The evaluation of a patient is designed to answer two primary questions: (1) Why does this patient have a wound? and (2) Why is the wound not healing? Answering these questions demands more than a wound assessment, although that is an integral part of the evaluation. It demands an evaluation of the patient, the medical history, and the four systems (integumentary, cardiopulmonary, neuromuscular, and musculoskeletal). Throughout the entire evaluation and treatment process, if the focus is on the patient and not just the wound, there will be a better understanding of why. In addition, the time spent obtaining this information will help develop trust and rapport with the patient, and will provide an opportunity to understand the patient goals. Attention to the patient allows the evaluator to recognize emergent or untreated conditions that warrant referral to either the primary care physician or an emergency care facility. Therefore, the focus of this chapter is on “the whole patient and not just the hole in the patient,” a phrase first coined by Carrie Sussman, a pioneer in physical therapy treatment of chronic wounds, but a phrase that has been used universally in the era of modern wound management.

Before the wound is uncovered and observed, there are questions that the evaluator can ask the patient (or care-giver) that are helpful in making a diagnosis and understanding why the wound is not progressing. A suggested list of questions is in TABLE 3-1 and is intended to serve as a guideline for initiating discussion with the patient. As the interview progresses, the evaluator will have additional and more pertinent questions relative to each individual patient. By the time the subjective history is completed, the evaluator will probably have a strong sense of the problems and is on the way to answering the question, why? There will also be an indication of the tests and measurements that are needed to make a definitive diagnosis (eg, laboratory tests, vascular screening, gait analysis, extremity girth).

If the patient is in an acute care or long-term care facility, a thorough chart review will also provide information that is helpful in directing the subjective interview, in determining the diagnosis, and in identifying the inhibiting factors. Chapter 11, Factors That Impede Wound Healing, provides a detailed discussion of inhibiting factors and includes a chart of laboratory values that are commonly abnormal for the patient with a wound. If, during the subjective evaluation, any of the signs and symptoms listed in TABLE 3-2 are observed or reported, the patient is advised to see the primary care physician or go to an emergency care facility. After the subjective evaluation is completed, the wound assessment is initiated.

In order to perform a complete wound assessment, good lighting and patient positioning for optimal visualization are recommended. Good patient position includes adequate support for the head and neck, covering for both modesty and comfort, and adequate exposure of the wound for both visualization and access (FIGURES 3-1 and 3-2).

Although the initial appearance of the wound and periwound skin is observed, the wound assessment is best completed after the wound is cleansed thoroughly with normal saline or sterile water and the wound base is exposed. The following substances are not advised for cleansing wounds, especially if there is exposed healthy tissue as in a traumatic injury:

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  Hydrogen peroxide (H₂O₂): While diluted H₂O₂ may be useful for removing particulate debris, recent coagulum, and dried blood or debris at the wound edge, undiluted H₂O₂ is cytotoxic to clean or granulating tissue.

  
  
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  Ionic soaps and detergents: These cleansers (eg, pHisohex) can irritate tissue and increase the potential for infection if used on the wound surface.

  
  
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  Iodine: 1% iodine is associated with decreased wound healing and has not been shown to decrease the risk of infection over normal saline (when cleansing a new, traumatic wound); concentrated iodine is cytotoxic.¹

After cleansing, the wound and integumentary assessment includes location, size, tissue type, drainage, periwound skin color, edema, edges, odor, signs of infection, and pain. A standardized assessment tool such as the one developed by Barbara Bates-Jensen can be helpful in guiding the clinician through the assessment process and provides an objective total score and subsequent outcome measures as the wound healing progresses, or can give an indication that the wound is deteriorating (TABLE 3-3).²

The Pressure Ulcer Scale for Healing (PUSH^©), developed by the National Pressure Ulcer Advisory Panel to measure progress or regression in pressure ulcers, grades a wound based on length, width, exudate amount, and tissue type.³ These parameters are based on the Centers for Medicare and Medicaid Services (CMS) definition of wound progress: a decrease in area or volume, amount of exudate, and amount of necrotic tissue.⁴ The study by Hon et al. found the PUSH^© to be responsive to wound progress in pressure, venous, and diabetic ulcers; however, it is more sensitive in larger wounds than in smaller wounds in the last stages of healing.⁴ The PUSH^© tool has also been found to be responsive to burns and scalds, skin tears, surgical wounds, and traumatic wounds.⁵

The Wound Healing Index (WHI) was developed to stratify patients with wounds according to the wound characteristics and underlying conditions that affect wound healing, and thus validly predict likelihood of wound healing.⁶ The WHI could then be used to stratify patients for random controlled trials and to identify patients early in treatment who would benefit from advanced therapies. Those variables that were identified as significant for patients with wounds of all types include the following: wound size, wound age, number of wounds of any etiology, evidence of bioburden, type of tissue exposed (eg, using Wagner scale or PU staging), being non-ambulatory, and requiring hospitalization in the course of treatment.⁶ Further studies have identified additional significant variables for diabetic foot ulcers (patient age, renal dialysis, and peripheral vascular disease⁷) and for pressure ulcers on any body area except the heel (PU Stage III or IV, patient age, having renal transplant, paralysis, malnutrition, and patient hospitalization for any reason⁸).

Chronic wounds are known to have a significant impact on patient quality of life,⁹ and assessing that impact is an important part of the initial evaluation, not only for understanding the patient emotional and functional status, but also for helping to set reasonable and meaningful goals. Several tools that have been developed to assess quality of life include the following: Freiburg Life Quality Assessment^10,11 (has a short version adapted for venous disease and lymphedema), Wound-QoL questionnaire,^12,13 the Cardiff Wound Impact Schedule,¹⁴ and the Wurzburg Wound Score for lower extremity arterial and vascular wounds.¹⁵

TABLE 3-4 provides a list of assessment tools intended to help the evaluator create an accurate picture of the wound status, assess pain associated with the wound, assess patient-reported quality of life issues, develop an effective and appropriate care plan, and document objectively the progression or regression of a wound.¹⁶ The literature provides several comparisons of the various tools used to assess wounds and/or predict risk for pressure ulcer development and the clinician is advised to select one that is most appropriate for the patient population being served.^17–20 Use of these assessment tools as applicable to each patient is highly recommended for determining efficacy of interventions and reporting progress to third-party payers.

Location

Location is an important component of determining the wound etiology. TABLE 3-5 provides a summary of the characteristics of the four typical wound etiologies (arterial, venous, pressure, and neuropathic) and the location differences that are a significant aspect of determining the wound etiology. Location is described by anatomical body part, using medical terms to define specifics (FIGURES 3-3 to 3-6).

Dimensions

Wound size is a major outcome measurement and is used to document improvement or lack of response to interventions, or to predict healing potential.^21,22 For example, diabetic foot wounds that decrease in size during the first 4–6 weeks of healing are more likely to have full closure.²³ Periodic measurements give objective feedback about the efficacy of treatment and serve as indicators as to when interventions need to be changed due to lack of tissue response. Wound dimensions are also one of the primary indicators used by third-party payers to determine treatment efficacy. Wound surface area can be calculated in several different ways; however, electronic assessment is the only method that is absolute.

Perpendicular Method

The perpendicular (or ruler) method measures the wound length at its longest dimension and the width at the longest dimension perpendicular to the length (FIGURE 3-7). Measurements are recorded in either centimeters (cm) or millimeters (mm), and can be multiplied for a surface area (A = length × width), although it would be approximate because wounds are rarely shaped like a rectangle. Elliptical surface area can also be calculated [A = (π × length × width)/4].²⁴ Volume can also be calculated with the ruler method (V = length × width × depth); the depth is measured with a sterile applicator perpendicular from the deepest area to the wound surface. The perpendicular method has been shown to have good reliability in wounds <4 cm^2,25 and it is quick, easy, and inexpensive; however, it has the disadvantage of over-estimating wound surface area.^24,26

Clock Method

The clock method imagines a clock super-imposed on the wound with 12:00 placed cephalically and 6:00 placed caudally. Measurements are then taken at any direction on the clock and documented (eg, 6 cm at 12–6:00 and 2 cm at 3–9:00) (FIGURE 3-8). When using the clock method, which is beneficial for sacral ulcers, the position of the patient is also documented in order to have consistency of wound configuration between measurements. For example, if a patient is positioned in right side lying for measurements at the time of initial evaluation and in left side lying 1 week later for reassessment, the wound will have a different orientation and configuration, and measurements may not be as valid. The clock method is also helpful in describing wound landmarks (eg, undermining and sinuses) as illustrated in FIGURE 3-9.

Tracing

Tracing uses a clear plastic measuring guide over the wound to trace the edges and is useful for wounds that have serpentine or uneven edges (FIGURE 3-10A, B). A clear film is placed over the wound first, and then the measuring guide, and the wound is traced with a permanent marking pen. Some guides have 1-cm grids that can be used to calculate surface area by counting the number of cross-sections or the number of blocks within the wound tracing.^24,27 Tracing has also been combined with planimetry software to determine more accurate wound surface: the wound is manually traced, scanned into computer software, and exact surface area calculated.^24,28 The disadvantages of wound tracing are the following: sinuses, undermining, and depth are not measured; discomfort to the patient with pressure on the wound; risk of contamination; and edges can be obscured if there is moisture under the film.²⁹

Photography

Digital photography has become the standard for wound photography due to its availability and its ability to be downloaded into electronic medical records. High resolution allows excellent visualization of wound characteristics. TABLE 3-6 lists some recommendations for achieving optimal results when using digital cameras. Some photographs also have the 1-cm grid described above to assist in calculating surface area.

Planimetry

Planimetry uses software to calculate dimensions from digital photography and has become the standard method for recording data for wound research. Results of surface area have been shown to be more accurate with planimetry, especially with wounds over 4 cm².¹⁶ Digital photographs are downloaded into the computer and software used to calculate dimensions, surface area, estimated volume, circumference, and in some cases, tissue type based on color analysis. Another type of planimetry involves the use of a digital camera that uses laser beams to ensure accurate focus on the wound, attachment from the camera to a personal computer, and software that allows the clinician to trace the wound bed and calculate the surface area.³⁰ (See FIGURE 3-11.) Planimetry has been shown to be the most accurate method for calculating wound measurements^25,31–33; however, using the same system throughout the healing process is required for consistency and accuracy.

Subcutaneous Extensions

Some wounds, especially pressure, diabetic foot, and surgical wounds, tend to have necrotic subcutaneous tissue that prevents the wound edge from adhering to the wound bed. The author terms these subcutaneous extensions because the actual wound extends beneath the visible epithelial edge. Examples include undermining, sinuses, tunnels, and fistulas. Because the presence of subcutaneous extensions may be an indication of underlying infection or lead to deeper abscesses, documentation of measurement (in depth) and location (using the clock method of anatomic position) is an essential part of the wound assessment.^3,34 Treatment plans need to include debridement, cleansing, and dressing application to subcutaneous extensions, as well as the visible wound bed.

Undermining is a result of necrotic hypodermal connective tissue that disrupts the attachment of the skin to the underlying structures. Dark discolored skin around the visible periphery of the wound may be an indication of undermining and is explored with a sterile instrument to determine the extent. Documentation includes the depth at the deepest point and the extent using the clock orientation (FIGURE 3-12A, B).

Sinuses are extensions that run along a fascial plane and usually have a small opening that connects to a deeper area of tissue loss. Sinuses may contain fluid trapped in the deeper area, and may lead to abscess formation if not explored and cleansed thoroughly. Suspicion of a sinus is indicated by observation of a dark area at the edge of a wound and warrants exploration. Depth is measured with a sterile alginate-tipped applicator and location recorded using the clock orientation (FIGURE 3-13A, B).

Tunneling occurs when two cutaneous wounds connect (FIGURE 3-14). The two cutaneous wounds may initially appear to be two separate wounds, but when probed reveal that the subcutaneous tissue between the openings is necrotic and not connected to the under surface of the skin. In this case, the sizes of the two openings and the length of the tissue loss between the openings are measured and documented.

A fistula is defined as an abnormal connection between two epithelium-lined structures where a connection does not usually exist. Sometimes it is created for medical purposes, for example, in the case of an arteriovenous fistula between an upper extremity artery and vein for hemodialysis access. The type most frequently encountered in wound care is an enterocutaneous or enteroatmospheric fistula that connects some part of the digestive system with the skin or wound surface (FIGURE 3-15). While the depth of the fistula is not appropriate to measure, the location is a component of the wound assessment. The type of drainage (eg, thin green, thick brown, or solid brown) can indicate the location of the digestive track where the fistula originates.

Tissue Type

Identification of the tissue type within a wound bed is necessary for understanding the phase of healing and for developing a plan of care, especially the optimal type of debridement and dressings. If one observes a structure that cannot be named or identified during the evaluation or treatment procedure, the procedure should be discontinued until research can help identify the tissue of concern. A documentation technique that is helpful in measuring outcomes is to assign a percentage of the total wound surface to each tissue type. While this is approximate at best, especially when using the perpendicular or ruler technique rather than sophisticated software, it does help document improvement in tissue quality as the wound progresses from inflammation to granulation to epithelialization. Normal structures (eg, skin, bone, muscle, tendon, and adipose) may be either viable or non-viable, healthy or not healthy, and are identified as such in the evaluation.

Eschar is non-viable or necrotic tissue that covers all or part of a wound base. It is composed of dead skin or subcutaneous cells and may vary in color (black, brown, gray, yellow, tan) and texture (hard, dry, rubbery, soft). Eschar is not synonymous with what is commonly called a “scab,” which is a result of blood and serum hardening over a fresh wound (FIGURE 3-16).

Slough is non-viable subcutaneous tissue, often found under eschar, and is a result of the body’s autolytic process to phagocytose dead cells. The usually soft and yellow substance has no real texture and is hard to grasp with forceps, unlike stringy, fibrous yellow or tan connective tissue that may also be under eschar (FIGURE 3-17).

Granulation tissue, the hallmark of the proliferative healing phase, is composed of extracellular matrix and capillaries. It is the tissue that the body produces to fill in a wound cavity and to support new epithelial growth, and has, as its name suggests, a granular appearance. Note that not all red tissue is granulation tissue; for example, immediately after surgery muscle and subcutaneous tissue may also be red but have a different texture. For this reason, describing wounds by color only (as is sometimes discussed in the literature) may be misleading in the documentation (FIGURE 3-18A, B).