28

- Cadexomer iodine (ie. Iodosorb) - Intended for exudative wounds - May penetrate biofilm - Be mindful if patient has a shellfish allergy

Question 29

Sustained-Release Silver

Answer 29

- Aquacel or Urgotul - Some donate silver to wound bed - Some kill bacteria within the dressing

Question 30

Broad-Spectrum AMD

Answer 30

Methylene blue, crystal violet, polyvinyl alcohol, polyurethane foam (ie. Hydrofera blue) AMD and anti-inflammatory effects AMD Gauze and Packing - Active agent = PHMB (polyhexamethylene biguanide) Manuka honey dressing - Effective autolytic debridement with AMD effects Dialkylcarbomoyl chloride (DACC) - Attracts bacteria to dressing surface

Question 31

Creating Environment to Promote Wound Healing

Answer 31

- Wick fluid from tunneling//undermining - Absorb exudate - Maintain moist wound surface - Provide waterproof bacterial barrier - Contribute to insulation - Provide atraumatic removal

Question 32

Deep + Wet Wound

Answer 32

> 0.25 cm deep OR tunnels/undermining + moderate-large amounts of exudate Goals - Wick fluid from tunnels/undermining - Absorb excess exudate - Provide bacterial barrier - Provide AMD if indicated Wicking dressings - Ribbon gauze (plain or AMD) - Hypertonic ribbon gauze (Mesalt) - Foam strips (Hydrofera blue) - Hydrofiber strips (Aquacel) Filler/Contact Layer - Alginates (Silvercel or Kaltostat) — Can absorb 20x weight in exudate - Hydrofibers (Aquacel) — Interact with wound to become a gel - Polymer absorptive dressing - Gauze — Can be woven or unwoven — Woven = Kerlix or standard 4x4 — Unwoven = Kling or packing strips — Plain or AMD Cover/Secondary Layer - Select based on volume of exudate + location of wound - Gauze + tape/Tegaderm - Gauze/foam + roll gauze - Adhesive bordered foam (Mepilex)

Question 33

Deep + Dry Wounds

Answer 33

>0.25 cm deep OR tunnels/undermining + minimal exudate Goals - Wick fluid from tunneled/undermined areas - Maintain moist wound surface - Provide bacterial barrier - AMD PRN Wicking dressings - Ribbon gauze (plain or AMD) - Hypertonic ribbon gauze (Mesalt) - Foam strips (Hydrofera blue) - Hydrofiber strips (Aquacel) Filler/contact layer - Layer of wound gel + dampened, fluffed gauze - Gel-impregnated gauze Cover/secondary layer - Gauze + Tegaderm - Adhesive bordered foam dressing (Mepilex)

Question 34

Shallow + Wet Wounds

Answer 34

<0.25 cm with no tunnels/undermining + moderate-large amounts of exudate Goals - Absorb excess exudate - Maintain moist wound surface - Provide bacterial barrier - AMD PRN Options - Alginate/hydrofiber with adhesive foam - Alginate/hydrofiber + porous foam gauze + roll gauze - Nonadherent contact layer + gauze + roll gauze - Adhesive foam only Foam dressing - Commonly is Mepilex or Melipex with border - Can be primary or secondary Contact layer - Commonly Jelonet or Adaptic - Porous and nonadherent - Protects wound bed and permits exudate through — 1st generation —— Petrolatum based —— Initially non-adherent but can dry out —— Ie. Adaptic, Jelonet — 2nd generation —— Silicone based —— Does not dry out —— Ie. Mepitel

Question 35

Shallow + Dry Wounds

Answer 35

<0.25 cm deep with no tunnels/undermining + minimal exudate Goals - Create/maintain wound edge - Protect healing wound Options - Solid Gel dressing — Hydrocolloid dressings — Ie. Duoderm — Provides minimal absorption - Nonadherent contact layer — Mepitel/Adaptic with roll gauze - Transparent adhesive — Ie. Tegaderm — Only if wound has ZERO exudate