Introduction
Wounds are often managed inappropriately because clinicians lack the knowledge required to accurately assess and diagnose wounds.1-4 Research indicates that physicians and nurses do not receive adequate wound education, perpetuating wound mismanagement.5-13 Wounds that are not managed appropriately may result in delayed healing, complications, decreased quality of life, and increased healthcare costs.3,4,14 Thus, having an evidence-based, systematic approach to wound assessment and management is imperative to ensure accurate diagnosis, promote healing, and increase clinician competence and confidence. Although there are several wound assessment tools available, many clinicians choose not to use them or use them inconsistently.15 In addition, many of the tools do not offer clinicians a holistic assessment of the patient.4,14 Barriers to using wound assessment tools may also arise from a lack of consensus and ambiguous information that lacks practical directives.4,16
This article outlines a systematic approach to wound assessment and management that utilizes best practices and combines elements of several wound assessment tools, providing clinicians with a holistic approach that guides them through all the necessary steps for accurate assessment and management. The ability of clinicians to accurately assess and manage wounds confers many benefits to both the patient and the healthcare system, including improved healing, documentation, and interprofessional communication, as well as decreased patient travel and healthcare costs.
The systematic approach that the authors recommend is the ABCDEFGHI approach (see ABCDEFGHI approach to wound assessment and management). This mnemonic outlines the basic overarching steps that members of the healthcare team should undertake for any patient encounter involving wound care. Each step is described in detail with clear and concise instructions to improve clinician competence and confidence in wound assessment and management. It is important to note that the extent to which a single clinician will carry out each of these steps is context specific. For example, in rural and underserviced communities where clinicians have a wider scope of practice, a single clinician may be more directly involved in many of the steps contained within the process. Alternatively, in a larger center with more resources and more clearly defined roles, members of the healthcare team may only be involved in a subset of steps within the process.
Methods
Information for this wound assessment and management approach was collected from guidelines from prominent national and international organizations including Wound Care Canada, Wounds UK, Wounds International, and the World Union of Wound Healing Societies. The authors also carried out a literature search using Google Scholar, MEDLINE, and PubMed databases to further inform the approach described in this article. Search terms included "wound," "assessment," and "management." Additional resources were identified by combing through the references of each of the guidelines and articles used in this study. The authors extracted information from the guidelines and articles that related to wound history and physical examination; laboratory investigations and imaging; factors associated with poor wound healing; and management strategies including cleaning, dressing, and referring the wound. The extracted information was condensed into an original, easy-to-follow, step-by-step process.
ABCDEFGHI Approach
A: Ask
Begin the patient encounter by taking a thorough history: Accurate wound assessment requires information about the whole patient, not just the wound.4,14 The history should include the patient's medical history, pain, medications, allergies, substance use, nutrition status, and psychosocial factors, including mental health status in addition to information about the wound (see Examples of questions and their significance).17-20 The Canadian Nutritional Screening Tool is a validated two-question tool that may be used to detect patients at increased nutrition risk.21 Patient-centered interview techniques, such as the FIFE model (Feelings, Ideas, Functioning, Expectations), may also be used to elicit the patient's illness experience and goals with respect to their wound and care plan.22 Together, these questions enable the clinician to accurately determine the wound etiology, note any patient factors that may pose a barrier to healing, and address any goals of care that are deemed important by the patient.
B: Barriers
Barriers to wound healing may include both local and systemic factors. Local factors are those that are specific to the wound and surrounding tissues,23 such as foreign bodies, infection, venous insufficiency, and oxygen status.23-25 Systemic factors are those that influence the patient's ability to heal.23 These include stressors, age, sex hormones, ischemia, diabetes, obesity, medications, substance use, immune status, and nutrition (see Factors that affect wound healing).17,18,20,23-26
C: Clean
Before assessing the wound, it should be cleaned to clear it of infection-causing microorganisms, foreign bodies, and debris. It is recommended that the wound be flushed with low-toxicity solutions, such as normal saline or water.17,18,27 Antiseptic solutions are required only when infection risk is a concern.27 The appropriate use of antiseptic solutions is discussed further in the "Good Healing" section.
In some instances, wounds may require debridement as part of the cleaning process. Debridement is indicated for wounds containing nonviable tissue such as necrotic tissue, eschar, and slough.17,18,27 Debridement may be achieved using autolytic, enzymatic, mechanical, or surgical methods (described in the "Good Healing" section).17,18,27
D: Do
Once there is clear visualization of the wound after cleaning, a physical examination may be performed (see Recommended examination and investigation of wounds). First, perform a visual inspection: locate the site of the wound, note the size of the wound, and assess the wound bed, wound edge, and periwound skin.4,17-19,24,26,28,29 Second, feel the wound and palpate surrounding structures, such as pulses and lymph nodes, with a gloved hand.17,18 If applicable, joint mobility may also be examined at this point. Third, use a measurement tool to accurately record wound dimensions, including length, width, and depth.18,19,24,28,29
After performing a physical examination, determine if further investigations are required. Consider obtaining wound cultures and other investigations such as blood tests, biopsies, or diagnostic imaging.24,25,29,30 If barriers to healing were identified, such as diabetes, obesity, and malnutrition, gather baseline measurements. With your patient, devise a plan to control these barriers and reassess the patient's measurements throughout the healing process to gain insight as to whether optimal control has been achieved. If the wound requires the expertise of a specialist or an allied healthcare provider, arrange a consult (see the "Involve" section). Suggested investigations are summarized later in the article.
E: Exposed
While examining the wound, note any exposed underlying structures, such as tendons, cartilage, bone, nerves, blood vessels.29 If underlying structures are exposed, a referral to plastic surgery may be required for reconstruction (see Exposed wound requiring reconstruction). In some cases where underlying tissue is not exposed, a referral to plastic surgery may still be required for skin grafting. Wounds may require skin grafting if they cannot be adequately closed by suturing techniques.
F: Factors
During the physical examination of the wound, make note of any factors that may complicate the healing process such as wound size or location or the presence of infection, necrosis, abnormal granulation tissue, or slough.4,17-19,24-26,28 Once identified, these factors must be controlled in the management plan (see Factors that complicate wound healing).
G, H: Good Healing
After identifying factors that may complicate the healing process, devise a management plan that controls these factors and optimizes the wound environment for healing. At this point, the wound may be categorized into one of three categories: healable, maintenance, or nonhealable.18,31 Depending on the categorization of the wound, various aspects of the wound and its environment must be considered when devising a management plan, such as the presence of infection or odor, moisture balance, edema, exudate, the depth of the wound, the need for debridement, and the presence of blood (see Dressing considerations to promote good healing).4,17-19,26-28,32
Approximately two-thirds of wounds fall under the healable category, in which there is adequate blood supply for healing once the initial cause of the wound has been addressed.18,31 The main considerations for treatment of a healable wound include debridement of nonviable tissue, treating local inflammation or infection with topical or systemic agents, and facilitating a moist environment that promotes healing.18,31 Topical treatment may be used for wounds containing three or more of the following features: nonhealing, exudative, bleeding, debris (slough, necrosis), or odor.31 Alternatively, systemic treatment may be utilized for wounds containing three or more of the following features: large size, temperature at least 3[degrees] F higher than mirror image site, probe to or exposed bone, new or satellite areas of breakdown, increased exudate, erythema and/or edema, and odor.31
For wounds in which there is adequate blood supply but healing may be impeded by lack of resources or patient nonadherance, the wound is considered maintenance.18,31 Approximately one-quarter of wounds fit into this category.18 For maintenance wounds, any debridement carried out is conservative and minimal.18,31 Prevention of bacterial growth is managed by cleansing the wound with low-toxicity topical antiseptic solutions, such as povidone-iodine, chlorhexidine, and polyhexamethylene biguanide or with systemic antibiotics. Further, there is an emphasis on strategies that reduce moisture.18,31
Nonhealable wounds are those in which the blood supply is inadequate and cannot be treated because of advanced disease.18,31 In caring for nonhealing wounds, the goals are to maximize patient comfort, prevent worsening of the wound, and assist the patient in carrying out activities of daily living.18 In this setting, debridement is only necessary for comfort or removal of slough.18,31 Similar to maintenance wounds, topical antiseptic solutions and systemic antibiotics may be used to help prevent infection, and moisture reduction strategies are utilized.18,31
Another good healing strategy involves correcting any modifiable risk factors that are associated with the initial wound etiology or act as barriers to healing. For example, improving patient nutrition, gaining better control of medical conditions that may contribute to wound risk, and encouraging patients to refrain from smoking or drinking alcohol may be beneficial. It is also important to help the patient manage pain to improve their quality of life during the healing process.
I: Involve
Wound management sometimes requires referral to a specialist. Urgent referral may be necessary if the patient has a difficult medical history, such as having multiple comorbidities or uncontrolled diabetes mellitus, if they are experiencing sepsis, or if the wound is complex. There are two main factors to consider when deciding on a referral: wound location and wound type.
Wound location will help determine which specialist is best suited to manage the referral. For example, abdominal wounds may be referred to general surgeons; wounds to the limbs that affect bones and joints may be referred to orthopedic surgeons; wounds in which pulses are not palpable may be referred to vascular surgery; and wounds that are ulcerating, located on the hands, or related to burns or frostbite may be referred to plastic surgeons.
The wound type will help distinguish how quickly to make the referral. Any wounds exhibiting features of necrotizing soft tissue infection must be referred immediately. Any wounds that are infected and discharging or wounds that are positive for group A Streptococcus should be referred urgently. Wound types that are nonurgent, meaning that they can be seen within 7 days, include chronic wounds, leg ulcers, and pressure injuries. Large wounds may be reviewed by a specialist in an ambulatory care setting.
If a nutrition risk has been identified, consulting a dietitian is critical for optimizing the patient's nutrition status. If the patient has difficulty with intake due to swallowing, a speech language pathology consultation may also be helpful.
Conclusion
This article presents a systematic ABCDEFGHI approach to wound assessment and management aimed at enhancing the basic wound care knowledge of clinicians. Following this stepwise approach will encourage the use of best practices, enhance the accurate diagnosis of wounds, and encourage the use of optimal healing strategies, thereby improving patient outcomes and clinician competence and confidence when presented with wounds.
Practice pearls
* A thorough patient history is key for identifying wound etiologies and barriers to healing that must be corrected to promote healing.
* The wound must be effectively cleaned to facilitate examination and to prevent infection and further tissue damage.
* Investigations, including serum markers, wound cultures, and imaging can identify local and systemic factors that must be managed to promote healing.
* While performing a physical examination, local wound factors that may complicate the healing process and manage these with appropriate dressings should be identified.
* When in doubt, a referral can be made to assist in the management of complex wounds.
REFERENCES