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Identify and Treat the Cause: 4.4 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

  1. Location
  2. Odour
  3. 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
  4. Exudate: Comment on amount, type and colour of exudate present
  5. Pain
  6. Wound bed appearance: colour and type of tissue present (fibrin, granulation or epithelial tissue) and presence of eschar or slough.
  7. Condition of peri-wound (surrounding skin) and wound edges
  8. Obtain photos following best practice

e. Wound Measurement

Level B: RNAO's Interpretation of Evidence

2
  1. Measure and document the surface area of surgical wound at regular intervals to monitor progress
  2. Measure depth of wound
  3. Measure size of wound: Area of wound measured by multiplying length (longest measurement) and width (shortest measurement) of wound
 
Expected Reduction in Wound Size3
Primary Intention:
  • Wounds with minimum tissue loss
  • Surgical closure joins the wound edges
  • Will re-epithelialize within 2-3 days
Secondary Intention:
  • Left open to ehal using moist wound healing
  • 20-30% reduction in size in the first 3-4 weeks
Tertiary intention (Delayed Primary Closure):
  • Used when wound heavily contaminated
  • Reduces risk of infection and controls debris/necrotic tissue
  • When the wound appears to be clean and healing, it closed surgically
 
   

f. Determine if the wound is "Healable, Maintenance or Non-Healable"

Healable: Have sufficient vascular supply, underlying ccause can be corrected, & health can be optimized

Maintenance: Have healing potential, but various patient factors are compromising wound healing at this time

Non-healable/Palliative wound:  Has no ability to heal due to untreatable causes such as terminal disease or end-of-life
 

g. Nutritional Assessment

Level B: RNAO's Interpretation of Evidence

4
 
 
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

 

The following assessments and blood work should be considered when investigating nutritional status of a person with a wound:
  • Calculate Body Mass Index (BMI)
  • Determine recent weight loss/gain
  • Complete Mini Nutritional Assessment (MNA)
    If screening section results < 11 = complete assessment section
    If assessment section results< 24 = Registered Dietician referral required
  • Review recent dietary consult
  • Identify barriers or risk factors to healthy eating
  • Link to EatRight Ontario to talk to dietitian www.eatrightontario.ca, 1-877-510-5102
In addition to inquiring about recent weight loss, signs of dehydration, and assessing the Braden Scale Nutritional sub-scale, which helps to capture protein intake, there are several signs of micronutrient deficiencies that are easy to detect when you know what to look for.
 

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 granuloma 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)

The Nestle Mini-Nutritional Assessment (MNA) (Toolkit item #9) 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 IconToolkit #9: Mini-Nutritional Assessment Form

 
Nutrition is an essential component of wound healing. Consider dietician referral for supplementation recommmendations.

Nutritional Supplementation

Nutritional supplementation should be provided to a patient only after a thorough nutritional assessment has been completed and the reason for malnutrition has been identified.5

Macronutrients

Macronutrients such as carbohydrates, proteins and lipids (fats) are required in adequate amounts to provide the body with total energy needs. Caloric intake of 30-35 kcal/kg of body weight is recommended for patients with chronic wounds. Patients that are underweight may require a caloric intake of 35-40% kcal/kg of body weight.6

These macronutrients should be consumed daily in the following amounts:
  • Carbohydrates 45-60%
  • Fat 25-30%
  • Protein 15-20% (1.25-1.5 g/kg of body weight)7
Protein needs are increased in order for healing to occur. Diets that include inadequate amounts of protein can be blamed for “increased skin fragility, decreased immune function, poorer healing and longer recuperation after illness”.8 Caution should be taken when administering protein to patients with liver or kidney failure. Consultation with a Registered Dietician is recommended with this patient population.

Arginine and Glutamine are amino acids that are needed in the production of collagen. Collagen is required for healing to occur. Although supplementation of Glutamine is controversial, it is believed to be helpful in those patients where malnutrition and chronic wound healing are being addressed. Arginine is required by the body when under metabolic stress. Supplementation of Arginine has been shown to improve healing. It is important to note that both Arginine and Glutamine require adequate protein intake to be of any value.9

Fats are an integral part of a healthy diet required for healing to occur. Omega 3 fatty acids are antithrombotic, vasodilators and anti-inflammatory. Omega 6 fatty acids are responsible for platelet aggregation, inflammation and vasoconstrictors. Further research is required before supplementation of Omega 3 or Omega 6 should be recommended.10

Micronutrients11

Zinc
  • Should only be supplemented if deficiency is determined
  • Recommended dose: 40mg of elemental zinc/day (176 mg zinc sulfate) for up to 10 days to enhance wound healing
Asorbic Acid (Vitamin C)
  • Recommended dose: 500 to 1000 mg daily in divided doses
Vitamin A
  • Recommended in patients taking corticosteroids
  • Recommended dose: 10,000-25,000 IU daily for 10-14 days
  • Use with caution in patients with protein deficiencies or liver failure
 

Optimize Medical Therapy12 13 14 15 16

The strategies of caring for patients with surgical wounds are to improve circulation, prevent infection and encourage self-management
  • Tobacco and nicotine cessation
    • Barriers to cessation should be addressed at each patient visit
    • Educational, pharmacological and behavioral techniques should be utilized
  • Control hypertension
  • Control blood sugar if diabetic
  • Prevent Moisture-Associated Skin Damage (MASD)
    • Assess for wound exudate, continence of urine and stool.
    • If incontinence is a concern, a continence assessment should be completed by a qualified practioner (e.g. an Enterstomal Therapist (ET) or Nurse Continence Advisor)
  • Encourage exercise
    • Assess mobility and dexterity aids currently being used (bedrail, superpole, trapezebar, therapeutic surfaces, raised toilet seat and seating devices)
    • Recommendations for exercise as per qualified professional
    • Referal to Physiotherapy/Occupational Therapy as necessary
  • Address dehydration
    • Can impair blood flow and oxygen delivery to wound
  • Control pain
    • Pain interferes with deep breathing and coughing (possible pneumonia)and limits movement
    • Encourage use of analgesics (pain medication) at regular intervals (eg. Every 3-6 hours) instead of taking only as needed
    • Coordinate medication administration with wound care treatment and physical therapy times.
       
Increased localized pain is a significant
predictor of deep compartment infection

 
  • Recommendations for nociceptive pain (described as sharp, aching or throbbing)
    • Non-Opioids – eg. ASA or Acetaminophen
    • Mild Opioids – eg. Codeine
    • Strong Opioids – eg. Morphine or Oxycodone
  • Recommendations for neuropathic pain (described as burning, stinging, shooting, stabbing or hyperesthesia – sensitivity to touch)
    • Second generation tricyclic agents – eg. Nortriptyline or Desipramine
    • If pain is not relieved try using Gabapentin or Pregabalin
  • Non-pharmacological Pain Control Options:
    • Support surfaces
    • Repositioning
    • Cognitive behaviour therapy
    • Music
    • Distraction
    • Relaxation techniques
    • Massage
    • Exercise
    • Heat and/or cold
Pain Red Flags
Possible Infection
  • Increase in pain level
  • New pain in patients with altered sensation
Any sudden, severe, acute pain could be an emergency situation and should be investigated immediately
 
Pain can be a trigger for autonomic dysreflexia that may occur in patients with spinal cord injury T6 or above
 
 

4.5 Surgical and Medical Intervention Strategies17

  1. Debridement (remove devitalized tissue or infected foreign material)
  2. Close a fistula
  3. Drain or remove sinus tract
  4. Vascular surgery
  5. Skin grafts
  6. Bioengineered tissue surgery
 

Identify and Treat the Cause: 4.6 Presence of Superficial Bacteria

 

  1. Ontario, Registered Nurses Association of. Assessment and Management of Venous Leg Ulcers. Toronto : s.n., 2004.
  2. Ontario, Registered Nurses Association of. Assessment and Management of Venous Leg Ulcers. Toronto : s.n., 2004.
  3. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Orsted Heather L., Keast David H., Kuhnke Janet, Armstrong Pamela et al. 1, s.l. : Wound Care Canada, 2010, Vol. 8.
  4. Ontario, Registered Nurses Association of. Assessment and Management of Venous Leg Ulcers. Toronto : s.n., 2004.
  5. Nutrition and Chronic Wounds. Molnar JA, Underdown MJ, Clark WA. 11, s.l. : Advances in Wound Care, 2014, Vol. 3.
  6. Nutrition and Chronic Wounds. Molnar JA, Underdown MJ, Clark WA. 11, s.l. : Advances in Wound Care, 2014, Vol. 3.
  7. Nutrition and Chronic Wounds. Molnar JA, Underdown MJ, Clark WA. 11, s.l. : Advances in Wound Care, 2014, Vol. 3.
  8. Nutrition and Chronic Wounds. Molnar JA, Underdown MJ, Clark WA. 11, s.l. : Advances in Wound Care, 2014, Vol. 3.
  9. Nutrition and Chronic Wounds. Molnar JA, Underdown MJ, Clark WA. 11, s.l. : Advances in Wound Care, 2014, Vol. 3.
  10. Nutrition and Chronic Wounds. Molnar JA, Underdown MJ, Clark WA. 11, s.l. : Advances in Wound Care, 2014, Vol. 3.
  11. Nutrition and Chronic Wounds. Molnar JA, Underdown MJ, Clark WA. 11, s.l. : Advances in Wound Care, 2014, Vol. 3.
  12. Excellence, National Institute for Health and Clinical. Surgical Site Infection - Prevention and treatment of surgical site infection. London, U.K. : Royal College of Obstetricians and Gynaecologists, 2008.
  13. Ontario, Registered Nurses Association of. Nursing Best Practice Guideline: Integrating Smoking Cessation into Daily Nursing Practice. 2007.
  14. Ontario, Registered Nurses Association of. Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients. 2010.
  15. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Orsted Heather L., Keast David H., Kuhnke Janet, Armstrong Pamela et al. 1, s.l. : Wound Care Canada, 2010, Vol. 8.
  16. Ontario, Registered Nurses Association of. Nursing Best Practice Guideline: Assessment and Management of Pain 3rd edition. 2013.
    10. Association, Canadian Nurses. Social Determinants of Health and Nursing: A Summary of the Issues.
  17. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Orsted Heather L., Keast David H., Kuhnke Janet, Armstrong Pamela et al. 1, s.l. : Wound Care Canada, 2010, Vol. 8.

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