Physical Examination
The Wound Healing Society often uses the mnemonic device TIME, which is a comprehensive description of the key elements associated with impaired wound healing, as follows:
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T = Tissue: Note the presence of devitalized or necrotic tissue, as well as specific characteristics of the tissue surrounding the wound
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I = Inflammation or infection: Note areas both within and surrounding the wound site
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M = Moisture: Note the state of moisture balance and whether the wound is macerated
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E = Edge of the wound: This includes assessing for reepithelialization versus nonadvancing or nonhealing edges; assessing the blood supply to the edges of the wound
Complications
Complications of nonhealing wounds include the following:
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Amyloidosis - See Macular Amyloidosis.
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Bacteremia - See Septic Shock.
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Cellulitis
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Heterotopic bone formation
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Maggot infestation
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Perineal-urethral fistula
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Pseudoaneurysm - See Peripheral Vascular Injuries.
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Septic arthritis
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Sinus tract or abscess
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Image of advanced sacral pressure ulcer shows the effects of pressure, shearing, and moisture.
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Sacral pressure ulcer before and after flap closure.
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Chronic ulcer of medial aspect of right leg due to pyoderma gangrenosum.
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Pressure ulcers of the lateral aspect of the right foot.
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Basal cell cancer manifesting as a chronic leg ulcer.
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Heel pressure ulcer.
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Sacral ulcer.
Tables
Category |
Examples |
Description |
Applications |
Alginate |
AlgiSite, Comfeel, Curasorb, Kaltogel, Kaltostat, Sorbsan, Tegagel |
Alginate dressings are made of seaweed extract contains guluronic and mannuronic acids that provide tensile strength and calcium and sodium alginates, which confer an absorptive capacity. Some can leave fibers in the wound if they are not thoroughly irrigated. These dressings are secured with secondary coverage. |
These dressings are highly absorbent and useful for wounds have copious exudate. Alginate rope is particularly useful to pack exudative wound cavities or sinus tracts. |
Hydrofiber |
Aquacel, Aquacel-Ag, Versiva |
An absorptive textile fiber pad, hydrofiber is also available as a ribbon for packing of deep wounds. This material is covered with a secondary dressing. The hydrofiber combines with wound exudate to produce a hydrophilic gel. Aquacel-Ag contains 1.2% ionic silver that has strong antimicrobial properties against many organisms, including methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci. |
Hydrofiber absorbent dressings used for exudative wounds. |
Debriding agents |
Hypergel (hypertonic saline gel), Santyl (collagenase), Accuzyme (papain urea) |
Various products provide some chemical or enzymatic debridement. |
Debriding agents are useful for necrotic wounds as an adjunct to surgical debridement. |
Foam |
LYOfoam, Spyrosorb, Allevyn |
Polyurethane foam has absorptive capacity. |
These dressings are useful for cleaning granulating wounds with minimal exudate. |
Hydrocolloid |
CombiDERM, Comfeel, DuoDerm CGF Extra Thin, Granuflex, Tegasorb |
Hydrocolloid dressings are made of microgranular suspension of natural or synthetic polymers, such as gelatin or pectin, in an adhesive matrix. The granules change from a semihydrated state to a gel as the wound exudate is absorbed. |
Hydrocolloid dressings are useful for dry necrotic wounds, wounds with minimal exudate and for clean granulating wounds. |
Hydrogel |
Aquasorb, DuoDerm, Intrasite Gel, Granugel, Normlgel, Nu-Gel, Purilon Gel, KY Jelly |
Hydrogel dressings are water-based or glycerin-based semipermeable hydrophilic polymers; cooling properties may decrease wound pain. These gels can lose or absorb water depending upon the state of hydration of the wound. They are secured with secondary covering. |
These dressings are useful for dry, sloughy, necrotic wounds (eschar). |
Low-adherence dressing |
Mepore, Skintact, Release |
Low-adherence dressings are made of various materials designed to remove easily without damaging underlying skin. |
These dressings are useful for acute minor wounds, such as skin tears, or as a final dressing for chronic wounds that have nearly healed. |
Transparent film |
OpSite, Skintact, Release, Tegaderm, Bioclusive |
Transparent films are highly conformable acrylic adhesive films with no absorptive capacity and little hydrating ability. They may be vapor permeable or perforated. |
These dressings are useful for clean, dry wounds with minimal exudate. They also are used to secure an underlying absorptive material, to protect high-friction areas and areas that are difficult to bandage (eg, heels) and to secure intravenous catheters. |
Stage |
Definition |
Appearance |
Appropriate topical treatment |
Average healing time (d) |
I |
Nonblanchable erythema of intact skin |
Pink skin that does not resolve when pressure is relieved; discoloration; warmth; induration |
DuoDerm q2-3d |
14 |
II |
Partial-thickness skin loss involving epidermis and/or dermis |
Cracking, blistering, shallow crater, abrasion |
Cleanse with saline; DuoDerm/Tegaderm dressing |
45 |
III |
Full-thickness skin loss into subcutaneous fatty tissues or fascia |
Distinct ulcer margin; deep crater (in general, 2.075 mm or deeper [the thickness of a nickel]) |
Debride; irrigate with saline; apply DuoDerm/Tegaderm |
90 |
IV |
Full-thickness skin loss with extensive tissue involvement of underlying tissues |
Extensive necrosis; damage to underlying supporting structures, such as muscle, bone, tendon, or joint capsule |
Surgically debride; irrigate with saline (possibly under pressure); apply advanced topical dressings; consider antibiotics |
120 |
*When the overlying skin is necrotic, the staging cannot be accurate until debridement is performed. |
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Class |
Type |
Principle |
Examples |
I |
Simple |
Pressure-relieving pad or mat |
3- to 5-inch foam mattress, gel overlay, egg-crate mattress |
II |
Advanced |
Powered air* overlay for mattress with low air loss feature; nonpowered advanced pressure-reducing mattress replacement or powered air* flotation bed with or without low air loss feature |
Roho dry floatation mattress system, Pegasus Renaissance mattress |
III |
Air fluidized |
Flotation by filtered air* flow pumped through porcelain beads |
Clinitron bed |
*Long-term use of powered air devices is relatively contraindicated for patients with chronic obstructive lung disease, such as chronic bronchitis, emphysema, and asthma. |
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Type |
Description |
Examples |
Single layer |
Single-layer simple tubular woven nylon/elastic bandages may be imprinted with rectangles that stretch to squares when appropriate wrapping tension (30-40 mm Hg) is applied. |
ACE bandage, Comperm (Conco Medical), Setopress (Seton Healthcare Group) |
Three layer |
The layers include a padding absorption layer, a compression bandage layer, and a cohesive compression bandage. Bandages may be left in place for up to 1 week depending on wound exudate. |
Dyna-Flex (Johnson & Johnson) |
Four layer |
The layers include a nonwoven wound contact layer that is permeable to wound exudate and 4 overlying bandages. Bandages may be left in place for up to 1 week depending on exudate volume. |
Profore (Smith & Nephew) |
Impregnated wrap |
The porous flexible occlusive dressing is composed of stretchable gauze and a nonhardening zinc oxide paste. |
Unna boot (ConvaTec) |
*Compression wraps are contraindicated in severe arterial compromise. Some of these products are contraindicated in patients who are allergic to latex. |
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