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4.2 Assess the Wound and Peri-Wound


d. Assess the Wound and Peri-wound

Wound and Peri-wound Assessment is best performed using a validated and reliable wound assessment tool.
A comprehensive wound assessment should include observation and documentation of the following:

  1. Location
  2. Odour
  3. Infection (PEDIS – IWGDF, NERDS -- STONEES)
  4. Sinus Tracts (including undermining and tunneling): Measurement can be obtained by gently inserting small probe into sinus tract, marking probe with end of finger and measuring length from end of probe to finger end
  5. Exudate: Comment on amount, type and colour of exudate present
  6. Pain: Use the numerical pain scale ( 0 – 10) to assess the pain level. Increased pain level/new pain is a 'red flag' in patients with altered sensation
  7. Wound bed appearance: colour and type of tissue present (fibrin, granulation or epithelial tissue) and presence of eschar or slough (estimate amounts)
  8. Condition of peri-wound (surrounding skin) and wound edges (comment on callous if present)

e. Wound Measurement

(Level B: RNAO’s Assessment and Management of Diabetic Foot Ulcers1)
  1. Measure (Length x Width x Depth) and document the surface areas of ulcers on admission and at least weekly to calculate the percentage reduction and monitor progress using the BWAT, PUSH, or LUMT tool since admission.
  2. Volume of wound (V) : Area of wound measured by multiplying length (longest measurement) and width (longest measurement) of wound and depth of wound (straight in) in cm.
  3. Identify how measurements are taken to allow for consistency of measurement
The two most important points are that measurements are done weekly, and using a standardized method within each organization.
 
  V (Initial) - V(Current)  × 100 = _______% reduction in volume  
  V (Initial)  
*(V = volume of wound calculated as Longest Length x Perpendicular Widest Width x Depth straight in)
 
 

50% reduction in wound surface area at 4 weeks of best practice treatment is a good predictor of wound healing 90% by 8 weeks and wound closure by 12 weeks.

 

f. Vascular Assessment

Peripheral Artery Disease (PAD) Assessment and Recommendations (The IWGDF Guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes 2)

  • Identifying PAD among patients with foot ulceration is important because its presence is associated with worse outcomes, such as a slower (or lack of) healing of foot ulcers, lower extremity amputations, subsequent cardiovascular events and premature mortality 34
  • Diagnosing PAD is challenging in patients with diabetes, as they frequently lack typical symptoms, such as claudication or rest pain, even in the presence of severe tissue loss 567
     
  • Arterial calcification, foot infection, edema and peripheral neuropathy, each of which is often present with diabetic foot ulceration, may adversely affect the performance of diagnostic tests for PAD 8
     
  • Peripheral arterial disease (PAD) is a component cause in approximately one-third of foot ulcers and is often a significant risk factor associated with recurrent wounds 9 10 11. Therefore, the assessment of PAD is important in defining overall lower-extremity risk status.
     
  • Vascular examination should include palpation of the posterior tibial and dorsalis pedis pulses 12 13, which should be characterized as either “present” or “absent”14
     
  • An Ankle Brachial Pressure Index (ABPI and /TBPI) measurement should be performed by a trained practitioner to rule out the presence of peripheral arterial disease. These measurements offer valuable information as a screening tool for lower extremity peripheral arterial disease. “All clinicians involved in the management of patients with lower limb ulcers should have direct access to an 8 MHz hand held doppler device. This should not be considered a special investigation limited to vascular laboratory”20
     
    The International Working Group has created the IWGDF Guidance  on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes 15. The Guideline outlines assessment procedures, recommendations, treatment and rationales.

Acute arterial occlusion is a life and limb threatening situation
which requires immediate emergency intervention

Signs and symptoms that may become severe
may be associated with the following:

  • Pale or blue skin
  • Skin cold to the touch
  • Sudden decrease in mobility
  • No pulse where one was present prior to this
  • Sudden and severe pain
ABPI 0.5 to 0.8 TBPI 0.64 to 0.7
Suggest Transcutaneous Oxygen Pressure(TcPO2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies
ABPI <0.5 TBPI <0.64
Urgent vascular surgical consult needed


PDF IWGDF Guidance
External site Waterloo Wellington Integrated Wound Care Program: Website Arterial Ulcers

g. Ankle Brachial Pressure Index (ABPI)/Toe Brachial Pressure Index (TBPI) (Table 6)

Ankle Brachial Pressure Index(ABPI) / Toe Brachial Pressure Index (TBPI ) Interpretations for Diabetic Population

ABPI
 > 0.9-1.2 ....Normal (1.2 or > could indicate calcification, seen in diabetes, patients that smoke, hypertension, rheumatoid arthritis, systemic vasculitis or advanced age). Referral is recommended for vascular arterial testing
0.80-0.9 ......Mild ischemia (inflow disease may be present)
0.50-0.79 ....Moderate ischemia (Would benefit from vascular surgeon consult to expedite wound healing)
0.35-0.49 ....Moderately severe ischemia  (Urgent vascular surgery consult recommended)
0.20-0.34 ....Severe ischemia (Urgent vascular surgery consult recommended)
<0.20 ..........Likely critical ischemia, but absolute pressure and clinical picture must be considered

(Urgent vascular surgery consult recommended)

TBPI:
> 0.7 …………Normal > 0.7 (When TBPI is high, a referral for vascular arterial testing is recommended)
 0.64 - 0.7…..Borderline
< 0.64………. Abnormal indicating arterial disease  (Urgent vascular surgery consult recommended)

Foot Assessment

RNAO recommends a 3 month complete reassessment if no evidence of healing and a 6 month reassessment for resolving and healing (but not yet healed) wounds1617
 

Right

 

Left

ABPI: TBPI: ABPI: TBPI:

 

An Ankle Brachial Pressure Index (ABPI) >1.2 and <0.8 warrants referral for further medical assessment. People with abnormally low or abnormally high ABPI should be further investigated for peripheral arterial disease. For example, an ABPI >1.3 is considered indicative of non- compressible vessels that are found in individuals with diabetes, chronic renal failure and who are older than 70 years of age.
 

Further Investigation Required (Table 7)(DFUs)18

Physical Assessment of the Lower Extremities Diagnostic Tests
Intermittent claudication (calf pain)
Peripheral pulses
 Colour (pallor on limb elevation, rubor on limb dependency, mottling)
Cool temperature
 Ischemic pain (pain causing frequent waking at night, or needing to dangle limb for pain relief)
 Dry gangrene
 Hair loss, dystrophic nails 
(damaged or misshaped nail plates)
 Shiny, taut, thin, dry skin
■  Ankle brachial pressure index (ABPI)
■  Toe pressures and toe brachial index (TBPI)
■  Arterial duplex scan
■  Transcutaneous oxygen (TcPO2)
■  Angiography (including CT angiogram and MR angiogram)

h. Nutritional Assessment

(Level B: RNAO’s Assessment and Management of Diabetic Foot Ulcer)19

The following assessments and blood work should be considered when investigating nutritional status of a person with a wound:

 
Body Weight (kg):      
 
Height (cm):      BMI:       
 
Recent  Weight Loss: Y  /  N            Weight Loss (kg): ___
Protein-Calorie Malnutrition
  • Pre-albumin if available (low scores indicate risk for malnutrition)
  • Serum albumin level (<30g/l will delay healing; <20g/l will be non-healable)
  • C-reactive Protein (CRP)
Check for anemia   CBC (including RBC, Hct, Hgb, MCV, Platelets etc.)

If anemic, proceed to checking →
  • Serum Iron
  • Total Iron Binding
  • Ferritin
  • Transferrin
  • B12
  • Red blood cell folate level
Kidney function (To check hydration)
  • BUN
  • Creatinine
  • Potassium
  • Albumin/Urine creatinine ratio
 

Targets for Glycemic Control for Most People with
 Type 1 and Type 2 Diabetes

  • Fasting plasma glucose of 4.0 to 7.0 mmol/L (8.0 for the elderly to prevent chance of hypoglycemia)
  • A1C ≤ 7.0% to reduce the risk of microvascular and macrovascular complications
  • 2-hour postprandial (after meal) plasma glucose targets of 5.0 to l0.0 mmol/L
  • (5.0 to 8.0 mmol/L if A1C targets not being met)
 
As recommended by the Canadian Diabetes Association (CDA) Clinical Practice Guidelines
(CDA CPG Expert Committee, 2008)
 

Signs of micronutrient deficiencies:

  • Reddish tongue with a smooth surface (Vitamin B deficiency)
  • Magenta flank-steak appearing tongue with cracks at corners of the mouth (called angular stomatitis) (Vitamin B2 deficiency)
  • Dementia, diarrhea, dermatitis (pellagra)—crepe paper skin with wrinkles in the skin and flat surfaces between the wrinkles –also associated with bullous pemphigoid and gramuloma annulare (Vitamin B3 deficiency)
  • Prominent “snowflake” exfoliation of the epidermis of the lower legs (Essential Fatty Acid deficiency)
  • Skin and capillary fragility with purpura, skin tears, increase risk of pressure ulcers, severe collagen deficiency so that the skin is like plastic wrap,  and extensor tendons and venous plexus is easily seen through the transparent epidermis (Chronic Scurvy/Vitamin C deficiency)
  • Reddish, scaly, itchy skin lesions (Vitamin A, E, and K deficiency)
  • Seborrheic-like rash that is red, flaky seen along the lateral eyebrows, nasal labial folds and chin (Zinc deficiency)
  • Prolonged tenting of the skin in the presence of adequate fluid intake

If the presence of any of these signs of micronutrient deficiencies is noted, a referral should be made to a Registered Dietitian who can work with the primary care provider for screening of dietary deficiencies and treatment.

Nestle Mini-Nutritional Assessment (MNA)

(Toolkit item #11) is a screening and assessment tool that identifies individuals age 65 and above who are malnourished or at risk of malnutrition, allowing for earlier intervention to provide adequate nutritional support.  It has not been validated for use with younger individuals. The screening tool consists of 6 questions.
  • Complete the screen by filling in the boxes with the appropriate numbers.
  • Total the numbers for the screening score.

    The screening score (max 14 points): 
    12- 14 points = normal nutritional status
    8-11 points = at risk of malnutrition 
    0 -7 points = malnourished

    Toolkit IconMini-Nutritional Assessment Form

Identify and Treat the Cause: 4.2 Presence of Superficial Bacteria

 

  1. Registered Nurses Association of Ontario, "Assessment and Management of Diabetic Foot Ulcers," Registered Nurses Association of Ontario, Toronto, 2013.
  2. International Working Group on the Diabetic Foot, "Guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes," International Working Group on the Diabetic Foot, Brussels, 2015.
  3. Prompers L, Schaper N, Apelqvist J, Edmonds M, Jude E, Mauricio D, Uccioli L, Urbancic V, Bakker K, Holstein P, Jirkovska A, Piaggesi A,, "Prediction of Outcome in Individuals with Diabetic Foot Ulcers: Focus on the Differences Between Individuals with and without Peripheral Artery Disease: The Eurodiale Study," Diabetologia, vol. 51, pp. 747-755, 2008.
  4. Elgzyri T, Larsson J, Thörne J, Eriksson KF, Apelqvist J., "Outcome of Ischemic Foot Ulcer in Diabetic Patients who had no Invasive Vascular Intervention," Eur J Vasc Endvasc Surg, vol. 46, pp. 110-117, 2013.
  5. Prompers L, Schaper N, Apelqvist J, Edmonds M, Jude E, Mauricio D, Uccioli L, Urbancic V, Bakker K, Holstein P, Jirkovska A, Piaggesi A,, "Prediction of Outcome in Individuals with Diabetic Foot Ulcers: Focus on the Differences Between Individuals with and without Peripheral Artery Disease: The Eurodiale Study," Diabetologia, vol. 51, pp. 747-755, 2008.
  6. Dolan NC, Liu K, Criqui MH, et al., "Peripheral Artery Disease, Diabetes and Reduced Lower Extrmity Functioning," Diabetes Care, vol. 25, pp. 113-120, 2002.
  7. Boyko EJ, Ahroni JH, Davignon D, Stensel V, Prigeon RL, Smith DG, "Diagnostic Utility of the History of Physical Examination for Peripheral Vascular Disease Among Patients with Diabetes," Clin Epidemiol, vol. 50, pp. 659-668, 2007.
  8. International Working Group on the Diabetic Foot, "Guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes," International Working Group on the Diabetic Foot, Brussels, 2015.
  9. Gardner, S.E., Frantz, R.A., Bergquist, S. & Shin, C.D. (2005). , "A prospective study of the pressure ulcer scale for healing (PUSH).," The Journals of Gerontology, vol. 60, no. 1, pp. 93-97., 2005.
  10. International Working Group on the Diabetic Foot, "Guidance on the dianosis and management of foot infection in persons with diabetes," International Working Group on the Diabetic Foot, Brussels, 2015.
  11. International Best Practice Wounds International Available from: www.woundsinternational.com, "Best Practice Guidelines: Wound Management in the Diabetic Foot Ulcer," Wounds International A division of Schofield Healthcare Media Limited, London SE1 9PG, UK, 2013.
  12. A. Bryant, Acute and Chronic Wounds Nursing Management, St Louis: Mosby, 2011.
  13. International Working Group on the Diabetic Foot, "Guidance on the dianosis and management of foot infection in persons with diabetes," International Working Group on the Diabetic Foot, Brussels, 2015.
  14. International Working Group on the Diabetic Foot, "Guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes," International Working Group on the Diabetic Foot, Brussels, 2015.
  15. International Working Group on the Diabetic Foot, "Guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes," International Working Group on the Diabetic Foot, Brussels, 2015.
  16. Registered Nurses Association of Ontario, " Nursing Best Practice Guideline: Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients," Registered Nurses Association of Ontario, Toronto, 2010.
  17. Wild, S; Rogklic, G; Green, A; Sicree, R; King, H, "Global Prevalence of Diabetes," Diabetes Care, pp. 1047-1053, 2004.
  18. Registered Nurses Association of Ontario, "Assessment and Management of Diabetic Foot Ulcers," Registered Nurses Association of Ontario, Toronto, 2013.
  19. Registered Nurses Association of Ontario, "Assessment and Management of Diabetic Foot Ulcers," Registered Nurses Association of Ontario, Toronto, 2013.
  20. World Health Organization, "Global status report on noncommunicable diseases 2014," World Health Organization, Geneva, 2014.

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