M7 V01 Principles of wound assessment

In this scenario, we’ll be showing you assessment, management and prevention principles for a pressure injury located on the sacrum. So, in this simulation here what you can see is that we have a bottom, head being in this direction and legs being in this direction and this being the natal cleft here.

The area that we’re concentrating on particularly in this scenario is this pressure injury located here on the sacrum. The first thing that we want to do is, if this was an initial presentation of an injury or if it’s a chronic wound, we want to look at measuring and tracking wound progress at least every 4 weeks.

One of the first things that we might like to do is to actually do a tracing of the wound bed itself. You can use something like an acetate tracing grid, remove your backing sheet and place over the wound area itself. Now, this grid here has a backing sheet on the back which you can discard at the end of the tracing and keep the clean tracing for the clinical record. Using a permanent marker, we would actually trace the inside edge of the wound itself, so just tracing the margins of the wound itself. Always making sure that we have it in the direction of the head so the head is in that direction and we can indicate that.

Once you’ve traced it, what some people would choose to do is then select the amount or trace the amount of sloughy or granulating tissue within the wound as well and what you can do is in this instance here we have yellow sloughy tissue and we have some bone visible in the base of this wound, so we trace around all of those sections and then what we could do later is actually label. So draw an arrow and write sloughy tissue, granulation tissue and bone. Okay, once we do that, taking it off the patient, peeling away the backing sheet, discarding this in the bin and keeping the backing sheet for inclusion in the chart.

What we can then do is count the number of squares to give the length and the number of squares to give the width and you can do a simple calculation to provide an overall surface area.

The next thing that we want to do is to measure, you can see in this wound here that there is actually some undermining of the wound edges as well. So we want to determine how far that undermining goes because this is showing that there’s some tracking, there could be something occurring further underneath. So, what we would use is use a sterile, moistened cotton tip and gently place into the wound to measure the depth of the wound. So taking it, pushing it in, just gently feeling around the margins and what we would then show is on the left hand side, pinching it off, or placing your finger at the wound edge, getting a ruler and then we can measure that the depth of the wound is about 7mm, the base of the wound again is about 1.5cm and at the top of the wound you can see again about 1.5cm and then we would document that in the patient’s medical record.

Right, the next thing we want to do is clean the wound and with a wound like this where there’s undermining or shelving of the surrounding skin, it’s really important that we use gentle irrigation to remove any devitalised or dead tissue that’s building, or even retained dressing product that’s built up underneath the wound edges.

Another technique that you may choose to do is also to palpate or feel what the surrounding skin looks like, feeling for any boggy or undermined areas. Just here at the top right hand corner of the wound we can actually feel that the skin is really soft and boggy underneath so that might indicate that there is further tissue damage occurring underneath and would be an area that we would need to monitor very closely. But in this assessment we can see that the surrounding skin for this wound itself is in really good condition, the skin is nice and moist and pink and healthy.

Okay, so cleaning the wound, what we might choose to do is to take a syringe filled with normal saline and then just warm to body temperature and then what we might choose to do is, Then we’re going to irrigate, just gently, putting the fluid in to irrigate the edges of the wound for the purposes of this simulation, we’ve used a 3ml syringe. It would be preferable in clinical practice if you could use something like a 20ml or 50ml syringe to reduce the amount of pressure that is being exerted as you’re pushing the syringe into the wound.

So, this is too small a syringe for a normal clinical situation, you’d actually be using a 20 or 50ml syringe to irrigate in normal circumstances. You can always apply an 18G syringe to the end of the needle, not to penetrate the skin but to increase the amount of force or fluid that’s going into the wound to irrigate any necrotic or devitalised tissue.

Okay, then, wound cleansing itself using non-woven gauze, so this is gauze that doesn’t shed fibres into the wound. We’ve actually moistened that with some sterile water, sorry, normal saline, aqueous chlorhexidine or even boiled cooled water that’s safe to drink.

So just moistening, cleaning out the wound bed, wiping all the surrounding skin to keep that in good condition So then just patting dry and no vigorous rubbing of that surrounding skin, because it’s advisable that you don’t rub or pat or scrub vigorously or else you’ll end up damaging that surrounding tissue. Okay, now we’re going to apply the dressing.

One of the first things that you want to do is, because this wound will be producing moderate to large amounts of exudates, you want to protect this fragile peri wound skin. So we might select something like a zinc based barrier cream and just gently apply this with a clean gloved finger to the surrounding skin.

It only needs to be a thin application, particularly down where the distal edge of the wound which is down this end, given that this is where the most amount of the fluid will pool. So just a thin smear of a barrier preparation on that surrounding skin. You could also use barrier preparation wipes, like skin prep or cavilon barrier wipes for instance, to prepare all of that surrounding area where an adhesive dressing may go.

Now what we need to do is we actually need to pack this wound just loosely, so that we’re promoting healing from the base of the wound. We know that there is bone on view here and it is really important that we actually protect that bone by keeping the wound nice and moist. And we have a large percentage of 50% about of sloughy tissue within the base of the wound and healthy granulation tissue on this side so what we’re going to do is to select a dressing that is going to help absorb moderate to large amounts of liquid or exudate and is going to help facilitate autolysis or breakdown of this sloughy tissue.

So what we’re going to do is to select a hydrofibre to gently pack this wound. What we’ll do is as you can see it is about 2cm wide and this dressing will not probably be large enough for this wound, so what is recommended is that if you’re using sheets of a packing is that you keep a count of how many packing strips that you’re actually putting in. So just gently placing it in the base of the wound and then just folding it over, poking it very gently into the edges to fill those undermined areas.

So just loosely packing, not tightly then with the second So now we’ve just gently packed that in, just a recommendation that you keep a little tail out there so that when you’re removing the dressing it’s easy to remove. With the second layer of your packing just gently filling that in to cover the remaining wound. This dressing goes in dry and as you can see we leave a little tail out on that side so we’ve got two pieces of packing in there, it’s loosely packed, not over packed and we haven’t got too much dressing on that surrounding skin which could potentially cause some trouble.

Okay, so when this dressing is working what’s happening is that this dry dressing, this is called a hydrofiber and absorbs moderate to large amounts of liquid. As the wound is producing exudate it will actually moisten and become a moist gel within the base of that wound. The next thing we want to do is use a secondary dressing that’s going to be at least 1 ½ to 2cm larger than this wound itself. And that’s adhesive, so it is going to reduce friction and sheer from the dressing, and it’s going to contain exudate and reduce the frequency of dressing changes for up to 5 to 7 days, or if there’s 70% strike through on that surrounding dressing.

So we’re going to select something that’s specifically designed for a sacral area. We can tell this dressing we’re using is designed for a sacral area because of the shape of the dressing. What we want to do is to remove the backing sheet and because it’s got a backing sheet like this we can actually place it easily into the fold of the skin, and then without stretching or placing any undue stretch on the dressing remove the second backing sheet, and lay this down. Try to keep wrinkles out of the dressing because these will be transferred onto the skin. The beauty with these silicone dressings particularly is that they can be replaced without causing trauma to the skin. Hold it in place for a few minutes just to help warm that dressing up and keep it in position.

Okay, now the dressing’s in place, what you can see on the surrounding skin is that we also have an area here of excoriation. This is like a nappy rash that’s on the skin and frequently this occurs because the wound is producing moderate to large amounts of leakage and it actually tracks down in the natal cleft and can cause burning and irritation of that surrounding skin.

So one of the best strategies to try and prevent this kind of thing from occurring or to treat an excoriation that has already occurred is to use a soap free body wash or cleanser to cleanse all of the surrounding skin, pat it dry and then you might choose to use a barrier preparation cream or wipe to prevent further excoriation to this area to seal that skin. There’s no reason to cover this, you don’t need to cover this with the dressing itself. You’re far better to apply barrier preparation cream and then also consider the frequency of pad changes and repositioning so that this person is reducing the risk of incontinence, excoriation and further pressure damage to that area.

Promoting Healthy Skin - Video Transcript