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The Triangle of Wound Assessment a Simple and Holistic Framework for Wound Management

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The Triangle of Wound Assessment a Simple and Holistic Framework for Wound Management The Triangle of Wound Assessment A simple and holistic framework for wound management Wound bed WOUND Wound edge Periwound skin We asked healthcare professionals around the world about their priorities ? for wound care We found that most people Respondents said that treating wounds are not protecting the periwound specialists in a hospital1 skin is very important1 Approximately Up to 79% of wounds are 70% of being treated in wounds are the community2 surrounded by unhealthy skin3 2 ...none However, in a recent met all of the study of 14 wound criteria for assessment tools ... optimal wound assessment4 The Triangle of Wound Assessment is a holistic framework that allows practitioners üto assess and manage all areas of the wound, including the periwound skin. It is a simple and systematic approach that guides the user Wound bed from complete wound WOUND assessment to setting management goals, and Wound edge Periwound skin selecting the optimal treatment. 3 The Triangle of Wound Assessment offers a systematic approach to wound management Optimal wound management starts with a holistic wound assessment. This will help to more efficiently set management goals, which will increase the potential for better treatment outcomes. Assessment Management Goals Treatment 4 This is achieved through a holistic framework The Triangle of Wound Assessment provides a framework to assess all three areas of the wound while remembering the patient behind the wound within their social context. Patient Wound bed Social context WOUND Wound Wound edge Periwound skin 5 It’s not just about the wound but also the patient behind the wound Optimal management of the wound starts with assessing the patient behind the wound, and the social context in which the patient lives. Patient & Social context Information • Age • Gender • Nutrition & Mobility • Smoking & Alcohol • Work & living arrangements Medical history • Co-morbidities • Medications Wound description • Type/diagnosis • Location & Duration • Size • Pain 6 “My wound is preventing me from living a normal life. I just want to have my life back” 7 Wound bed assessment The wound bed needs to be monitored closely due to its unpredictability. Problems often arising in this area can have an impact on both the wound edge and the periwound skin.6,7,8 Wound bed Assessment • Tissue type • Exudate • Infection Wound bed WOUND Wound edge Assessment Periwound skin Assessment Wound edge Periwound skin 8 Wound bed Assessment • issue type Wound bed Assessment • udate Wound Assessment Tissue type • issue type • Infection • udate NecrNecroticotic % % GranulatingGranulating % % • Infection SloughySloughy % % EpithelialisingEpithelialising % % Wound bed Wound bed Exudate Level Dry Low Medium High WOUND Level Dry Low Medium High Type Thin/watery Cloudy Thick WOUNDWound Assessment Wound Assessment Purulent Clear Pink/red Wound edge Periwound skin TypeInfection Thin/watery Cloudy Thick Local Spreading/systemic Increased painPurulent IncreasedClear erythema Pink/red Wound edge Assessment Periwound skin Assessment Erythema Pyrexia Oedema Abscess/pus Wound edge Periwound skin Local warmth Wound breakdown Local Increased exudate Cellulitis Spreading/systemic Delayed healing General malaise IncrFriableeased granulation pain tissue Raised WBC count Increased erythema ErythemaMalodour Lymphangitis Pyrexia Pocketing Oedema Abscess/pus Local warmth Wound breakdown9 Increased exudate Cellulitis Delayed healing General malaise Friable granulation tissue Raised WBC count Malodour Lymphangitis Pocketing Wound edge assessment Wound edge assessment provides valuable information of wound progression. Advancement of the epithelial edge is a reliable predicitive indicator of wound healing.6,7,8 Wound bed Assessment Wound bed WOUND Wound edge Assessment Periwound skin Assessment • Maceration Wound edge Periwound skin • Dehydration • Undermining • Thickened/rolled edges 10 Wound edgeedge AssessmentWound Assessment Wound bed Assessment Maceration Maceration Dehydration Wound edge Wound Assessment Wound bed AssessmentDehydration Wound bed Maceration UnderminingDehydration Wound bed Mark position Undermining Undermining Extent: ____ cm WOUND WOUND Rolled edgesRolled edges Wound edge Assessment WoundPeriwound Assessment skin Assessment • Maceration Wound edge Periwound skin Wound edge Assessment • DehydWoundPrationeriwound Assessment skin Assessment Rolled edges Wound edge Periwound skin • Undermining • Maceration • Thickened/rolled edges • Dehydration 11 • Undermining • Thickened/rolled edges Periwound skin assessment When damaged, the periwound skin (defined as skin within 4cm of the wound edge, or any skin under the dressing) can lead to delayed healing times as well as pain and discomfort for the patient.6,7,8 Wound bed Assessment Wound bed WOUND Wound edge Assessment Periwound skin Assessment Wound edge Periwound skin • Maceration • Excoriation • Dry skin • Hyperkeratosis • Callus • Eczema 12 PeriwoundPeriwound skinskin AssessmentWound Assessment Wound Assessment bed Assessment Maceration CM Maceration CM Excoriation CM Excoriation CM Wound bed Dry skin CM DryHyperk skineratosis CM CM Wound edge Assessment WOUND Periwound skin Assessment Callus CM • Maceration Hyperkeratosis CM • Excoriation Eczerma CM Wound edge Periwound skin • Dry skin • Hyperkeratosis Callus 13CM • Callus • Eczema Eczerma CM From wound assessment to management goals When setting management goals, it is important to consider assessment of all three areas, as well as the patient’s expectations. Wound bed Assessment Management goals • Remove non-viable tissue Wound bed • Manage exudate • Manage bacterial burden • Rehydrate wound bed WOUND • Protect granulation/epithelial tissue Wound edge Periwound skin Wound edge Assessment Periwound skin Assessment Management goals Management goals • Manage exudate • Manage exudate • Rehydrate wound edge • Protect skin • Remove non-viable tissue • Rehydrate skin • Protect granulation/epithelial tissue • Remove non-viable tissue 14 Wound bed Assessment • issue type Wound bed • udate Assessment Management goals Treatment examples • Infection TissueNecrotic type% Granulating % Sloughy % Epithelialising % • Necrotic Remove non-viable tissue Debridement Wound bed • Sloughy • Granulating Level Dry Low MediumProtectHigh granulation/ • Epithelialising Hydrocolloid WOUND epithelial tissue ExudateType Thin/watery Cloudy Thick Purulent Clear RehydratePink/red wound bed Hydrogel Wound edge Assessment Periwound skin Assessment • Dry Wound edge Periwound skin • Low Appropriate dressing for Local• Medium Spreading/systemic Increased pain ManageIncreased erythema exudate exudate level (e.g. hydrocolloid • High Erythema Pyrexia for low, foam for high) Oedema Abscess/pus Infection Local warmth ManageWound brea kdbacterialown burden Antimicrobial •Incr Signeased eofxudat infectione Cellulitis Delayed healing General malaise Friable granulation tissue Raised WBC count MalodourWoundWound edge Wound edge AssessmentLymphangitis AssessmentPocketing Management goals Treatment examples Wound bed Assessment Maceration Appropriate dressing for • Maceration Manage exudate exudate level (e.g. hydrocolloid Dehydration for low, foam for high) Wound bed • Dehydration Rehydrate wound edge Barrier cream Undermining Remove non-viable tissue • Undermining + Protect granulation/ Debridement + Hydrocolloid WOUND • Rolled edges Rolled edges epihelial tissue WoundPeriwound Assessment skin Assessment Wound edge Assessment PeriwoundPeriwound skin Wound skin Assessment • Maceration Wound edge Periwound skin • Dehydration Wound Assessment bed Assessment Assessment Management goals Treatment examples Maceration CM • Undermining Appropriate dressing for • Thickened/rolled edges • Maceration Manage exudate exudate level (e.g. hydrocolloid Excoriation CM for low, foam for high) Wound bed • Dry skin Rehydrate skin Barrier cream • Excoriation Dry skin Protect skin CM Barrier film • Eczema Wound edge Assessment WOUND Periwound skin Assessment • Hyperkeratosis Remove non-viable tissue Debridement • Maceration • Callus Hyperkeratosis CM • Excoriation 15 Wound edge Periwound skin • Dry skin • Hyperkeratosis Callus CM • Callus • Eczema Eczerma CM Choosing the optimal treatment An accurate wound assessment and setting of management goals allows for optimal treatment to be chosen at each assessment and reassessment of the wound.6,7,8 Wound Assessment Management Goals Treatment • Include primary and secondary dressings, and any skin care products if relevant • Always consider the underlying cause of the wound and include any further treatment needed (e.g. compression therapy) • Consider if referral to a specialist is needed 16 “The Triangle of Wound Assessment addresses all aspects of the holistic approach to wound management- assessment, diagnosis, treatment plan, documentation and communication. It is provided in a very clear, concise and practical way that helps the practitioner manage the patient and the wound” Simon, Tissue Viability Nurse 17 The Triangle of Wound Assessment used in clinical practice Patient 68 year old gentleman with a nonhealing venous leg ulcer treated with compression therapy. The patient had poor nutrition and supplements were prescribed. He had reduced mobility, requiring a walking stick to mobilise. Wound Assessment Wound Assessment • issueissue typ typee 70% slough, • udate 30% necrotic • Inudatfectione Medium • Infection No Signs Wound bed WOUND Wound Assessment Wound Assessment • Maceration ✓ • Maceration ✓ • ehydration Wound edge Periwound skin • coriation • ndermining
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