Wound Assessment: What Does This Wound Need?

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Introduction

For the wound healing process to be successful, it must pass through four stages: hemostasis, inflammation, proliferation, and remodeling or maturing. Wound healing requires inflammation, but it can be detrimental if it is persistent or encouraged by other factors, such as infection. It is during this phase that wound healing is most likely to stall.

What Is a Chronic Wound?

Wounds that do not go through the four stages of healing after 30 days are considered chronic wounds. As a result of the presence of biofilm, the size, depth, and location of the wound, as well as the duration the wound took to heal, all have an impact on the wound’s healing process. Wound bed preparation has been demonstrated to be a significant advancement in the treatment of nonhealing or chronic wounds. This protocol involves practices such as good wound cleansing, one or more methods of debridement as appropriate, moisture balance, and bacteria balance. Educating clinicians about the importance of wound bed preparation is critical for identifying barriers to manage and accelerate the healing of nonhealing chronic wounds.1

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Identifying Tissue Types

The best way to manage a wound is to have practical knowledge of the various tissue types. Tissues are determined by the color, consistency, and texture of the wound. Necrotic or devitalized tissue is another term for "nonviable tissue." These are terms used to describe avascular tissue that has lost its typical cellular structure and physical properties. The term "viable tissue" refers to vascular tissue that has a high level of biological activity.2

Epithelial Tissue

The formation of epithelial tissue (epithelialization) is the process by which the epidermis regenerates over a partial-thickness wound surface or in scar tissue that forms on a full-thickness wound. The epithelium appears light pink with a pearly sheen. Epithelial cells migrate outward from the wound margins and crawl across the wound bed to the site of closure. Once the epithelium is formed, it gradually becomes stronger.3

Granulation Tissue

Granulation tissue is a strong indicator of healing. Healthy granulation is pink or red, with an uneven, mounded texture.4 Unhealthy granulation is dark or darkish red, quickly bleeds, and may suggest the presence of infection. Hypergranulation refers to excessive granulation or "proud flesh." The wound tissue will manifest above the typical wound bed surface.3

Slough

Slough is tissue that is no longer viable or devitalized and may be fibrinous, sticky, stringy, or thickened. One or more methods of debridement may be indicated. Colors include yellow, gray, green, brown, and tan. Slough houses harmful organisms, increases infection risk, and impedes healing by maintaining the wound in an inflammatory phase or state; consequently, debridement treatments are necessary.3

Eschar

Eschar is devitalized tissue found in a full-thickness wound. Eschar can appear as a result of a burn injury, gangrenous ulcer, fungal infection, necrotizing fasciitis, spotted fevers, or anthrax exposure. The current standard of care guidelines advises against removing stable, intact (dry, adherent, intact without erythema, or fluctuance) eschar from the heels. If the eschar becomes unstable (wet, draining, loose, boggy, edematous, or red), it should be debrided in accordance with the specific facility protocol.5

Steps for Infection Prevention

Localized or systemic infection can occur in any wound. Wound cleansing is an important element of wound bed preparation because it aids in the reduction of bacteria and foreign debris. Monitor wounds on a regular basis for signs and symptoms of infection, including localized biofilm. Bacteria are present in all chronic wounds, regardless of origin, and most chronic wounds contain bacteria and fungi. It has been discovered that combining debridement procedures improves the management of complex wounds with pathological concerns.6

Wound Assessment

Wounds are assessed weekly and are monitored for signs of healing progress. When there are no signs of healing progress within 2 weeks, re-evaluation of the care plan is indicated. Wounds that have stalled and failed to heal as planned are known as chronic wounds or nonhealing wounds. These wounds are usually full-thickness and stall during the inflammatory phase of wound healing. Poor wound healing is linked to a variety of causes. The presence of biofilm, medical conditions such as poorly managed diabetes, underlying immunodeficiency, malnutrition, vascular or heart disease, and cancer are among these factors.3

The Importance of Debridement

Debridement is important to avoid infection and promote re-epithelialization in chronic wounds with devitalized tissue or biofilm. To maximize the healing environment, one or more types of debridement can be utilized alone or in combination. Enzymatic and autolytic debridement treatments, for example, can be utilized in addition to sharp debridement on a weekly basis. Therefore, debridement can assist in healing, reduce the risk of infection, and bolster patient outcomes.

In wounds where there are no signs of progress, the wound should be re-evaluated to determine the appropriate advanced wound care treatment. This may include one or more treatment modalities outside of debridement.

Options for Topical Antimicrobial Dressings

Numerous innovative wound care dressings have been developed specifically for the treatment of chronic wounds. These dressings may contain silver, polyhexamethylene biguanide, medical-grade honey, methylene blue, gentian violet, povidone-iodine, dialkylcarbamoyl chloride, chlorhexidine gluconate, and other antimicrobial agents. As topical antimicrobials, these dressings may help to control the amount of bioburden in the wound and inhibit protease activity.7

When assessing the use of dressings with topical antimicrobials, clinicians should be aware of the product’s indications. Advanced wound care antimicrobial dressings should be used only in wounds that suggest the presence of bioburden or biofilm that has delayed healing or when there is a high risk of infection. Antimicrobial dressings should be monitored every 2 weeks during dressing changes for signs of healing progression. If there are no signs of progress after 2 weeks, the antimicrobial dressing should be discontinued.8

Conclusion

Chronic wounds continue to be substantial concerns in clinical practice, and they can have a negative influence on the quality of life for the patients who have them. Involving patients in their care, as well as understanding the biological processes that take place in the wound bed, can assist clinicians in optimizing these circumstances and selecting the most appropriate treatment for patients to overcome the hurdles that cause the healing of chronic wounds to take longer.

References

  1. Schultz GS, Sibbald RD, Falanga V, et al. Wound bed preparation: a systematic approach to wound management. Wound Repair Regen. 2003;11(suppl):S1-28.
  2. European Wound Management Association (EWMA). Position Document: Wound Bed Preparation in Practice. MEP Ltd; 2004. Accessed March 30, 2022. http://ewma.org/fileadmin/user_upload/EWMA.org/Position_documents_2002-2....
  3. Grey JE, Enoch S, Harding KG. Wound assessment. BMJ. 2006;332(7536):285-288. Accessed March 31, 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360405/
  4. Polypharmacy and complex wounds. WoundSource.com. 2022. Accessed April 11, 2022. https://www.woundsource.com/blog/polypharmacy-and-complex-wounds
  5. Carver C. Knowing the difference between scab and eschar. WoundSource.com. 2016. Accessed March 31, 2022. http://www.woundsource.com/blog/knowing-difference-between-scabs-and-eschar
  6. Attinger C, Wolcott R. Clinically addressing biofilm in chronic wounds. Adv Wound Care (New Rochelle). 2012;1(3):127-132. doi:10.1089/wound.2011.0333
  7. Chamanga ET. Clinical management of non-healing wounds. Nurs Stand. 2017;32(29):48-62.
  8. Wounds UK Best Practice Statement. The Use of Topical Antimicrobial Agents in Wound Management. 3rd ed. Wounds UK; 2013.

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.

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