Wound assessment and reporting

References

1. Fogh et al. Wound Repair and Regeneration 2012;20: 815-821

2. Gottrup et al. Wound  Repair and Regeneration 2008;6:615-25

3. Palao I Domenech et al. Journal of Wound Care 2008;17(8):342-48

The three most common types of leg ulcers are:

• Venous leg ulcers (70%)
• Arterial leg ulcers (10%)
• Mixed venous and arterial leg ulcers (10–15%)

Venous leg ulcers

Venous leg ulcers are caused either by dysfunction of the venous valves or an inadequate calf muscle pump. In both cases, blood isn’t sufficiently returned to the heart. This leads to higher venous pressure, which can cause edema. And an increased fluid level between cells can result in cell death, leading to ulcers. This is why compression therapy is an essential part of treating venous leg ulcers.

Venous leg ulcers are often located in the gaiter area of the leg and characterized by:

• Irregular shape
• Brown pigmentation in the peri-ulcer skin area (often with eczema)
• Normal foot pulse

Venous leg ulcers are often painful, especially during daytime. Elevation of the leg can relieve some of the pain.

References

1. Lavery et al. Diabetes Care 2006;29(6):1288–93 2

Up to 15% of diabetics are likely to develop a foot ulcer at some stage in their lives. Diabetic ulcers have a considerable negative impact on patients’ lives, and are highly susceptible to infection that all too often leads to amputation. This makes infection control of paramount importance in diabetic foot ulcer management.

Successfully managing a diabetic foot ulcer requires a comprehensive understanding of the wound: its cause, progression, risk, and treatment.

The main causes of diabetic foot ulcers are:

• Neuropathy
• Poor blood supply (ischemia)

Neuropathy

Neuropathy is the most common diabetic foot condition and is caused by damaged nerves in the lower extremity. The condition is permanent and can lead to loss of sensation, which increases the risk of accidental injuries, and painful feet. Treatment involves attention to feet, self-care and custom-made footwear.

Poor blood supply (ischemia)

A very serious condition, ischemia, is the main reason for amputations. Ischemia is caused by impaired circulation, which can be due to arteriosclerosis or occlusion of tissue. Impaired circulation causes reduced pulse – the foot is cold and blue – and this leads to tissue death and the eventual development of an ulcer. Your patient may need vascular surgery.

Infection

References

1. Brem and Lyder. The American Journal of Surgery 2004;188:9S–17S

2.  NPUAP-EPUAP Pressure Ulcer Prevention, Quick Reference Guide, 2010 (pdf)

3.  NPUAP-EPUAP Pressure Ulcer Treatment, Quick reference guide, 2009 (pdf)

4. Gottrup et al. Wound  Repair and Regeneration 2008;6:615-25

5. Palao I Domenech et al. Journal of Wound Care 2008;17(8):342-48

6. Fogh et al. Wound Repair and Regeneration 2012;20: 815-821

A pressure ulcer (decubitus ulcer) is a localized injury to the skin and/or underlying tissue, usually over a bony prominence. This type of ulcer is the result of pressure, or pressure in combination with shear (2). The pressure prevents the blood from circulating properly, and causes cell death, tissue necrosis and the development of ulcers. Wheelchair users or people confined to a bed (for example, after surgery or an injury) are especially at risk.

Major cause of morbidity

Pressure ulcers are a major cause of morbidity and mortality, especially for people with impaired sensation, prolonged immobility, or advanced age. The most common places for pressure ulcers are over a bony prominence, such as elbows, heels, hips, ankles, shoulders, the back, and the back of the head.

Classification

Pressure ulcers are classified according to the degree of tissue damage observed. In 2009 the EPUAP-NPUAP advisory panel agreed upon four levels of injury (3):

Category/Stage I: Non-blanchable redness of intact skin

Buttocks, Stage I, NPUAP copyright & used with permission.

Intact skin with nonblanchable erythema of a localized area, usually over a bony prominence. Discoloration of the skin, warmth, edema, hardness or pain may also be present. Darkly pigmented skin may not have visible blanching.

Category/Stage II: Partial thickness skin loss or blister

Buttocks, Stage II, NPUAP copyright & used with permission.
Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguinous filled blister.

Category/Stage III: Full thickness skin loss (fat visible)

Ischium, Stage III, NPUAP copyright & used with permission.

Full thickness tissue loss. Subcutaneous fat may be visible, but no bone, tendon or muscle is exposed. Some slough may be present. May include undermining and tunneling.

Category/Stage IV: Full thickness tissue loss (muscle/bone visible)

Sacral Coccyx, Stage IV, NPUAP copyright & used with permission.

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often include undermining and tunneling.

Category/Stage: Unstageable

References

1. Enoch and Price 2004. (Pathophysiology Of Healing)
2.Winter. Nature 1962;193:293
3. Winter. Journal of Tissue Viability 2006;16(2):20-23

An acute wound is an injury that causes a break in the skin and sometimes the tissue. Acute wounds are classified into two principal types:

• Acute traumatic wounds, such as abrasions, lacerations, penetrations or bites, and burns
• Acute surgical wounds resulting from surgical incisions