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Wound assessment and reporting

Wound healing is determined by the general health of your patient, so a comprehensive assessment of your patient is crucial when planning and evaluating treatment. Learn more about wound assessment and reporting

Patient report

When assessing and reporting on a patient, be sure to note the following: 

  • Full medical history such as diabetes, vascular diseases, compromised immune system, connective tissue disorders and allergies
  • Medication
  • Nutritional status
  • Lifestyle, for example tobacco and alcohol habits or impaired mobility
  • Psychological problems 
  • Quality of life 

Wound assessment

Diagnosing the underlying cause of a wound is an essential part of wound assessment – and you can only treat the wound once this has been determined. You’ll also need to assess the wound bed and the surrounding skin. After you’ve made these assessments, you can select the best dressing. 

 

Wound report

When assessing and reporting on a wound, you’ll want to note the following:

  • Wound location, size and type
  • Characteristics of the wound bed, such as necrotic tissue, granulation tissue and infection
  • Odor and exudate (none, low, moderate, high)
  • Condition of the surrounding skin (normal, white, shiny, warm, red, dry, scaling, thin)
  • Clinical signs of wound infection (delayed healing, odor, abnormal granulation tissue, increased wound pain and/or excessive exudate)
  • Wound pain (location of the pain, pain duration, pain intensity, nociceptive or neuropathic). 

In many countries Coloplast offers training in wound assessment and management for health care professionals.

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Wound types

Leg ulcers Four out of ten chronic wounds are venous leg ulcers. Learn more about leg ulcer types and their treatment options

References

1. Fogh et al. Wound Repair and Regeneration 2012;20: 815-821

2. Gottrup et al. Wound  Repair and Regeneration 2008;6:615-25

3. Palao I Domenech et al. Journal of Wound Care 2008;17(8):342-48

The three most common types of leg ulcers are:

  • Venous leg ulcers (70%)
  • Arterial leg ulcers (10%) 
  • Mixed venous and arterial leg ulcers (10–15%) 

Venous leg ulcers

Venous leg ulcers are caused either by dysfunction of the venous valves or an inadequate calf muscle pump. In both cases, blood isn’t sufficiently returned to the heart. This leads to higher venous pressure, which can cause edema. And an increased fluid level between cells can result in cell death, leading to ulcers. This is why compression therapy is an essential part of treating venous leg ulcers.

Venous leg ulcers are often located in the gaiter area of the leg and characterized by:

  • Irregular shape
  • Brown pigmentation in the peri-ulcer skin area (often with eczema)
  • Normal foot pulse

Venous leg ulcers are often painful, especially during daytime. Elevation of the leg can relieve some of the pain.

leg ulcer

 

Arterial ulcers

Arterial leg ulcers are caused by insufficient blood supply to the leg or feet due to arteriosclerosis. The condition reduces the supply of oxygen and nutrients to the cells, resulting in tissue death and, eventually, ulcers.
Patients with arterial ulcers should not be treated with compression therapy, but will often need vascular surgery.

Arterial ulcers are often located in the gaiter area and on the feet, and are characterized by:

  • Fairly regular shape
  • Atrophic, pale peri-wound skin
  • Weak foot pulse 

Arterial ulcers can be very painful, especially at rest.


Mixed venous and arterial leg ulcers 

Mixed venous and arterial leg ulcers are ulcers caused by both venous and arterial disease. The majority of patients diagnosed with mixed venous ulcers have ulcers of venous origin and develop arterial insufficiency over time.


Treatment needs

Venous leg ulcers should normally be treated with graduated compression therapy. However, not all patients can tolerate full compression. Mixed aetiology ulcers are likely to require a reduced level of compression. Arterial leg ulcers should not be treated with compression therapy.

Wound dressings for leg ulcers should offer superior absorption and exudate management properties that enable them to absorb and retain exudate under compression bandages (venous leg ulcers). Suitable dressings include Biatain Silicone, Biatain Non-Adhesive and Biatain Super.

 

A silver-releasing dressing, such as Biatain Ag or Biatain Silicone Ag, can help prevent or resolve wound infection.

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Diabetic foot ulcers Diabetic foot ulcer infections increase the risk of amputation 155 times (1). Learn about their causes and available treatment options

References

1. Lavery et al. Diabetes Care 2006;29(6):1288–93 2

Up to 15% of diabetics are likely to develop a foot ulcer at some stage in their lives. Diabetic ulcers have a considerable negative impact on patients’ lives, and are highly susceptible to infection that all too often leads to amputation. This makes infection control of paramount importance in diabetic foot ulcer management. 

Successfully managing a diabetic foot ulcer requires a comprehensive understanding of the wound: its cause, progression, risk, and treatment.

The main causes of diabetic foot ulcers are: 

  • Neuropathy
  • Poor blood supply (ischemia)

Neuropathy

neurophatic foot ulcer

Neuropathy is the most common diabetic foot condition and is caused by damaged nerves in the lower extremity. The condition is permanent and can lead to loss of sensation, which increases the risk of accidental injuries, and painful feet.Treatment involves attention to feet, self-care and custom-made footwear. 


Poor blood supply (ischemia)

Ischemic foot ulcer

A very serious condition, ischemia, is the main reason for amputations. Ischemia is caused by impaired circulation, which can be due to arteriosclerosis or occlusion of tissue. Impaired circulation causes reduced pulse – the foot is cold and blue – and this leads to tissue death and the eventual development of an ulcer. Your patient may need vascular surgery. 

 

Infection

Infected foot ulcer

Diabetes can change the body’s ability to combat infection. Not only are the feet more prone to infection, it’s also harder to get rid of an infection once it’s there. So it’s crucial that you assess the patient regularly to prevent and react quickly to infections.

 

Treatment needs

  • Treat the underlying causes of a diabetic foot ulcer if possible
  • To support the healing process, use appropriate moist wound healing dressings with superior absorption and exudate management properties, such as Biatain Non-Adhesive or Biatain Alginate dressing
  • A silver-releasing moist wound healing dressing, such as Biatain Ag or Biatain Alginate Ag, can help prevent or resolve wound infection

Download our tips for preventing, assessing and treating diabetic foot ulcers:

Diabetic foot ulcers – prevention and treatment: A Coloplast quick guide (pdf).

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Pressure ulcers Responsible for a two-fold increase in mortality rates (1), pressure ulcers demand timely, effective treatment. Learn more about assessing and treating pressure ulcers

References

1. Brem and Lyder. The American Journal of Surgery 2004;188:9S–17S

2.  NPUAP-EPUAP Pressure Ulcer Prevention and Treatment Guide, 2014 (pdf)

3. Gottrup et al. Wound  Repair and Regeneration 2008;6:615-25

4. Palao I Domenech et al. Journal of Wound Care 2008;17(8):342-48

5. Fogh et al. Wound Repair and Regeneration 2012;20: 815-821

A pressure ulcer (decubitus ulcer) is a localized injury to the skin and/or underlying tissue, usually over a bony prominence. This type of ulcer is the result of pressure, or pressure in combination with shear (2). The pressure prevents the blood from circulating properly, and causes cell death, tissue necrosis and the development of ulcers. Wheelchair users or people confined to a bed (for example, after surgery or an injury) are especially at risk.

 

Major cause of morbidity

Pressure ulcers are a major cause of morbidity and mortality, especially for people with impaired sensation, prolonged immobility, or advanced age. The most common places for pressure ulcers are over a bony prominence, such as elbows, heels, hips, ankles, shoulders, the back, and the back of the head.

 

Classification

Pressure ulcers are classified according to the degree of tissue damage observed. In 2009 the EPUAP-NPUAP advisory panel agreed upon four levels of injury (3):

 

Category/Stage I: Non-blanchable redness of intact skin

Pressure ulcer Category/Stage I: Non-blanchable redness of intact skin

Buttocks, Stage I, NPUAP copyright & used with permission.

Intact skin with non-blanchable erythema of a localized area, usually over a bony prominence. Discoloration of the skin, warmth, edema, hardness or pain may also be present. Darkly pigmented skin may not have visible blanching.


Category/Stage II: Partial thickness skin loss or blister

Pressure ulcer Category/Stage II: Partial thickness skin loss or blister

Buttocks, Stage II, NPUAP copyright & used with permission.
Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous-filled blister.

 

Category/Stage III: Full thickness skin loss (fat visible)

Pressure ulcer Category/Stage III: Full thickness skin loss (fat visible)

Ischium, Stage III, NPUAP copyright & used with permission.

Full thickness tissue loss. Subcutaneous fat may be visible, but no bone, tendon or muscle is exposed. Some slough may be present. May include undermining and tunneling.

 

Category/Stage IV: Full thickness tissue loss (muscle/bone visible)

Pressure ulcer Category/Stage IV: Full thickness tissue loss (muscle/bone visible) 

Sacral Coccyx, Stage IV, NPUAP copyright & used with permission.

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often include undermining and tunneling.

Category/Stage: Unstageable

Unstageable wound

Full thicnkess skin or tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.


Treatment needs (2,3)

  • Pressure must be relieved or removed by appropriate measures.
  • Wound care must be optimised by:
  1. Debridement of necrotic tissue
  2. Appropriate cleansing of wound and surrounding skin
  3. Use of appropriate moist wound healing dressings

Suitable wound dressings for pressure ulcers are foam or alginate dressings with superior absorption and exudate management properties, such as Biatain Silicone or Biatain Adhesive foam dressing or Biatain Alginate dressing. A silver-releasing dressing such as Biatain Ag or Biatain Alginate Ag can help prevent or resolve wound infection.

 

 

Download our tips for preventing, assessing and treating pressure ulcers:

Pressure ulcers – prevention and treatment: A Coloplast quick guide (pdf)

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Acute wounds Acute wounds must be treated promptly to stop bleeding and protect tissue. Read more about managing acute wounds

References

1. Enoch and Price 2004. (http://www.worldwidewounds.com/2004/august/Enoch/Pathophysiology-Of-Healing.html)

2.Winter. Nature  1962;193:293

3. Winter. Journal of Tissue Viability 2006;16(2):20-23

An acute wound is an injury that causes a break in the skin and sometimes the tissue. Acute wounds are classified into two principal types:

  • Acute traumatic wounds, such as abrasions, lacerations, penetrations or bites, and burns
  • Acute surgical wounds resulting from surgical incisions

acute wound

 

Acute wounds – signs and symptoms

  • A cut or tear in the skin
  • Bleeding, swelling, pain, and/or difficulty moving the affected area
  • There may be dirt or foreign objects inside the wound
  • Exudate is normally clear
  • Large or deep, acute wounds with heavy bleeding need acute medical attention to stop bleeding and check for damage to vital organs or tissue. 

 

Treatment needs

Foreign objects should be removed from the wound and necrotic tissue debrided, as it can function as a base for infection and delay wound healing. Wound cleansing with SeaClens Wound Cleanser, may be appropriate.

Exudate production is part of the natural wound healing process (1), but the exudate needs to be managed appropriately. Exudate levels are often high during the inflammatory phase of wound healing, and leakage of exudate under the dressing can damage the surrounding skin. Wound exudate must be absorbed and managed by a dressing with moist wound healing properties. This supports the healing process and reduces scar formation. (2-3)

With appropriate care, smaller acute wounds will normally close within days or weeks depending on the size, depth and position of the wound.

Suitable dressings for acute wounds are dressings with superior absorption and exudate management properties that support a moist wound healing environment. These include Biatain Silicone, Biatain Adhesive or Comfeel. Where infection is present, Biatain Silicone Ag and Biatain Ag are appropriate choices.

 

Why do some acute wounds become chronic?

If a person has a condition affecting the circulation system and/or immune response, normal wound healing processes may be impaired, and the wound may become chronic. Chronic wounds are often defined by the underlying condition that prevents wound healing, such as venous leg ulcers, arterial leg ulcers, diabetic foot ulcers or pressure ulcers.

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Wound and skin condition

Necrosis If a wound contains dead (necrotic) tissue, it’s a sign that the wound is not healing normally. Learn more about debridement of necrotic tissue

Necrotic tissue is often black or yellow. It may be soft or it may form a scab (eschar). Necrotic tissue can contain bacteria – and if the bacteria grow, the wound will become infected.

Necrosis

 

Removal of necrotic tissue (debridement)

Necrotic tissue must be removed in order to support wound healing. Removal can be surgical, mechanical, enzymatic (such as maggot therapy), or it can be achieved by supplementing the body’s own ability to break down necrotic tissue (autolytic debridement). 


Choice of dressing

The autolytic debridement process is optimized when the wound is moist. Coloplast has a range of dressings that support moist wound healing. For optimal moisture balance in the wound, the hydrocolloid Comfeel dressing, Triad hydrophilic wound dressing, and the unique properties of the Biatain foam dressing each support the natural autolytic debridement process.


Purilon gel is ideal for gentle and effective autolytic debridement of tissue in both dry and moist necrotic wounds, when used in combination with a secondary dressing such as Comfeel or Biatain.

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Peri-wound skin The skin surrounding a wound is vulnerable. This may be associated with age, disease processes or exposure of the skin to wound exudate or dressing adhesives. Learn more about peri-wound skin.

Maceration 

Exudate leaked from ulcers can cause maceration, a softening or sogginess and breakdown of the skin that results from on-going contact with excessive moisture. Maceration can lead to skin breakdown, causing the wound to grow or creating satellite ulcers. Macerated tissue is white in color.

macerated skin


Erythema

Erythema is an abnormal redness of the skin caused by dilation of blood vessels. Redness of the peri-wound skin may be a sign of inflammation or wound infection. 


Fragile skin

As we grow older, the texture of our skin changes and our skin becomes thinner, weaker and less protective. If a wound is surrounded by fragile skin, dressings are more likely to cause skin irritation. You must examine the skin carefully before deciding to use either an adhesive or a non-adhesive dressing.

Fragile skin


Choice of dressing

The Biatain dressing range offers dressings with superior absorption and exudate management properties for all types of skin conditions.

If a wound is surrounded by fragile skin, a dressing with silicone adhesive such as Biatain Silicone is an excellent alternative, as it can be used on both fragile and healthy skin.

Normal, healthy skin has a smooth and resilient structure. With proper wound treatment and use of dressings with superior absorption and exudate management, the skin surrounding a wound may be perfectly healthy and suitable for adhesive dressings such as Biatain Adhesive or Biatain Super, Adhesive.


If the skin is very fragile, consider using a non-adhesive dressing such as Biatain Non-adhesive or Biatain Alginate.

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Wound exudate Whether a wound is low, medium or high-exuding, superior absorption and control of exudate are essential for optimal healing. Learn more about wound exudate

References

1. White RJ and Cutting KF. British Journal of Nursing 2003;12(20):1186-1201

2. Adderly UJ. Wound Care, March 2010:15-20

3. Colwell JC et al. Wound Ostomy Continence Nursing 2011;38(5):541-53

4. Enoch B and Harding K. Wounds: A Compendium of Clinical Research and Practice 2003;15(7):213-29

5. Andersen et al. Ostomy/Wound Management 2002;(48)8:34-41

6. Thomas et al. http://www.dressings.org/TechnicalPublications/PDF/Coloplast-Dressings-Testing-2003-2004.pdf

7. White R and Cutting KF. http://www.worldwidewounds.com/2006/september/White/Modern-Exudate-Mgt.html

8. Romanelli et al. Exudate management made easy. Wounds International 2010;1(2).

In the inflammatory phase of wound healing, exudate levels are usually high. Non-healing, or chronic, wounds are often stuck in the inflammatory phase and may produce large amounts of exudate. Increased exudate levels can be a symptom of infection and increased oedema.

Wound exudate is a fluid composed of plasma, blood cells and platelets. Most of the wound exudate filters from the blood and/or lymph system into the wound area, but red blood cells and platelets leak from injured capillaries. Composition and viscosity varies, from thin and clear plasma fluid to thick yellow secretion containing high concentrations of white blood cells and bacteria.


Controlling exudate

If wound exudate is not properly controlled, it can leak from the dressing and result in the peri-wound skin being exposed to the exudate (1). This causes over-hydration maceration of the skin and can ultimately delay healing (2,3).

Maceration is a softening or sogginess and breakdown of the skin caused by on-going contact with excessive moisture. Macerated tissue looks white and maceration can cause an ulcer to grow or create satellite ulcers.


Macerated skin(2,3)

  • Delays healing
  • Increases risk of infection
  • Increases friction risk
  • Can result in wound enlargement

macerated skin


It is therefore very important that excess exudate is removed from the wound by an absorbent dressing. (4)

Control of exudate, removal of unhealthy tissue by debridement and management of bacterial load are all part of good wound bed preparation. The optimal wound dressing keeps the wound moist and absorbs exudate, locking it inside the dressing to prevent maceration.


Dressings for exuding wounds

We recommend the Biatain dressing range, which provides superior absorption - of low to high exuding wounds. Biatain dressings effectively absorb and retain wound exudate, ensuring a moisture balance that is optimal for wound healing. (7,8)

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Wound infection All wounds contain bacteria – even wounds that are healing normally. But if the bacteria count rises the wound may become infected. Learn more about treating infected wounds

References

1. Jørgensen et al. International Wound Journal 2005;2(1):64-73

2. Münter et al. Journal of Wound Care 2006;15(5):199-206

3. Reitzel & Marburger. EWMA 2009

4. Ip et al. Antimicrobial activities of silver dressings: an in vitro comparison. Journal of Medical Microbiology 2006;(55):59-63.

5. Basterzi et al. In-vitro comparison of antimicrobial efficacy of various wound dressings. Wounds 2010; July.

6. Data on file (Independent laboratory testing performed by Wickham Laboratories).

7. Thomas et al. www.dressings.org/TechnicalPublications/PDF/ Coloplast-Dressings-Testing-2003-2004.pdf

Wounds that are not healing normally may have a bacterial imbalance resulting in local infection of the wound.

Likely signs of wound infection are one or more of the following:

  • Delayed or stalled healing
  • Odor
  • Increased wound exudate
  • Absent/abnormal/discolored granulation tissue
  • Increased pain at wound site

infected wound

 

Other symptoms

Additional clinical symptoms may arise if the infection spreads to the healthy tissue surrounding the wound. Depending on the type of bacteria, the wound exudate may become more puss-like, and the peri-wound skin may be tender, red and painful. The patient may also have a fever.

Please remember that diabetic foot ulcers do not always present with the classical signs of local infection.

 

Dressings for infected wounds and wounds at risk of infection

If a wound is healing normally, a foam dressing with superior absorption such as Biatain or Biatain Silicone is ideal. If the wound is infected or there is risk of wound infection, we recommend silver dressings such as Biatain Ag, Biatain Silicone Ag or Biatain Alginate Ag. These provide superior absorption for infected wounds (1-7). If the infection is spreading beyond the wound, the silver dressing must be combined with systemic antibiotic treatment at the discretion of a physician. 

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Resources

External Resources For more information about Wound Care, you can contact the resources below. List of External Resources
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Wound Care Organizations

  • American Academy of Dermatology

The academy members include practicing dermatologists who are committed to excellence in patient care, medical and public education, research, professionalism and member services support . Learn more about this academy at www.aad.org.  

  • Association for Professionals in Infection Control and Epidemiology

APIC is a professional association dedicated to improving health and patient safety by reducting risks of infection and other adverse outcomes. Learn more about this association at www.apic.org.

  • Association for the Advancement of Wound Care

AAWC is a non-profit association for anyone involved in wound care. Join in to learn more about wound care at www.aawconline.org

 

  • Diabetic Foot Study Group

The aim of the DFSG is to promote improvements in diabetic foot care. Read more about this group at www.dfsg.org

  • European Pressure Ulcer Advisory Panel

EPUAP works to lead and support all European countries in the efforts to prevent and treat pressure ulcers. You can learn more about their activities at www.epuap.org

  • European Wound Management Association

The EWMA deals with all clinical and scientific issues related to wound healing. Each year, EWMA hosts one of the largest international events within wound management and wound healing in Europe. Learn more about this association at www.ewma.org

  • International Working Group on the Diabetic Foot

IWGDF works to improve outcomes of diabetic foot problems and strengthen the communication between healthcare professionals. Learn more about their work atwww.iwgdf.org.

  • International Association for the Study of Pain

IASP is the world's largest multidisciplinary organization working to support the study of pain and to translate that knowledge into improved pain relief worldwide. Read more about them at www.iasp-pain.org.

  • National Pressure Ulcer Advisory Panel

NPUAP is an American organization working for the prevention and improved treatment of pressure ulcers. Read more at www.npuap.org

  • Strategic Marketplace Initiative (SMI)

A consortium of executives representing healthcare providers; medical products, pharmaceuticals and supply chain distribution companies; and service businesses united to reengineer and advance the future of the healthcare supply chain for the purpose of improving the overall healthcare marketplace in the United States. Learn more by visitingwww.smisupplychain.com.

  • World Wide Wounds

World Wide Wounds is an electronic wound management journal dedicated to providing practical guidance and information on all aspects of wound management to healthcare professionals worldwide. Read the journal at www.worldwidewounds.com

  • Wound Healing Society

The Wound Healing Society is a non-profit organization for clinical and basic scientists dedicated to improve the area of wound healing. Learn more about their activities atwww.woundheal.org

  • Wound, Ostomy and Continence Nurses Society

The WOCN Society is a professional nursing society. It supports its members by promoting educational, clinical and research opportunities to advance the practice of expert healthcare to individuals with wounds, ostomies and incontinence. Read more about this society atwww.wocn.org

  • World Union of Wound Healing Societies

WUWHS is an international organization dedicated to improving the wound care standards for patients and the healthcare performance of professionals. It also works to ensure universal access in all healthcare systems. For more information go to www.wuwhs.org

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