Step 5- Evaluate the wound

Working in from the periwound to the wound edge we now begin the assessment of the actual wound! And the crowd goes wild!

The wound edge says a lot. It can give helpful diagnostic clues, as in the case of pyoderma gangrenoum, as well as provide a clue as to chronicity and the effects of pressure. Some typical wound edge characteristic and their associated causes are listed below

• Irregular flat borders- venous leg ulcers or malignancy
• Well circumscribed/ punched out borders- arterial or inflammatory ulcers
• Purple elevated edges- pyoderma gangrenosum
• Callus- pressure effect/neuropathic
• Epibole- chronic ulcer edges
• Maceration- overly moist wound bed
• Undermining- pressure effect

When evaluating the wound itself, measurements are the typically your indicator of improvement or failure of treatment. The basics are to measure length, width and depth. While there are lots of fancy ways to measure a wound most wound care centers, hospitals and physicians offices do it the old-fashioned way using a ruler. The key to good measurements is to consistently measure from the same place and use the wound covention of measuring length in relation to the patient’s head (12 o’clock), and width from 6-9 o’clock. Depth is usually measured from the deepest portion of the wound bed.

The wound bed is a dynamic environment and the bed of a wound reflects that as it changes for the better or worse throughout the course of treatment. Important things to document is the presence of any deep structures including but not limited to bone, ligament, tendon, joint capsule, muscle or blood vessels. This gives a both diagnostic and treatment related information, so inspect the bed carefully and note these items.

Granulation tissue is also important to note. Granulation tissue is the good guy in this story and it’s an indicator of a wound bed that is healthy. Be familiar with the appearance of granulation tissue and recognize it as a good sign of progress. That being said look out for it’s disruptive relative hypergranulation tissue. This is an exuberant growth of tissue which can interfere with the orderly healing of a wound and needs to be controlled.

Other things to note are :

• Fibrin
• Slough
• Exudate (amount,quality and color)
• Odor
• Eschar
• Necrosis
• Infection
• Biofilm
• Tunneling and/or sinuses

With a detailed description of the patient history, wound location, periwound features and wound bed charactristics we can begin to formulate a more detailed differential diagnosis.