Wound Care Assessment Tool for Healthcare Professionals

Chronic wounds cost the Australian health and aged care budget more than $6.6 billion/yr, with individual out of pocket expenditure of $4,000/year (Wounds Australia, 2024). Blackburn et al. (2022) state the cost of wound care is of great international concern, and these costs are partially attributable to inappropriate wound care. Inconsistent clinical practice, omission of evidence-based interventions, and unsupported treatment changes perpetuate chronicity (Dowsett & Hall, 2019).

Comprehensive, person-centred assessment is essential for successful wound management (Mahoney, 2020). A thorough medical/surgical history highlights comorbidities, current medications, allergies and social determinants of wound healing (Brown, 2024). The baseline wound assessment ascertains aetiology, healing potential, previous treatment, and objective data like dimensions and tissue characteristics for serial comparison. Awareness of aetiology directs treatment plans and informs strategies to prevent recurrence. Many validated, aetiology specific, prevention and treatment protocols exist such as those for pressure injuries (PI), incontinence associated dermatitis (IAD), venous leg ulcers (VLU), diabetic foot ulcers (DFU) and skin tears. (Bates-Jensen, 2022).

Weekly reviews continue to document wound dimensions including depth and the presence of any undermining. Digital clinical photography is an integral part of documentation and patient consent should be obtained according to local policy. At a minimum, photographs must; be dated, clearly show the location of the wound, include a metric measurement tool and patient label (Bates-Jensen, 2022).

The T.I.M.E wound assessment tool (WAT) was introduced in 2003 (Lumbers, 2019) as a systematic framework outlining four major elements of wound assessment (Ermer-Seltun & Rolstad, 2022). It is the tool most commonly used by practitioners to guide wound management, with proven advancements in clinicians’ knowledge and practice (Dowsett & Hall, 2019). The mnemonic guides assessment of Tissue, Infection/inflammation, Moisture balance, and Edges. The tool has been adapted for aetiology- specific wounds including VLU, PI, DFU surgical wound dehiscence (SWD) (Blackburn et al., 2022).

See page 18 of World Union of Wound Healing Societies Consensus Document, Appendix A

[https://woundsinternational.com/wp-content/uploads/2023/02/22d08364ecdb637f5fb532fdee7e3a54.pdf]

For optimum framework utility, clinicians must be familiar with types of wound tissue and exudate, the implications of their presence and correct terminology (Ermer-Seltun & Rolstad, 2022).

Granulation tissue, or extracellular matrix (ECM) consists of collagen and new blood vessels. The appearance is red, slightly granular with a level surface (Bietz, 2022). Suboptimal granulation may be described as gelatinous, pale or friable (Swanson, 2019).

Slough is a by-product of the inflammatory phase, composed of fibrin, cellular debris, leukocytes, proteins and microorganisms (Angel, 2019). The colour ranges from white to yellow/tan, and consistency varies between gelatinous and fibrous so it may be loosely or tenaciously attached to the wound bed (Swanson, 2019). Slough supports bacterial growth and biofilm development. It obstructs contact between the wound bed and topical treatments. Debridement is essential to disrupt the integrity of slough and biofilm, enhancing susceptibility to treatment (IWII, 2023).

Hypergranulation is excessive granulation that overgrows the wound bed. It is also referred to as “proud flesh” and impedes epithelial migration across the wound surface (Ermer-Seltun & Rolstad, 2022).

Necrotic tissue or eschar is dry (usually) black/brown non-viable tissue that occludes the wound bed, preventing contact with therapeutic dressings. It harbours pathogens and debris that cause infection and malodour (Triplett, 2024). Eschar may result from pressure related tissue hypoxia, haematoma or ischemic disease processes (Swanson, 2019).

Infection/inflammation is a high priority assessment component, as urgent interventions may be needed. The International Wound Infection Institute (IWII, 2022) describes infection as a continuum beginning with contamination and colonisation that does not negatively impact the person or healing process.

As microorganism proliferate, the bioburden increases and signs of local infection will be evident. Typical signs and symptoms are new/increased pain, periwound erythema (extending <2cm), localised warmth, swelling, purulent exudate, malodour and wound breakdown. Less obvious signs include hypergranulation, epithelial bridging, bleeding, friable granulation and delayed healing.

Spreading infection or cellulitis follows, with pathogens infiltrating surrounding tissues, observable through extending erythema (beyond 2cm), induration, lymphangitis, wound breakdown and satellite lesions. Progression to systemic infection may present as malaise/lethargy, fever, and sepsis.

Microbiological analysis to identify organisms and susceptibility should be performed if clinical signs and symptoms suggest spreading infection. Although tissue biopsy is preferred, the specimen is usually obtained by swab as it is simpler and less invasive (IWII, 2022).

Inflammation is a natural response to injury that usually subsides by day seven. Persistent inflammation permits ongoing degradation of the ECM and inhibition of growth factors. Clinicians must therefore be competent in differentiating normal healing from infection and be alert to non-infective causes of inflammation such as autoimmune diseases and other inflammatory conditions. Optimised systemic management of these conditions is necessary to support wound healing (Leaper et al, 2012).

Appropriate moisture balance of the wound surface is critical for cell regeneration and can be difficult to manage as exudate levels fluctuate. Chronic wound exudate contains higher levels of MMP’s and inflammatory cytokines that degrade the ECM and prolong the inflammatory phase (Ermer-Seltun & Rolstad, 2022).  A dry wound bed delays healing by preventing autolytic debridement and epithelial migration (Wound Care Today, 2024).

Suboptimal exudate management is associated with biofilm development, while adequate exudate removal promotes healing. Exudate characteristics and volume inform clinicians of wound status and guide dressing selection. Excess exudate often leads to periwound maceration and resultant wound deterioration (Leaper et al, 2012). Effective exudate management is critical to quality of life because leakage, soiling of clothes/linens, and malodour often initiate social isolation and psychological distress (The Wound Pros, 2024).

Wound edges should be pale pink, thin, flat and level with the wound bed, allowing epithelial migration. Rolled, thick edges or undermining are simultaneously signs of, and contributors to protracted healing (Ermer-Seltun & Rolstad, 2022). Contraction and epithelialisation of wound edges is the clearest indicator of healing (Leaper et al., 2012).

The science of wound healing and management therapies is continually evolving (Leaper et al., 2012). In response to such developments, the framework has been extended to incorporate Repair/regeneration of tissue, and Social factors affecting healing (Lumbers, 2019).

Advanced regenerative therapies such as bioengineered tissue products, negative pressure wound therapy (NPWT), electrical stimulation or surgical flaps/grafts may be beneficial. The updated mnemonic prompts consideration of such modalities (Netsch, 2022).

Lastly, the impact of social factors is explored, incorporating education and collaboration regarding goals and plans of care. Potential barriers include limited financial resources, poor health literacy, lack of support networks, geographic location and cultural norms (Ermer-Seltun & Rolstad, 2022).