Wound Assessment

ABDUL MANAN BIN OTHMAN
BSc (Hons) NPD Northumbria UK, CCWC (Mal)
Assistant Medical Officer
National Wound Care Committee
Wound Care Clinician
Kota Tinggi District Health Office

1. Wound assessment as simple as abc ABDUL MANAN BIN OTHMAN BSc (Hons) NPD Northumbria UK, CCWC (Mal) Assistant Medical Officer National Wound Care Committee Wound Care Clinician Kota Tinggi District Health Office email: [email protected]

2. DISCLaimer The contents presented in these slides are the opinions of the speaker Treatment modalities mentioned are for scientific discussions only and are not recommended for off-label recommendations If there are any products mentioned, it is for the purpose of the topic discussion only.

3. What ….. when who…where… how ..

4. Goal in wound care cycle No Yes Prevention

5. WOUND ASSESSMENT A ge (extreme of age) D isease and co-morbid (DM, malignancy) O besity M edication (steroid, chemotherapy) N utrition I mpaired blood supply (arterial and venous ulcer) L ifestyle (smoking)

6. h.e.i.d.i

7. H-history Medical Surgical Pharmalogical Social HOPWI

8. Once you have your story it’s time to use your senses: HEAR SEE SMELL TOUCH

9. E- Examination The patient as a whole- systemic Focus on the wound Pain- PQRST TIME assessment

10. Pain in pqrst P-Provokes/ Palliates >what causes pain? >what makes it better >Worse Q- Quality >What does it feel like >Is it sharp >Dull/Stabbing >Burning >Try to let patient describe the pain

11. R-Radiates > Where does the pain radiate > Is it in one place > Does it go anywhere else S- Severity > How severe is the pain > Scale 1-10 > Wong baker faces

12. T- Time > Time pain started > How long did it last?

13. i -investigation What bloods?? X-rays Scan?? Ultrasound C&S HPE Tissue Analysis That require to help you make your diagnosis

14. D- diagnosis Stage what of PI Wagner Stage for DFU Venous Ulcer Arterial Ulcer Surgical Wound Burns how many % Traumatic Wound PAD PVD Cancerous / Malignancy

15. i -implementation Start planning Cleansing solution Primary Dressing Secondary Dressing Compression Emollient/ barrier

16. WOUND PICTURE W - Wound or ulcer location O - Odor assess before and during dressing U - Ulcer category, stages, PI , DFU, Burn N - Necrotic Tissue D - Dimension of wound- shape, length, width, depth, drainage color

17. P - Pain score – 0-10 I - Induration –( surrounding tissue, hard or soft) C - Color of wound bed- red, pink, yellowish, black T - Tunneling U - Undermining- clock references R - Redness or discolorationin surrounding skin E -Edge of skin-loose or tightly adhered?

18. T.I.M.E wb preparation A tool during wound assessment to identify barriers to healing Implement a plan to remove barriers and promote healing

19. History of time Originally developed from Plastic Surgery Team- 1977,Philadelphia. Concept and framework to prepare wound bed before split skin graft- also called Wound Bed Preparation Later extended into chronic wound management Proposal of Wound Bed Preparation concept in year 2004 to EWMA – emphasizing on debridement, moisture balance and bioburden

20. T.I.M.E 4 main components of wound bed preparation: 1) T issue Management 2) Control of I nfection & I nflammation 3) M oisture Imbalance 4) Advancement of E pithelial E dge of the wound

21. Triangle of wound assessment (TOWA)

22. Triangle of wound assessment (TOWA) WOUND Wound bed Wound edge Periwound skin Tissue type Exudate Infection Maceration Excoriation Dry Skin Hyperkeratosis Callus Eczema Maceration Dehydration Undermining Rolled

23. Position Document from World Union Wound Healing Societies, 2016

24. Adapted from small teaching of Dr Wan Zuraini , KK Telok Datok , Kuala Langat

25. Adapted from small teaching of Dr Wan Zuraini , KK Telok Datok , Kuala Langat

26. Adapted from small teaching of Dr Wan Zuraini , KK Telok Datok , Kuala Langat

27. 2017 M.O.I.S.T A CONCEPT FOR THE TOPICAL TREATMENT OF CHRONIC WOUNDS Dissemond J, et al. J Dtsch Dermatol Ges.2017.

28. T.i.m.e concept as a wound bed preparation

29. Source: International advisory board of wound bed preparation 2003

30. 1) T issue Management Pathology : defective matrix, non-viable tissue and cell debris impairs healing Plan: Episodic or continuous debridement Effect of actions: restoration of wound base and functional extracellular matrix proteins (chronic ->acute wound) Clinical outcomes : Viable wound base

31. Tissue Types Necrotic eschar Slough Granulation Hypergranulation Poor quality granulation Epithelium

32. HOW to IDENTIFIED viable/ non viable 4C FORMULA C OLOUR C ONSISTENCY C ONTRACTION C IRCULATION

33. non viable muscle/ tissue can be identified by its dark color , its mushy consistency , its failure to contract when pinched with forceps, and the absence of bleeding from a cut surface

34. Debridement??? Process of removal of non viable tissue and contaminants from a wound to promote healing.

35. METHod of debridement B - Biological debridement A - Autolytic debridement S - Surgical debridement U - Ultrasonic debridement H - Hydrostatic debridement M - Mechanical debridement E - Enzymatic debridement C - Combination

36. CROSS HETCHING ESCHAR?????? ######### ##### ##########

37. 2) Control of I nfection & I nflammation Pathology : high bacterial count/prolonged inflammation -> ↑ cytokines & protease activity, ↓ growth factor activity Plan : -remove foci of infection (local/systemic) - antimicrobials/ antiinflammatory Effect of actions: low bacterial count & controlled inflammation Clinical outcomes : bacterial balance and reduced inflammation

38. PATHWAY OF WOUND INFECTION

39. Contamination

40. Colonization

41. O2 O2 O2 pH pH pH pH O2 Critical colonization

42. Infection

43. BIOFILM Community of microorganisms encased within an extracellular polymeric matrix, which accumulates at a surface . It has been estimated that biofilms are associated with 65 percent of nosocomial infections . Play a significant role in a large number of infections in humans. due to the intrinsic resistance of these structures to antimicrobial agents and host defense mechanisms, wound with biofilm cannot be treated effectively with antibiotic.

44. 3 ) M oisture Imbalance Pathology : dessication & excessive fluid- slows epithelial migration and margin maceration Plan : moisture balance dressing, compression , negative pressure dressing. Effect of actions : restored epithelial migration and avoidance of maceration Clinical outcomes : moisture balanced for wound healing

45. Wound assessment sequence for exudative wound mx 1. Assess the patient 2 . Assess the region of the wound 3. Assess the current dressing 4. Assess the exudate 5 . Assess the wound base and edge 6. Assess the periwound skin 7 . Manage exudate and related problems (World Union of Wound Healing Societies 2007)

46. 4 ) Advancement of E pithelial E dge of the wound Pathology : non-migrating keratinocytes, non responsive wound cells, abnormal protease activity and ECM Plan: reassess cause (T.I.M, extrinsic factor) and consider; debridement, skin grafts, biologic agent Effect of actions: migrating keratinocytes and responsive wound cells Clinical outcomes : advancing epithelial edge

47. Surrounding skin?????

48. Peri Wound Skin Classification Grade Type Description Normal skin 1 At risk skin 2 (Exudate Centred) A Dessication B Maceration C Allergy 3 Inflammed 4 Infection 5 Atypical Dr. Harikrishna K.R.Nair 2015

49. Source: International advisory board of wound bed preparation 2003

50. WOUND C O L O U R MODEL

51. Lets start the assessment

52. DOCUMENTATION CONSENT- DEBRIDEMENT GENERAL ASSESSMENT- ADOMNIL LOCAL ASSESSMENT- SIZE, SHAPE, DEPTH, WIDTH TYPES OF WOUND- STAGES…GRADE…. PHOTO CONSENT PROGRESS NOTE NUTRITIONAL STATUS MEDICATION PLAN OF DRESSING AND CHOICE OF DRESSING CENCUS/ RETEN

53. Take home message Accurate holistic assessment of the patient and the wound will provide an understanding of primary treatment objectives resulting in improved patient outcomes and reduced costs. Practitioners involved in wound care need to ensure they have the essential skills required to plan, implement and evaluate care on an individual basis .

54. Be creative!!!

55. People are often unreasonable and self- centered FORGIVE THEM ANYWAY ..if you are kind, people may accuse you of ulterior motives.. BE KIND ANYWAY …if you are honest, people may cheat you.. BE HONEST ANYWAY …if you find happiness, people may be jealous.. BE HAPPY ANYWAY ..the good you do today may be forgotten.. DO GOOD ANYWAY …give the world your best and it may never be enough… GIVE YOUR BEST ANYWAY …for you see, in the end it is between YOU AND GOD …it was never between you and them anyway……. Mother Teresa

56. ‘WOUND HEALING WITH PASSION’ -LEARN -HELP -HEAL

57. Dear ocean, Thank you for making us feel tiny, humble, inspired, and salty……all at once Be kind and have courage Manners maketh man…

58. Thank You Abdul Manan bin Othman Assistant Medical Officer Wound Care Clinician Bsc Hons Nursing Practice Development, Northumbria University, CCWC(Mal). [email protected] + 60132634113

59. Thank you

60. WOUND CLEANSING

61. WOUND DRESSING SOLUTIONS Non Antiseptic Solutions Antiseptic Solutions

62. Wound cleansing is a process of removing inflammatory contaminants from the wound surface These contaminants can impede healing and increase risk of infection

63. The contaminants are : Necrotic tissues Excess exudates Foreign objects Infected tissues

64. NON-ANTISEPTIC SOLUTIONS Commonly used non-antiseptic solutions are: Normal Saline Water for irrigation

65. Normal Saline Preferred cleanser for most types of wounds (physiologic and safe). Less effective in dirty and necrotic wounds . Not advisable in MRSA and Pseudomonas infected wound . (peter et al 2008) Once the container is opened, it should be used within 24 hours. Water for irrigation Less physiologic compared to normal saline but still safe to be used. Can be used in MRSA and Pseudomonas infected wounds.

66. ANTISEPTIC SOLUTIONS Antiseptic solutions are used to clean the wound which are dirty and infected. Commonly used antiseptic solutions are : Chlorhexidine gluconate 1:200 in Aqueous solution Super-oxidized solution Polyhexamethylene biguanide (PHMB) solution

67. Chlorhexidine gluconate 1:200 in Aqueous solution Effective against Gram positive bacteria, fungi and also enveloped viruses. Less effective against Gram negative bacteria. Has both bactericidal and bacterostatic action. Readily available in healthcare setting.

68. Super-oxidized solution Good bactericidal, virucidal , fungicidal and spongicidal . Also blocks the inflammatory process. May help in biofilm removal . Two components in this solution are oxidized water and chlorine . The oxidized water is broken down into oxygen, ozone and other oxidized species. Costly.

69. Polyhexamethylene biguanide (PHMB) solution Helps to soften and remove the slough . It can remove and reduce the biofilm formation . Less painful. Costly.

70. These solutions besides painful on application also cause harm to the normal tissues if used as dressing solutions (cytotoxic), however a short term use may be permissible   Povidone iodine Hydrogen peroxide Sodium hypochlorite Acetic acid Eusol

71. TYPES OF WOUND DRESSING MATERIALS

72. Modern Dressings

73. FILM

74. HYDROGEL

75. HYDROCOLLOID

76. CALCIUM ALGINATE

77. FOAM

78. HYDROFIBER

79. SILVER

80. ROLE OF DRESSING

81. Role of dressing To achieve a wound bed that is sufficiently moist for healing, but that does not cause problems such as maceration, whilst treating underlying contributory factors, enhancing patient quality of life , encouraging healing , adressing exudate- related problems and optimising healthcare resource use . World Union of Wound Healing Societies 2007

82. Regular comprehensive assessment and documentation Documented improvement of the wound and progress LEAD TO

83. Healthy or improving periwound skin Healthy wound bed with no sign of infection Reduced dressing change requirements Lack of reduction in wound odour Reduction in or lack of wound pain

84. SIGNS of lack of progress The patients quality of life is not improving The periwound skin remains unhealthy The wound bed shows signs of increasing bacterial load There is soiling outside the dressing The patient has made adjustments to accommodate the exudate Dressing changes are very frequent Wound odour is uncontrollled Wound pain is continuing

85. I.A.D MARSI

86. Take home message Accurate holistic assessment of the patient and the wound will provide an understanding of primary treatment objectives resulting in improved patient outcomes and reduced costs. Practitioners involved in wound care need to ensure they have the essential skills required to plan, implement and evaluate care on an individual basis .

87. Be creative!!!

88. People are often unreasonable and self- centered FORGIVE THEM ANYWAY ..if you are kind, people may accuse you of ulterior motives.. BE KIND ANYWAY …if you are honest, people may cheat you.. BE HONEST ANYWAY …if you find happiness, people may be jealous.. BE HAPPY ANYWAY ..the good you do today may be forgotten.. DO GOOD ANYWAY …give the world your best and it may never be enough… GIVE YOUR BEST ANYWAY …for you see, in the end it is between YOU AND GOD …it was never between you and them anyway……. Mother Teresa

89. ‘WOUND HEALING WITH PASSION’ -LEARN -HELP -HEAL

90. Dear ocean, Thank you for making us feel tiny, humble, inspired, and salty……all at once Be kind and have courage Manners maketh man…

91. Thank You PPP Abdul Manan bin Othman Assistant Medical Officer Wound Care Clinician Bsc Hons Nursing Practice Development, Northumbria University, CCWC(Mal). [email protected] + 60132634113