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Wound Assessment and Dressing Selection

Geoff Sussman
Director, Wound Dressing Education and Research, and Senior Associate, Department of Pharmacy Practice, Monash University, Melbourne, VIC

An acute wound should first be cleaned and decontaminated, then if necessary, the wound edges should be held together by sutures or tape, and finally an appropriate dressing applied

The difficulty in the management of any chronic wound is that there is always an underlying physiological cause of the wound that must be treated

Wound assessment includes wound location, size and depth

A thorough wound assessment also evaluates the wound bed, the quality and amount of exudate, the presence or absence of infection

Wounds are dynamic and as such the choice of dressing will change as the wound changes

Choice of dressing is based on three simple rules, 'C D E', which indicate the three major aspects of any wound: colour, depth and exudate

Also consider the presence of infection, the peri-wound tissue, the need to apply graduated compression, the fragility of the skin and any medical condition that may impact on the dressing choice


Wound management is no longer simply the application of a dressing to an acute or chronic wound. It is the provision of an appropriate environment for healing by both direct and indirect methods, together with the prevention of skin breakdown. This article describes the practical aspects of wound management - use of topical agents, type of wound, wound assessment and selection of appropriate dressings.

Wound Aetiology
Wounds may be either acute or chronic in nature: from lacerations, grazes, burns and postoperative wounds to leg ulcers, diabetic wounds and pressure sores. The relative differences between each of these types of wounds are described in

Table 1. Relative differences between acute and chronic wounds

Acute Wounds

Chronic Wounds

Heal mostly by primary intention

Heal by secondary intention

Higher risk of infection due to the inflammatory phase and the presence of debris contaminating the wound

Have a lower risk of infection

Symptoms of underlying cause

Will vary in appearance from granulating to sloughy or covered with eschar


General Principles of Management
The basic principles of wound manage are as follows:

  • Define the aetiology

    Control both intrinsic and extrinsic factors affecting healing

  • Select the appropriate dressing · Plan for management.

Acute Wounds
The major objective is to facilitate optimal healing. That is, with as little scar tissue as possible, with a good cosmetic appearance. Therefore, to treat an acute wound, it should first be cleaned and decontaminated, then if necessary, the wound edges should be held together by sutures or tape, and finally an appropriate dressing applied. Tetanus vaccination should be considered if foreign bodies may be trapped in the wound.
All traumatic wounds have some form of contamination, so it is very important to remove any dirt, foreign material or potential bacterial contamination from the wound before closure and dressing.[1,2]
The choice of cleansing solution will depend on the severity of the wound and the level of contamination. If the wound is basically clean, then water or saline is most suitable. If there is any level of contamination, a surfactant solution such as chlorhexidine/ cetrimide is the most satisfactory, due to the ability of the product to remove material by a soap-like action.
The use of topical antiseptics and antibiotics in acute wounds is entirely different to that used in chronic wounds. In a traumatic wound the risk of infection from contamination at the time of wounding is very high. This is also the case in major burns, since the presence of necrotic tissue is a focus for infection. Therefore it is mandatory to use topical therapy in the treatment of acute wounds. The aim is to use antiseptics and antibiotics prophylactically in order to reduce the level of bacteria in the wound, and then to allow the body's own mechanisms to destroy the rest.[3-5]
Chronic Wounds
Large proportions of wounds seen in clinical practice are chronic in nature. Chronic wounds may be classified into the following groups:

  • Pressure wounds

    Leg ulcers

    Postoperative wounds

    Neoplasia

  • Chronic infected wounds.

The difficulty in the management of any chronic wound is that there is always an underlying physiological cause of the wound that must be treated. Many patients have multifactorial shortages; for best results the basic cause of the problem must be attacked, and the negative factors altered.
It must be understood that some patients may never heal due to the basic pathophysiology of the disease process, and the inability to alter some or all of the major factors influencing the non-healing of the wound. However, even in the most extreme cases, good wound care can be a great help in minimising the worst effects of such chronic wounds.
Pressure Wounds
Of all of the chronic wounds seen in practice, surely the most preventable are the pressure wounds. The essential part of prevention is patient assessment and active intervention in the case of high-risk patients. Pressure wounds may be as simple as the blister most of us may have experienced over the years from footwear or the extensive pressure sores experienced by bedridden patients suffering from afflictions like stroke, spinal injury, multiple sclerosis, dementia.[6,7]
A pressure wound develops when the capillary blood flow to the skin and tissue over a bony prominence is decreased for a sufficient period of time. The main causes of pressure wounds are pressure, friction and shearing forces.
Pressure
Direct pressure on tissue over a bony prominence in excess of 30 mmHg will cause ischaemia in the surrounding tissue. This can occur with a patient in bed, on a trolley or sitting in a chair (Fig. 1). The extent of tissue damage will depend on the intensity of the pressure and the length of time the pressure remains unrelieved. The tissue can tolerate pressure for short periods of time, however, even low pressure over a long period of time will have some detrimental effect (Fig. 2).
Friction
Friction occurs when the top layers of skin are worn away by continued rubbing against an external surface. This can manifest itself in a simple blister, tissue oedema or an open pressure wound. Friction can be caused by ill fitting footwear, or even bed linen.
Shearing Forces
Shearing occurs when the skin remains in place, usually unable to move against the surface it is in contact with, while the underlying bone and tissue are forced to move. Shearing forces will contribute to the destruction of deep tissue and the obstruction of blood vessels in a manner similar to direct pressure. This type of pressure injury is seen in patients left sitting up in bed or on a chair, while gravity causes the patient to slide down with the skin adhering to the bed linen or the surface of the chair.

Fig 1. Grade 2 pressure wound in the sacral region.

Fig 2. Escharotic heel due to pressure and friction - requires autolytic or sharp debridement before healing can occur.


Leg Ulcers
Venous Ulcers
Venous ulcers are most often found in the gaiter area of the leg and where there is a history of varicose veins. They are usually irregular in shape, not painful and oedema is often present. The skin is often stained around the ulcer area (Fig. 3) with past fractures or trauma with a possible silent deep vein thrombosis, skin changes, eczema, atrophie blanche (white stippled scars on the skin), ankle flare or distended small veins on the medial aspect of the foot.[8]

Fig 3. Pseudomas spp. infection in venous ulcers in 75-year-old female.

The main feature is a lack of venous return caused by a malfunction of the valve system, either in the deep or the peripheral system (Figs 4-9).

Figures 4-9. 88-year-old female with bilateral venous ulcers on the medial malleoli - infected on first presentation. Progressive pictures of each leg (left leg, Figs 4-6; right leg, Figs 7-9). Treated initially with cadexomer iodine to clear surface infection, then zinc and compression for venous disease.

Fig 4

Fig 5

Fig6

Fig7

Fig8

Fig9

Arterial Ulcers
Arterial ulcers are very painful, especially at night. The pain is as marked in small ulcers as in larger ulcers. Their edges are sharply defined and the ulcer is 'punched out'. The base is often covered with slough and this may deepen to bare the tendons. The skin is often shiny and friable (Figs 10, 11). Uncontrolled diabetes and smoking are significant factors causing arterial insufficiency. Healing is often slow and may depend on control of the underlying cause. There is usually a history of intermittent claudication, dependant foot (dusky foot) white on elevation or peripheral vascular disease.
It is important to note that between 10 and 15% of leg ulcers are of mixed aetiology (Figs 12, 13). Infections may lead to ulceration, which are often hard to heal due to associated oedema, cellulitis, thrombophlebitis, diabetes or underlying vascular disease, rheumatoid diseases (especially in bedridden patients) and skin conditions associated with malnourishment.[8,9]
The diabetic ulcer is associated with peripheral neuropathy and reduced arterial blood flow. There is also abnormal plantar pressure. Surgical wounds may become chronic due to dehiscence of the suture line and subsequent infection of the wound base. These wounds are often slow to heal, and close by contraction and secondary intention.
A small number of chronic ulcers may be as a result of neoplasia and some may develop into non-healing ulcers. The most common of these are squamous cell and basal cell carcinomas (Fig. 14).

Figures 10, 11. Classic arterial ulcers located on foot; very regular punched out appearance, weak pulses, low Ankle Brachial Index (ABI), very painful.

Fig10

Fig11

Figures 12, 13. Two views (lateral, Fig. 12; posterior, Fig. 13) of the same patient with mixed venous and arterial components to the ulcer. The ulceration is almost circumferential and is highly exudative.

Fig12

Fig13

Fig 14. Basal cell carcinoma - may be mistaken for a non-healing wound and is diagnosed on biopsy.


Controlling Intrinsic and Extrinsic
Control of intrinsic and extrinsic factors is essential to assist in the healing of any wound, either acute or chronic. Factors such as nutrition, smoking, circulation, immune function, medications and infection should be addressed. See earlier article 'Wound Management and the Physiology of Healing'.Wound Assessment
After patient assessment, the next step is to carefully assess the wound. Wound assessment includes wound location, size and depth. A thorough wound assessment also evaluates the wound bed in terms of type of tissue present, the quality and amount of exudate and the presence or absence of infection. It also involves assessment of the condition of the peri-wound area and evaluation of any past and current treatments.[10,11] Location
Location of the wound can indicate the need for special attention. For example, sites that are exposed to urine and faeces need special protection. Peripheral wounds tend to heal more slowly and blood flow improvement is important. Location of wounds can be documented by using body outline drawings.
Size and Depth
Wound size and depth are helpful in predicting the speed and quality of healing. Measurement of the wound area provides an objective guide to the healing progress. Measurements of wound areas generally apply only to wounds healed by secondary intention - open wounds that must fill with granulation tissue and re-epithelise from the wound edges. Wounds that heal by primary intention (eg surgical wounds closed with sutures or staples) do not have a measurable area.
It should be noted that while a decrease in wound area indicates healing, an increase in the area does not always signal deterioration. For example, when necrotic debris is removed the wound area is often larger, but this is a positive sign as it allows healing to progress.
The patient should be in the same position for each measurement; this position should be noted in the documentation so that continuity is maintained and the measurements are meaningful.
Undermining
Undermining is an area where skin covers an open area or 'dead space'. There may be sinus tracts that run under the wound. The skin appears grey or purplish in colour and should be probed carefully to determine the extent of undermining.
Wound Bed
The type of tissue at the wound bed reveals important information such as the phase and progress of wound healing.
Epithelial Tissue
Partial-thickness wounds heal mainly by epithelisation. Whereas deeper, full-thickness wounds heal mainly by contraction, filling with granulation tissue and epithelial migration from the wound edges. Epithelial tissue is 'pearly pink' in colour.
Granulation Tissue
The presence of the classical 'shiny, beefy, red' granulation tissue denotes healing progress and is a healthy sign. Danger signs to look for in the granulating wound bed are grey or purple colouring, indicating an inadequate blood supply.
Necrotic Tissue
Necrotic tissue in a wound bed delays healing and must be removed. Yellow necrotic tissue is referred to as slough. The thick, hard, black necrotic material seen covering wounds is called eschar. Both slough and eschar interfere with healing - their removal is essential. The area and depth of a wound cannot be properly assessed until this debris is cleaned away.
Exudate
Wound exudate or drainage is an indication of the inflammatory processes taking place in the wound. Drainage is not necessarily a negative phenomenon. Wound fluid is rich in white blood cells and growth factors that will facilitate healing. Difficulties arise, however, when drainage increases dramatically or has a foul odour and purulent appearance. This can increase the chances of bacterial infection and possibly prolong the inflammatory process, which delays the progression of healing.
The amount of drainage can be described as small, moderate or large. The type of drainage can be described as purulent, serous, clear or bloody.
Peri-Wound Area
Assessment of peri-wound skin, or wound margins, can give indications of problems. Erythema of the wound margin can signal infection. A blue-grey or blanched margin can indicate an undermined area. White margins can result from maceration. These areas should be noted and documented.

Current and Prior Treatment Modalities
It is helpful to know what treatments have been used and what result was obtained. Hopefully, one modality will have been used long enough to evaluate its effectiveness. If no improvement is seen in 2-4 weeks after a treatment is initiated, a re-evaluation of the aetiology, systemic factors and treatment regimen is needed.
Selection of the Appropriate Dressing
Wounds are dynamic and as such the choice of dressing will change as the wound changes. The choice should be based on three simple rules, 'C D E', which indicate the three major aspects of any wound: colour, depth and exudate.[12,13]
Other aspects that will need to be considered are the presence of infection, the peri-wound tissue, the need to apply graduated compression, the fragility of the skin and any medical condition that may impact on the dressing choice.
Colour
Pink
The Pink wound is in the final stages of healing. With new epithelium covering the wound, the major aim is to protect this very delicate tissue, prevent the wound from drying out (to maintain a moist environment) and to insulate.
Red
The Red wound is a granulating wound with new tissue filling the deficit and with some islets of epithelium present. The aim is to absorb any excess exudate, maintain a moist environment and protect the wound. Yellow
The Yellow wound contains a level of slough. This is non-viable tissue that must be removed or healing will not take place. The aims are slough removal by rehydration with dressings such as hydrogels or hydrocolloids, and absorption of exudate. Surgical removal of slough may be necessary.
Black
The Black wound has an outer layer of thick hard eschar - this must be removed to commence the healing process. The fastest and most effective method is surgical removal. The use of dressings such as hydrogels to aid autolytic debridement will at best be slow.

Depth
The wound may be superficial, partial-thickness or a deep cavity. The product choice will depend on the shape, position and type of wound.
Exudate
Most wounds will contain some exudate; this will vary from very little to copious levels. The choice of both primary and secondary dressing will depend on this level and the depth of the wound.

Dressings
The dressing chosen will depend on the amount of exudate from the wound, the need for a waterproof cover, the location of the wound (ie if it is on a flexor), along with the need for a dressing that will be elastic in its properties. Some examples of suitable dressings are listed in the Guide Chart 'Treatment Options Based on Wound Type', facing page 40 of the May issue of Current Therapeutics.
Bandages
In addition to the dressing used to cover the wound, some wounds will require extra protection in the form of a bandage around the wound and limb. For simple extra support a lightweight cohesive bandage (eg Handy gauze cohesive or Easy fix cohesive) is suitable. When support is also required, a heavyweight crepe bandage or a heavyweight cohesive bandage may be used.[14]
Reassessment
Only after a thorough wound assessment can appropriate treatment be planned. Reassessment is just as important; as the wound changes, so should the treatment plan.

Web Site Wound Education and Research Group, Monash University
http://www.vcp.monash.edu.au/werg

1. Wijetunge DB. Management of acute and traumatic wounds: main aspects of care in adults and children. Am J Surg 1994; 167 Suppl. 1a: 50S-56S
2. Ilulten L. Dressings for surgical wounds. Am J Surg 1994; 167 Suppl. 1a: 42S-45S
3. Lawrence C. Antibacterial prophylaxis in burns and other surface wounds. Wound Management 1992; 2: 13-15
4. Dire JD. A comparison of wound irrigation solutions used in the emergency department. Ann Emerg Med 1990 Jun: 704-7
5. Sleigh JW. Hazards of hydrogen peroxide. Br Med J 1985;
6. Young JB. Pressure sores: epidemiology and current management concepts. Drugs Aging 1992; 2: 42-57
7. Leigh IH, Bennett G. Pressure ulcers: prevalence, aetiology and treatment modalities: a review. Am J Surg 1994; 167 Suppl. 1a: 25S-30S
8. Group TA. Consensus paper on venous leg ulcers. Phlebology 1992; 7: 48-54
9. Harper D, Hajivassiliou C. The aetiology of leg ulcers. Wound Management 1991; 1 (3): 10-11
10. Morgan DA. Wound management: which dressing. The Pharmaceutical Journal 1993 May 29: 738-43
11. Thomas S. Handbook of wound dressings. London: MacMillan, 1994
12. Sussman G. Wound Management. In: Sansom L, editor. 2000, Pharmaceutical Society of Australia. Canberra: Pharmaceutical Society of Australia, 2000: 204-12
13. Thomas S. Functions of a wound dressing. In: Wound management and dressings. London: The Pharmaceutical Press, 1990: 9-19
14. Thomas S. Bandages and bandaging. The Pharmaceutical Journal 1993 May 29: 744-5


Author Details
Geoff Sussman, PhC (Vic), AFAIPM, is the Director of Wound Dressing Education and Research, and a Senior Associate at the Department of Pharmacy Practice, Monash University. His research interests include tissue repair and wound healing, wound dressings and the role of drugs in wound healing.
Correspondence:
Wound Dressing Education and Research Department of Pharmacy Practice, Victorian College of Pharmacy, Monash University, 381 Royal Parade, Parkville, VIC 3052
email:
geoff.sussman@vcp.monash.edu.au

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