By Holly M. Hovan MSN, APRN, GERO-BC, CWOCN-AP
Chronic wounds impact more than 8 million Americans in a multitude of ways ranging from affecting quality of life along to creating a significant economic burden, with the estimated cost of care in the United States currently at 30 billion dollars. 1 As technology and medicine continue to advance, our aging population continues to grow, and the number of those impacted by chronic wounds is likely to increase.1 This blog will take it back to the basics—using our senses to guide wound assessment and management—while incorporating technology/telemedicine and wound photography to guide treatment and track progress.
How to Use the Senses to Evaluate a Wound
Take a walk back in time. Remember learning about the 5 senses as a child? As we know, senses send messages through cells to our brain, using our nervous system to deliver a message and ultimately help us understand what is happening around us. What are our senses?
We can use all 5 at once without even realizing it sometimes! Now, how do our senses play into our wound care assessment and treatment toolbox? They are actually the nuts and bolts—the basics. Without 4 out of our 5 senses, we would likely be unable to assess or treat a wound effectively in many situations.
Let’s take a look at the 4 senses involved in wound assessment and treatment. The following are a series of questions wound care professionals can ask themselves when assessing a wound with 4 of their 5 senses:
What does the wound look like? What colors and tissue types are present in the wound bed? What percentage of the tissue is necrotic, granular, or epithelial? Are underlying structures exposed (bone, muscle, tendon)? Is there tunneling or undermining? What are the wound measurements (remember to always measure length first: head-to-toe, next, width: side-to-side, and last, depth: the deepest point in the wound)? What color is the wound drainage? How much drainage is present? What is the condition of the periwound skin? Is there periwound maceration (from moisture)? Are rolled wound edges (epibole) present, and what would this mean? Do you have wound photos or a prior assessment to compare to the current assessment? A comparison is often helpful as knowing the baseline is vital to determine improvement or worsening in the wound.
Additionally, during the peak of the COVID-19 pandemic, the health care field adopted more remote/virtual approaches to patient care in multiple specialties, including wound care and management. Video visits, photography, and telemedicine are areas that continue to grow in terms of the way clinicians manage and treat acute and chronic wounds. When used appropriately, telemedicine wound care visits may assist in reducing costs associated with management and increase access to care, especially for those in rural areas or with limited access to transportation or poor mobility.1
Is there an odor? Is the odor related to chronic wound drainage, autolytic debridement, infection, contamination (stool/urine), or the treatment used? Is the odor present after cleansing the wound? It is important to note that wound drainage may sometimes have an odor and is not always related to infection. The wound should be cleansed, and the old/soiled dressing should be discarded from the wound before determining the presence (or absence) of wound odor. Malodor in a wound may mean many things, and it is essential to note wound etiology, the treatment used, and other factors that may be contributing to the presence or absence of odor in a wound.
Is there induration, firmness, or erythema? Can you palpate bone? Is purulent drainage expressed when the wound or periwound is palpated? Is the periwound warm to the touch? Is there a temperature difference in the skin around the wound compared to skin on other parts of the body? It is important to note that in pressure injuries if bone is able to be palpated, the wound would be a stage 4 pressure injury. What happens when we assess the wound (measuring, using a cotton-tipped applicator, applying a new dressing); is the patient in pain? These questions will lead to our final sense, which helps assess and manage our wound care patient population.
Is the patient complaining of pain? Has the pain been treated before assessment and treatment? What is the patient's history/back story? How did the wound happen, and how long has it been present? What are we hearing about the wound, the current state of the wound, and the patient's history? What treatments have been tried in the past (if any)? Are there any allergies or product sensitivities? All this information will play into how the wound is treated initially and long-term and often involves an interdisciplinary approach.
Taking it back to basics is vital, but do not forget that the health care field is constantly evolving, and there are always new things to be learned. Incorporating the basics, our senses, and new and different approaches to wound management (telemedicine, photography) will likely result in improved patient outcomes and increased access to care.
Each patient and wound is unique, so it is essential to individualize the care plan and determine when an in-person visit is necessary, as some of our senses discussed above cannot be utilized in telemedicine. Certain patients and situations may require an in-person visit. A holistic, comprehensive, evidence-based, interdisciplinary approach is often the best when managing a complex, chronic wound patient—exploring all resources and reaching out to all our interdisciplinary team players will often yield the best outcomes for our chronic wound population.
- Onuh, Ogechukwu C. BA; Brydges, Hilliard T. BS; Nasr, Hani MD; Savage, Elizabeth MSN, APRN, ACNS-BC, CWON, IIWCC-NYU; Gorenstein, Scott MD; Chiu, Ernest MD. Capturing Essentials in Wound Photography Past, Present, and Future: A Proposed Algorithm for Standardization. Advances in Skin & Wound Care: September 2022 - Volume 35 - Issue 9 - p 483-492 doi: 10.1097/01.ASW.0000852564.21370.a4
About the Author
Holly is a board certified gerontological nurse and advanced practice wound, ostomy, and continence nurse specialist at VA Northeast Ohio Healthcare System in Cleveland, Ohio. She has a passion for education, teaching, and our veterans. Holly has been practicing in WOC nursing for approximately ten years. She has much experience with the long-term care population and chronic wounds as well as pressure injuries, diabetic ulcers, venous and arterial wounds, surgical wounds, radiation dermatitis, and wounds requiring advanced wound therapy for healing. Holly enjoys teaching new nurses about wound care and, most importantly, pressure injury prevention. She enjoys working with each patient to come up with an individualized plan of care based on their needs and overall medical situation. She values the importance of taking an interprofessional approach with wound care and prevention overall, and involves each member of the health care team as much as possible. She also values the significance of the support of leadership within her facility and the overall impact of great teamwork for positive outcomes.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.