Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 12  |  Issue : 2  |  Page : 50-55

Wound bed assessment in patients at a tertiary hospital in Nigeria—A preliminary report


Department of Plastic Reconstructive and Aesthetic Surgery, University College Hospital, Ibadan, Nigeria

Date of Web Publication17-Mar-2017

Correspondence Address:
Ayodele O Iyun
Department of Plastic Reconstructive and Aesthetic Surgery, University College Hospital, Ibadan
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0794-9316.202438

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  Abstract 

Introduction: Wound assessment is fundamental for the management of wounds. It is the foundation in the care plan and helps in determining the effectiveness of interventions. Wound assessment also assists in making appropriate decisions regarding the type of wound dressing to be applied. Detailed wound assessment takes into account all aspects of the patient’s well-being and not just the wounds the patient has.
Objectives: The study assessed chronic wounds in the patients at a tertiary Nigerian hospital (University College Hospital, Ibadan) and utilized the information for preparing a standardized wound assessment format for health facilities in the subregion.
Materials and Methods: The study was conducted at the University College Hospital, Ibadan, South West Nigeria. Patients with chronic wounds from various causes were treated prospectively in the hospital for over a month and had detailed assessment of their wounds performed. The data obtained were entered into a predesigned form, and this was subsequently analyzed using Statistical Package for the Social Sciences version 21 software.
Results: Seventy-eight wounds were reviewed during the study period. The area of the wounds ranged from 1 to 1248 cm2 (median 24 cm2). The type of granulation tissue related to the wound type was not statistically significant. Assessment of the exudates of the wounds revealed that 44.9% of the wounds had seropurulent or purulent discharge, whereas 19.2% had serous discharge.
Conclusion: Wound care management can be improved with appropriate wound assessments, which form the foundation in the care plan. Wound assessment will enhance objective measurement of the status of the wound and helps in choosing appropriate wound care dressing to promote wound healing.

Keywords: Wound assessment, wound care management, wound healing


How to cite this article:
Iyun AO, Ademola S, Michael A, Olawoye O, Oluwatosin O. Wound bed assessment in patients at a tertiary hospital in Nigeria—A preliminary report. Nigerian J Plast Surg 2016;12:50-5

How to cite this URL:
Iyun AO, Ademola S, Michael A, Olawoye O, Oluwatosin O. Wound bed assessment in patients at a tertiary hospital in Nigeria—A preliminary report. Nigerian J Plast Surg [serial online] 2016 [cited 2017 Aug 17];12:50-5. Available from: http://www.njps.org/text.asp?2016/12/2/50/202438


  Introduction Top


Wound assessment is a cumulative process involving observation, data collection, and evaluation of the wound. It is an important component of patient care, as it includes a record of initial assessment, ongoing changes, and treatment interventions.[1] Wounds are virtually ubiquitous in clinical practice; wound assessments are the foundation in the care plan and are the only means of determining the effectiveness of interventions.[2] Wound bed assessment in many health facilities tends to be subjective rather than objective, with the clinician stating that the wounds are improving, static, or worsening. Such a response occasionally leads to frustrations in the patients when inquiring regarding the status of the wound to a clinician doing clinical ward rounds and is evaluating the wound for the first time or on review. Many a times, wound dressings will have to be removed prematurely to have a better picture of the status of the wound. It is, therefore, pertinent to have standardized wound assessment documentation to assist in appropriate wound care. Though this is desirable for all wounds, it is even more important for chronic wounds or difficult-to-heal wounds. The status of wounds is dynamic, and the changes that occur in a wound will dictate the choice of dressings and its management.

Methods of wound assessment include the following: physical observation techniques, tape rule or ruler for measuring area and depth, tracing method, and photographic method.

The aim of the study was to assess the chronic wounds in patients at a tertiary hospital (University College Hospital, Ibadan, Nigeria) over a 1-month period, and thereby provide a platform for preparing a standardized wound care assessment format.


  Materials and methods Top


The study was conducted at the University College Hospital, Ibadan, South West Nigeria, which is an 800-bedded tertiary hospital. A detailed wound bed assessment was performed in patients with chronic wounds, who were treated for over a month in November 2012. Patients who were admitted to the University College Hospital, Ibadan or who attended the surgical outpatient clinic with chronic wounds were included in the study. Chronic wounds were defined as wounds lasting for a duration of at least 6 weeks during the period of review. The assessment included the duration of the wound, size, and wound bed assessments such as granulation tissue, exudate, and presence of wound infection. The wound was measured using a paper ruler, which was calibrated in centimeters; this entailed measuring the length, which was the longest area of tissue breakdown, and the width, which was the longest measurement perpendicular to the length.[2] The percentage of the surface area of the wound covered by granulation tissue versus slough or necrotic tissue was estimated. Granulation tissue was said to be healthy when it was bright, beefy red, shiny, and granular with a velvety appearance. Unhealthy granulation tissue appeared as pale pink or blanched to dull, dusky red color. Necrotic tissue was the black dead tissue on the wound, whereas sloughs were the thin or thick mucinous tissue seen on the wound. The exudate type that was predominant in the wound according to color and consistency was then determined. The exudate that was thin and bright red was bloody, serosanguineous, and watery pale red to pink. The exudate was said to be serous when thin and watery clear, purulent when thin or thick, opaque when tan to yellow, and foul purulent when thick and opaque yellow to green with offensive odor. The odor was assessed as follows: no odor, when there was no odor evident even at the patient’s bedside with the dressings removed; faint, when the odor was evident at close proximity when the dressing was removed; moderate, when the odor was evident on entering the room with the dressing removed; and strong, when the odor was evident on entering the room with the dressing intact.[3]

The information obtained was then entered into the Statistical Package for the Social Sciences version 21 software (SPSS Inc., Chicago, IL, USA). Descriptive analysis was subsequently done.


  Results Top


Seventy-eight wounds were reviewed during the study period. The duration of the wounds ranged from 6 to 780 weeks; the median duration of the wounds was 10 weeks. The area of the wounds ranged from 1 to 1248 cm2. The mean surface area was 86.3 cm2 (median 24 cm2). On wound bed assessment, it was found that the floor of most wounds (47.4%) had unhealthy granulation tissue. This was seen more in the wounds of patients with diabetic and postinfective ulcers. The absence of granulation tissue was also noted particularly in wounds of patients with pressure, diabetic and post-traumatic ulcers [Table 1]. This was, however, not statistically significant on relating the type of granulation tissue to the wound type (x2 = 25.54, P = 0.111). The granulation tissue covered more than 75% of the wound surface in 10 (41.7%) of the pressure ulcer wounds, 5 (62.5%) of the traumatic wounds, 6 (100%) of the chronic postburn wounds, 11 (44%) of the acute burn wounds, 6 (54.5%) of the postinfective ulcer wounds, and 1 malignant wound (50%) [Table 2]. There was a significant difference when the wound type was compared with the surface area covered by granulation tissue (x2 = 44.29, P = 0.007). Majority of the wounds, 30 (38.5%) in number, had no slough [Table 3]. Diabetic ulcer wounds (7; 26.9%), traumatic ulcer wounds (1; 12.5%), and infective ulcer wounds (1; 9.1%) had more than 75% of their surface covered with slough. There was a statistical difference in the wound type and the surface area covered by slough (x2 = 38.08, P = 0.03). Pressure ulcer wounds (10; 41.7%) and diabetic ulcer wounds (3; 11.5%) had more than 75% of their surfaces covered with necrotic tissue. There was also statistical difference in the type of wound and the surface area covered by necrotic tissue (x2 = 29.31, P = 0.045) as shown in [Table 4].
Table 1: Description of the surface area of chronic wounds (type of granulation tissue)

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Table 2: Description of the surface area of chronic wounds (percentage of the surface area covered by granulation tissue)

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Table 3: Description of the surface area of chronic wounds (surface area slough)

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Table 4: Description of the surface area of chronic wounds (surface area necrotic tissue)

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The assessment of the exudates of the wounds revealed that 44.9% of the wounds had seropurulent or purulent discharge, whereas 19.2% had serous discharge. Seropurulent discharge was the most frequent discharge in the wounds caused by diabetic ulcers (53.8%) [Table 5]. There was a significant association between the wound type and the exudate type (x2 = 61.34, P = 0.001). The quantity of exudates was scanty in 44% of the wounds, moderate in 26.7% of the wounds, and large in 6.7% of the wounds. There was profuse discharge in wounds caused by pressure ulcers (4; 16.7%) and infective ulcers (1; 12.5%) [Table 6]. The odor of the discharge was faint in 16.7% of the wounds, moderate odor was perceived in the room in 14.1% of the wounds, and there was a strong odor in the room in 7.7% of the wounds. The odor was strong for wounds caused by diabetic ulcer (2; 7.7%), infected ulcer (3; 27.3%), and malignant ulcer (1; 50%) [Table 7].
Table 5: Assessment of the exudates from chronic wounds (discharge quality)

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Table 6: Assessment of the exudates from chronic wounds (discharge quantity)

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Table 7: Assessment of the exudates from chronic wounds (odor)

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  Discussion Top


Wound assessments are the foundation of the care plan and are the only means of determining the effectiveness of interventions.[2] Clinical studies have shown that a reduction in the ulcer area (approximately 20–40%) after 2–4 weeks of treatment is a predictor of healing for pressure ulcers, venous leg ulcers, and foot ulcers in patients with diabetes mellitus.[4],[5]

A reevaluation of the patient, the wound, and the care plan should be done if there was no reduction in the size of the wounds after 2–4 weeks of treatment.

The most commonly used techniques for measuring the wound area/size in the clinical setting include tape measurements or tracing.[2] The tape measure or ruler, which was used in this study, entails measuring the length, which is the longest area of tissue breakdown, and the width, which is the longest measurement perpendicular to the length, using a disposable measuring guide/ruler calibrated in centimeters.[2] The length and width, method of measurement, and patient position at time of assessment are documented. The advantage of this method is that it is easy, inexpensive, fast, and has good interrater and intrarater reliability. It also provides a clinically reliable record of changes in the wound size over time. The limitation of the use of this technique is the difficulty in determining the wound edge, as the length multiplied by the width does not provide the actual wound size. The reliability of the technique also decreases with increasing wound size.[2] Measurement using the length and breadth also tends to overestimate rather than underestimate the size of the wound. Rectangular areas overestimate the true area by 44%, whereas for elliptical areas, it estimates the true area by 13%. Langemo et al.[6] in a comparative study using plaster of Paris, L-shaped, pear-shaped, and fairly symmetrical wound models demonstrated an overestimation of the true area using the length and breadth measurements, which was as high as 73.9% for the pear-shaped wound.[6] The use of centimeter-square grid is advocated as a more accurate method for determining the true area.

The choice of the use of the disposable paper ruler for the clinical measurement is to have a method of measurement that is very simple, easy, fast, and reliable.

It is worthy of note that there are limitations to the development and implementation of a wound measurement protocol. First, though an index area of the wound is achieved when measuring the two-dimensional wound, which is valuable in monitoring the progress of the wound, multiplying the length and the width is only accurate if the wounds have a regular geometric shape.[7] Second, though there is excellent correlation between planimetric wound area, wound width, length, width × length, perimeter, and area based on the formula for an ellipse for smaller wounds (<40 cm), 48 (61.5%) out of the 78 wounds reviewed had an area greater than 40 cm2. The accuracy of the length × width measurements and acetate tracings varies depending on the size of the wound.[8],[9]

The third aspect to consider is that all research related to the validity and reliability of the ruler measurements were performed by measuring the longest measurements of the wound (=length) followed by the longest measurement perpendicular to the length (=width). This measurement method is much more reliable and valid than other methods including the “clock” method (head-to-toe = length and side-to-side = width).[10]

The appearance of the wound bed needs to be assessed and documented following the measurement of the size of the wound. Many wounds contain a combination of granulation and necrotic tissue or fibrin slough. The wound beds were assessed by estimating a range such as <25% necrotic tissue, 25–50% necrotic tissue, 50–75% necrotic tissue, and >75% necrotic tissue. Similar ranges have been studied as part of the pressure sore tool.[11]

Description of wound bed on the basis of the percentage of necrotic tissue/fibrin slough is suggested as a valid concept for determining the type of dressing to be used. These data can be used when documenting the status of the wound.[11] In this manner, descriptions were used in the study.

The type and amount of wound exudate were also assessed because these characteristics provide important information about wound status and the most appropriate treatment. It may also be a pointer to the presence of infection. The amount of wound exudate was rated as follows: when the wound is dry, there is no exudate; a moist wound is indicative of scanty or small amount of exudate; when the tissues are wet/saturated and there is exudate in the wound bed, the amount of exudate is rated as moderate; when the tissues are saturated and the wound is bathing in fluid, this includes wounds with maceration of the skin, the exudate is considered to be large.[11]

The exudate type was recorded as serous (clear fluid without blood, pus, or debris); serosanguineous (thin, watery, pale red to pink fluid); sanguineous or bloody (bloody and bright red); and seropurulent or purulent (thick, cloudy, and yellow or tan).[11]

It is worthy of note that there is significant difference in the wound type and the type of exudate; seropurulent discharge is more common in diabetic wounds, and profuse discharge is more common in pressure ulcers. This underscores the need for appropriate clinical and wound assessment of patients with chronic wounds by well-trained staff. All chronic wounds are not the same, and wounds will behave differently based on the causative nature of the wound. The clinical implication of this finding includes the appropriate dressing for different types of wounds and treating the patient for all aspects of well-being and not just the wound.It should, however, be noted that all wounds particularly after they had been occluded will emit an odor; the odor that accompanies the removal of moisture-retentive dressings is sometimes mistaken for infection.[2] Odor is a subjective assessment and cannot be quantified; however, a descriptive odor assessment may provide useful information. This is because a change in the type and amount of the odor may be indicative of a change in the status of the wounds. The type of odor was not emphasized in this study, though odor assessment may include a description of the odor such as sweet-like or as fresh blood. There was strong odor in the wounds caused by diabetic, infective, and malignant ulcers in our study. Necrotic tissue tends to have an offensive odor, and wound infection with anaerobic bacteria tends to produce a distinct acrid or putrid smell.[12]

There was statistical difference in the wound type and the percentage surface area covered by granulation tissue, slough, and necrotic tissue. Approximately 27% of the diabetic ulcer wounds had more than 75% of their surface area covered by slough and 41.7% of the pressure ulcer wounds had more than 75% of their surface covered by necrotic tissue. This buttressed our usual clinical practice of serial bedside debridement for patients with pressure ulcers and the use of desloughing agents such as honey or collagenase for patients with diabetic ulcer in our institution. This was, of course, based on the wound assessment.

The assessment of the wounds helped in standardizing the description of wounds that we reviewed in our hospital. It also allowed for evaluation of the progress of wounds over time, comparison of reports on wounds, and interpreting literature about wounds. Although wound reviews were documented prior to this, the description was somewhat subjective. It was not uncommon to have instances when the documentation of the wound was that the wound was improving or better. This was only helpful for a person that had reviewed the wounds prior to the documentation and would, therefore, not engender proper interrater (or interobserver) evaluation.


  Conclusion Top


Wound bed assessment and treatment need to be based on best evidence practice for most successful outcomes. There should be standardized wound assessment formats in institutions, which will make room for objective assessment of the clinical progress of the patients. Wound assessment, however, goes beyond the wound, and the patient should be assessed for all aspects of well-being. Patient-centered concerns such as financial constraints should be put into consideration when deciding the wound care plan.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Baranoski S, Ayello EA, editors. Wound Care Essential Practice Principles. Ambler, 2nd ed. PA: Lippincott Williams & Williams; 2008.  Back to cited text no. 1
    
2.
van Rijswijk L, Catanzaro J. Wound assessment and documentation. In: Krasner DL, Rodeheaver GT, Sibbald RG, editors. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 4th ed. Malvern, PA: HMP Communications; 2007. p. 143-52.  Back to cited text no. 2
    
3.
Haughton W, Young T. Common problems in wound care: Malodorous wounds. Br J Nurs 1995;4:959-63.  Back to cited text no. 3
    
4.
Polansky M, van Rijswijk L. Utilizing survival analysis techniques in chronic wound healing studies. Wounds 1994;6:150-8.  Back to cited text no. 4
    
5.
van Rijswijk L. Full-thickness leg ulcers: Patient demographics and predictors of healing. Multi-Center Leg Ulcer Study Group. J Fam Pract 1993;36:625-32.  Back to cited text no. 5
    
6.
Langemo D, Anderson J, Hanson D, Hunter S, Thompson P. Measuring wound length, width, and area: Which technique? Adv Skin Wound Care 2008;21:42-5.  Back to cited text no. 6
    
7.
Mayrovitz HN. Shape and area measurement considerations in the assessment of diabetic plantar ulcers. Wounds 1997;9:21-8.  Back to cited text no. 7
    
8.
Kantor J, Margolis DJ. Efficacy and prognostic value of simple wound measurements. Arch Dermatol 1998;134:1571-4.  Back to cited text no. 8
    
9.
Gethin G, Cowman S. Wound measurement comparing the use of acetate tracings and Visitrak digital planimetry. J Clin Nurs 2006;15:422-7.  Back to cited text no. 9
    
10.
Bryant JL, Brooks TL, Schmidt B, Mostow EN. Reliability of wound measuring techniques in an outpatient wound center. Ostomy Wound Manage 2001;47:44-51.  Back to cited text no. 10
    
11.
Bates-Jensen BM, Vredevoe DL, Brecht ML. Validity and reliability of the Pressure Sore Status Tool. Decubitus 1992;5:20-8.  Back to cited text no. 11
    
12.
Cutting KF, Harding KG. Criteria for identifying wound infection. J Wound Care 1994;3:198-201.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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