Information to be documented
1. Date and time of assessment
2. Type of wound and underlying etiology
3. Factors that could delay wound healing
4. Location of wound
5. Duration of wound
6. Wound measurements
7. Depth of damage
8. Type and color of tissue in wound bed
9. Presence of infection
10. Exudate levels and type
11. Presence of odor
12. Presence of pain and its level
13. Wound margins
14. Dressing selection and regimen
Wound assessed at each dressing and measured at 4 weeks interval
Various parameters and techniques have been used to describe and document an ulcer on the lower extremities. Firstly, an ulcer anywhere in the body should be described under the following headings (Fig. 29.1).
Fig. 29.1
Chronic diabetic ulcers of the lower extremity
1.
Document the location of the ulcer
For example, venous ulcers are more common in the gaiter area and pressure ulcer on pressure points like the sacrum, ischial tuberosity, and heel.
2.
Document the type of wound according to etiology
For example, arterial, pressure ulcer, venous, diabetic, or neuropathic
3.
Document the size
It is measured in cm in three dimensions:
Length (maximum measurement in a head to toe direction)
Width (maximum measurement at right angle to above)
Depth (deepest part of the visible wound bed is measured)
4.
Document any sinus tract/undermining/tunneling
Undermining or tunneling is described as tissue destruction underneath the intact skin margins (Fig. 29.2). When this undermined area gets epithelialized, it forms a sinus tract.
Fig. 29.2
A diabetic foot ulcer with undermined edges
5.
Document type/amount/odour of exudate:
Type – serous, serosanguinous, sanguinous, purulent
Amount – none, scant, small, moderate, large
Odour – absent or present
6.
Describe the presence or absence of necrotic tissue
Describe the amount and color. Describe whether it is nonadherent, loosely adherent, or firmly adherent.
7.
Document about granulation tissue:
Whether it is pale or red, whether it is occupying whole of the floor or partial area of the ulcer floor, i.e., in islands or complete wound (Fig. 29.4).
Fig. 29.4
Chronic ulcer showing granulation tissue on its floor
8.
Define the wound edges:
Defined or undefined. Whether macerated, fibrotic, or callused.
9.
Describe the surrounding tissue:
Whether the surrounding skin is normal, hyperpigmented, have evidence of lipodermatosclerosis, or have prominent veins.
29.4 Classification of Ulcers
Various systems are available to describe the various types of ulceration.
29.4.1 Wagner System [6]
Has six grades from Grade 0 to Grade 5
Grade 0 – Pre- or post-ulcerative site
Grade 1 – superficial ulcer
Grade 2 – ulcer penetrating to the tendon or joint capsule
Grade 3 – lesion involving deeper tissue
Grade 4 – forefoot gangrene
Grade 5 – whole-foot gangrene involving more than 2/3rd of the foot
Another system has been described by the University of Texas:
29.4.2 University of Texas System
Grade 0 | Grade 1 | Grade 2 | Grade 3 | |
|---|---|---|---|---|
Pre or post ulceration site | Superficial wound not involving the tendon, capsule, or bone or joint | Wound penetrating to the tendon or capsule | Ulcer penetrating to the bone or joint | |
Lesions without infection or ischemia | ||||
Infected/nonischemic lesions | ||||
Noninfection/ischemic lesions | ||||
Infected ischemic lesions |
Another system is SAD System.
29.4.3 S(AD) SAD System (Area, Depth, Sepsis, Arteriopathy, and Denervation) [7]
Grade | Area | Deep | Sepsis | Arteriopathy | Denervation |
|---|---|---|---|---|---|
0 | Skin intact | Skin intact | – | Pedal pulses present | Intact |
1 | Lesion <1 cm2 | Superficial (skin with SC tissue) | No infected lesions | Pedal pulses reduced or missing | Reduced |
2 | Lesion from 1 to 3 cm2 | Lesion penetrating to the tendon, periosteum, and joint capsules | Cellulite-associated lesion
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