Wound assessment is a component of wound management. As far as may be practical, the assessment is to be accomplished before prescribing any treatment plan. The objective is to collect information about the patient and about the

wound A wound is any disruption of or damage to living tissue, such as skin, mucous membranes, or organs. Wounds can either be the sudden result of direct trauma (mechanical, thermal, chemical), or can develop slowly over time due to underlying diseas ...

, that may be relevant to planning and implementing the treatment. __TOC__

Wound assessment principles

Wound assessment includes observation of the wound, surveying the patient, as well as identifying relevant clinical data from physical examination and patient's health history. Clinical data recorded during an initial assessment serves as a baseline for prescribing the appropriate treatment.

TIME framework and Triangle of Wound Assessment (TWA)

To assist clinicians in standardizing the wound assessment and preparation of wound bed for treatment, the TIME framework was developed in 2002 by a group of wound care experts. The TIME acronym stands for Tissue, Infection/Inflammation, Moisture, and Edge – components that, per the TIME recommendation, should be thoroughly assessed to optimize the treatment. Depending on the clinical findings for each component, TIME recommends certain clinical actions aimed at correcting the issues and facilitating

healing With physical trauma or disease suffered by an organism, healing involves the repairing of damaged tissue(s), organs and the biological system as a whole and resumption of (normal) functioning. Medicine includes the process by which the cells ...

. A recent global anthropological study has prompted clinicians to review the TIME framework and resulted in a 2016 development of a comprehensive tool for wound assessment – the Triangle of Wound Assessment (TWA). Based on the study's findings, TWA identifies three zones (wound bed, wound edge, and

periwound The periwound (also peri-wound) is tissue surrounding a wound. Periwound area is traditionally limited to 4 cm outside the wound's edge but can extend beyond this limit if outward damage to the skin is present. Periwound assessment is an import ...

skin) that must be included in wound assessment to arrive at clinical decisions that will help heal the wound in the most efficient way. TIME framework components are integrated into the assessment of each zone. The introduction of periwound skin as a component of wound assessment identifies a significant departure from traditional methods; it emphasizes the importance of addressing periwound skin during treatment in the same measure as wound bed and wound edge. Wound assessment is a holistic process that considers the patient's current state of health, the factors that may impede wound healing, and the cause, duration and state of the wound. As such, this process is applicable to any wound.

Wound assessment components

Health history

A patient's health history may include disorders that affect the body's ability to heal itself. These disorders are called

comorbidities In medicine, comorbidity refers to the simultaneous presence of two or more medical conditions in a patient; often co-occurring (that is, concomitant or concurrent) with a primary condition. It originates from the Latin term (meaning "sickness" ...

and may interfere with circulatory and metabolic body functions, levels of various physiological assessment components (sugar, albumin, etc.), and induce other factors that negatively affect the healing. Common co-morbidities are:

diabetes Diabetes mellitus, commonly known as diabetes, is a group of common endocrine diseases characterized by sustained high blood sugar levels. Diabetes is due to either the pancreas not producing enough of the hormone insulin, or the cells of th ...

, venous insufficiency or

peripheral arterial disease Peripheral artery disease (PAD) is a vascular disorder that causes abnormal narrowing of arteries other than those that supply the heart or brain. PAD can happen in any blood vessel, but it is more common in the legs than the arms. When narr ...

respiratory The respiratory system (also respiratory apparatus, ventilatory system) is a biological system consisting of specific organs and structures used for gas exchange in animals and plants. The anatomy and physiology that make this happen varies gr ...

and

cardiovascular disorders Cardiovascular disease (CVD) is any disease involving the heart or blood vessels. CVDs constitute a class of diseases that includes: coronary artery diseases (e.g. angina, heart attack), heart failure, hypertensive heart disease, rheumatic h ...

malignancies Malignancy () is the tendency of a medical condition to become progressively worse; the term is most familiar as a characterization of cancer. A ''malignant'' tumor contrasts with a non-cancerous ''benign'' tumor in that a malignancy is not ...

and

autoimmune disorders An autoimmune disease is a condition that results from an anomalous response of the adaptive immune system, wherein it mistakenly targets and attacks healthy, functioning parts of the body as if they were foreign organisms. It is estimated tha ...

Impeding factors

Among other factors that may impede the healing of a wound are: * patient's age *

obesity Obesity is a medical condition, considered by multiple organizations to be a disease, in which excess Adipose tissue, body fat has accumulated to such an extent that it can potentially have negative effects on health. People are classifi ...

* presence of

infection An infection is the invasion of tissue (biology), tissues by pathogens, their multiplication, and the reaction of host (biology), host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmis ...

* poor

nutrition Nutrition is the biochemistry, biochemical and physiology, physiological process by which an organism uses food and water to support its life. The intake of these substances provides organisms with nutrients (divided into Macronutrient, macro- ...

or hydration * prescribed medication *

substance abuse Substance misuse, also known as drug misuse or, in older vernacular, substance abuse, is the use of a drug in amounts or by methods that are harmful to the individual or others. It is a form of substance-related disorder, differing definition ...

and

smoking Smoking is a practice in which a substance is combusted, and the resulting smoke is typically inhaled to be tasted and absorbed into the bloodstream of a person. Most commonly, the substance used is the dried leaves of the tobacco plant, whi ...

* general effect of the wound on a patient's lifestyle (pain, wound odor, excessive drainage)

Wound

Wound cause

If the wound is chronic, is it the result of: an underlying illness (diabetic, venous and arterial ulcers), poor handling of the patient ( pressure injuries, deep tissue injuries, wounds with cavities and undermining), poor previous treatment choices that slowed down the healing (untreated infection, inappropriate wound care product choice, lack of necessary procedures). If the wound is acute, is it the result of:

traumatic injury Injury is physiological damage to the living tissue of any organism, whether in humans, in other animals, or in plants. Injuries can be caused in many ways, including mechanically with penetration by sharp objects such as teeth or with b ...

burn A burn is an injury to skin, or other tissues, caused by heat, electricity, chemicals, friction, or ionizing radiation (such as sunburn, caused by ultraviolet radiation). Most burns are due to heat from hot fluids (called scalding), soli ...

, or

surgery Surgery is a medical specialty that uses manual and instrumental techniques to diagnose or treat pathological conditions (e.g., trauma, disease, injury, malignancy), to alter bodily functions (e.g., malabsorption created by bariatric surgery s ...

Wound duration

For chronic wounds: time the current wound has been present, is it a recurring wound, how many times it has recurred in the past, how long it took to heal each time. For acute wounds: when the wound was first acquired before the clinician visit.

Wound state

Wound bed, wound edge and periwound skin should be examined before the initial treatment plan is devised. It should also be re-assessed at each visit or each dressing change. For wound bed, the following parameters are assessed: * Tissue type; presence and percentage of non-viable tissue covering the wound bed * Level of

exudate An exudate is a fluid released by an organism through pores or a wound, a process known as exuding or exudation. ''Exudate'' is derived from ''exude'' 'to ooze' from Latin language, Latin 'to (ooze out) sweat' (' 'out' and ' 'to sweat'). Medi ...

* Presence of infection Wound edge must be examined to detect: * Maceration * Desiccation * Undermining * Elevation above surrounding tissue (raised edge) * Epibole (rolled edge) For periwound skin, the following conditions should be diagnosed or ruled out: * Maceration * Dry, scaly skin * Desiccation * Excoriation and skin stripping * Hypergranulation and hyperkeratosis *

Eczema Dermatitis is a term used for different types of skin inflammation, typically characterized by itchiness, redness and a rash. In cases of short duration, there may be small blisters, while in long-term cases the skin may become thickened ...

* Callus build-up and epibole * Infection and inflammation

References

{{reflist Healing Skin physiology