ulcer assessment

ulcer assessment

see Table 1 and Table 2
Table 1: 'High-risk' patient categorization
Risk categoryExamples
Vascular and peripheral vascular diseaseArterial (macro- and microvascular) disorders
Venous disease
Lymphatic disease
Cardiac disease
Neurological diseasePeripheral and central nervous system diseases that lead to motor, sensory and autonomic signs and symptoms
Immune compromisePrimary compromise: AIDS, complement cascade disorders, neutrophil and macrophage compromise
Secondary to drug therapies: steroids, immunosuppressant drugs, chemotherapy
ArthritidesRheumatoid arthritis with sensory neuropathy, vasculitis and anaemia Sero-negative arthropathy, such as psoriatic arthropathy, ankylosing spondylitis, systemic lupus erythematosus
Severe Raynaud's disease
Metabolic and endocrine diseaseDiabetes mellitus, thyroid disease, disorders of adrenal function
OedemaOedema compromises tissue perfusion
Oedema is associated with many systemic pathologies, such as heart and renal disease, and venous incompetence
Blood disordersAnaemias (reduce tissue oxygenation)
Leukocyte dysfunction (compromises immune response)
Nutritional deficitMalabsorption or reduced intake of essential nutrients (proteins, vitamins, minerals)
Psychosocial problemsDepressional or attitudinal states where patients are unable to care for themselves adequately
Medication regimesLong-term parenteral or high-dose topical corticosteroids
Immunosuppressant drugs

AIDS, acquired immunodeficiency syndrome.

Table 2: Examination of chronic wounds (ulcers): appearance of the wound
Point of noteFeatures to be recorded
SiteThe exact anatomical location of the wound
SizeThe dimensions of the wound, in millimetres:
• Width (medial-lateral distance)
• Length (longitudinal distance)
• Depth
AppearanceThe appearance of the wound and the surrounding tissues:
• Callosity
• Maceration
• Signs of local infection
• Signs of spread of infection (cellulitis, lymphangitis, lymphadenitis)
SidesThe orientation of the walls of the wound in relation to the skin surface:
• Undermined (extending wound)
• Vertical (static wound)
• Saucer-shaped (healing wound)
BaseThe nature of the wound floor:
• Sloughy (infected, non-healing)
• Granulating (healing)
• Hypergranulating (non-healing or traumatized wound)
• Deep structures, such as joint capsule/tendon/bone, visible through wound base (extending wound)
DischargeA deep swab of the discharge should be sent for pathology laboratory culture and sensitivity
The amount and type of discharge should be noted (the amount can be inferred by the state of the dressing in relation to how long it has been in situ):
• Colour - yellow/green (extending wound or infection); red/brown (blood or infection); turquoise green (Pseudomonas infection); clear (joint fluid or healing wound)
• Texture - thick (staphylococcal infection or extending wound); thin (streptococcal infection or healing wound)
• Amount - copious (infection); plentiful (extending or non-healing wound); scarce (healing wound)
• Odour - very smelly (necrotic, infected); sweet (healing)
References in periodicals archive ?
All cases were documented by photography and registration on a modified version of the WHO Buruli ulcer assessment form (1).
Further well-designed, large scale research is required most urgently in the areas of risk of delayed healing/complications to healing, pressure ulcer assessment, support surfaces, use of antimicrobials, nutrition and surgery.
The new definitions developed by NPUAP will better enable the caregiver to correctly document pressure ulcer assessment.
Each pressure ulcer assessment tool should be used for what it is designed to do, she emphasized.
This wide cost span reported in the literature may be related to inconsistencies or inaccuracies in data collection on ulcer assessment and management cost.
Which of the following will the ultrasound pressure ulcer assessment technology described by Mogensen and Hertig ("Stopping Pressure Ulcers--Before They Start") not detect?