Wound Assessment

Martin Vera's picture
sickle cell anemia testing - atypical wound etiology assessment

By Martin D. Vera LVN, CWS

As devoted clinicians to the field of wound management we take a responsibility to educate ourselves and others about wound etiologies and characteristics, as well as management of barriers to achieve positive outcomes. We spend a great deal of our careers learning about the most common offenders, such as pressure injuries, diabetic foot ulcers, venous stasis ulcers, arterial wounds, amputations, and traumatic wounds, to name a few. However, as our careers unfold we are faced with extra challenges, and atypical wounds are among them.

WoundSource Practice Accelerator's picture
moisture-associated skin damage

by the WoundSource Editors

It has long been known in clinical practice that long-term exposure of the skin to moisture is harmful and can lead to extensive skin breakdown. The term moisture-associated skin damage was coined as an umbrella term to describe the spectrum of skin damage that can occur over time and under various circumstances. To have a moisture-associated skin condition, there must be moisture that comes in contact with that skin.

WoundSource Practice Accelerator's picture
surgical instruments for debridement

by the WoundSource Editors

One of the greatest challenges when dealing with biofilms in chronic wounds is identifying their existence in the first place. The extracellular polymeric substance or EPS on biofilms essentially is an invisible cloak that protects and hides biofilms from both the body's immune system and antimicrobial therapies. This biofilm property keeps the wound from advancing through the phases of wound healing and thus remaining in the inflammatory phase, thereby allowing further proliferation of biofilms. This is a common theme in wounds with biofilms, but other signs and symptoms will depend on the type and degree of functional impairment the host experiences. Types of inflammatory cells seen may be polymorphonuclear neutrophils, leucocytes, or mononuclear cells, but the type will depend on the predominating immune response of the host.

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WoundSource Practice Accelerator's picture
biofilm culture under microscope

by the WoundSource Editors

Have you ever had plaque buildup on your teeth, seen a thin clear film on the top of your pet's water bowl, or stepped into a locker room shower where the floor felt slick and slimy? If so, then did you realize these were all forms of biofilm? Biofilm is a complex microbial community containing self- and surface-attached microorganisms that are embedded in an extracellular polymeric substance, or EPS.1,2 The EPS is the slimy substance in the previous examples and is primarily a polysaccharide protective matrix synthesized and secreted by the microorganisms that attaches the biofilm firmly to a living or non-living surface. This film protects the organisms from destruction first by being tenacious and keeping the microbial community strongly attached to a surface.

Temple University School of Podiatric Medicine's picture
Wound Care Journal Club Review

Temple University School of Podiatric Medicine Journal Review Club
Editor's note: This post is part of the Temple University School of Podiatric Medicine (TUSPM) journal review club blog series. In each blog post, a TUSPM student will review a journal article relevant to wound management and related topics and provide their evaluation of the clinical research therein.

Holly Hovan's picture
patient mobility and activity

By Holly Hovan MSN, APRN, CWOCN-AP

The Braden Scale for Predicting Pressure Sore Risk® category of activity focuses on how much (or how little) the resident can move independently. A resident can score from 1 to 4 in this category, 1 being bedfast and 4 being no real limitations. It is important to keep in mind that residents who are chairfast or bedfast are almost always at risk for skin breakdown

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Holly Hovan's picture
enteral nutrition feeding

By Holly Hovan MSN, APRN, CWOCN-AP

A common misconception by nurses is sometimes predicting nutritional status based on a resident's weight. Weight is not always a good predictor of nutritional status. Nutritional status is determined by many factors and by looking at the big picture.

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WoundSource Editors's picture
tunneling wound assessment

By the WoundSource Editors

Perhaps the most difficult type of wound for health care professionals to treat is a tunneling wound. Tunneling wounds are named for the channels which extend from the wound, into or through subcutaneous tissue or muscle. These tunnels sometimes take twists or turns that can make wound care complicated. Tunneling is often the result of infection, previous abscess formation, sedentary lifestyle, previous surgery at the site, trauma to the wound or surrounding tissue, or the impact of pressure and shear forces upon many tissue layers causing a “sinkhole-like” defect on the skin. Tunneling wounds need careful wound assessment and management.

WoundSource Practice Accelerator's picture
pressure injury risk assessment

By the WoundSource Editors

Pressure ulcers/injuries pose a major risk to patients by increasing morbidity and mortality and causing significant discomfort.1 They are also prevalent, particularly in long-term care facilities, where patient populations may be at higher risk of developing pressure injuries as a result of factors of age, immobility, and comorbidities.2 To reduce the incidence of pressure injuries effectively, nurses and other health care professionals should be aware of the risk factors and the means to evaluate patients. This will allow caregivers to take steps to prevent problems before they develop and treat them more effectively if they do.

Holly Hovan's picture
Moisture on Skin

By Holly Hovan MSN, APRN, CWOCN-AP

When nurses hear the term moisture, they usually almost always think of urinary or fecal incontinence, or both. There are actually several other reasons why a patient could be moist. Continued moisture breaks down the skin, especially when the pH of the aggravating agent is lower (urine, stomach contents—think fistula, stool). When there is too much moisture in contact with our skin for too long, we become vulnerable to this moisture, and our skin breaks down. Increased moisture places a patient at risk for a pressure injury as the skin is already in a fragile state.