TOOLS FOR WOUND HEALING

Contents
Pressure Ulcer Scale for Healing . . . . . . . . . . . . . . . . . . . 2 Wagner Scale for Diabetes . . . . . . . . . . . . . . . . . . . . . . . 7 Semmes-Weinstein Monofilament Exam. . . . . . . . . . . . 8 Sussman Wound Healing Tool . . . . . . . . . . . . . . . . . . . . 9 Bates-Jensen Wound Assessment Tool . . . . . . . . . . . . 10

Wound healing should be determined by using validated assessment tools. There are several tools available that evaluate the progress of a wound using objective, rather than subjective, data. Wound healing should never be measured by reverse staging, by a decrease in size alone, or any other solitary parameter.

Pressure Ulcer Scale for Healing

A useful tool for monitoring the change of a pressure ulcer over time is the Pressure Ulcer Scale for Healing (PUSH) Tool, developed by the National Pressure Ulcer Advisory Panel (NPUAP). Although this is an excellent tool, it should be used in conjunction with good clinical judgment. This tool is intended for use only with pressure ulcers. Other types of wounds should be evaluated using a different tool. To use the PUSH Tool, the pressure ulcer is assessed and scored on the following three elements:
Length x Width is measured and scored from 0 to 10. Exudate Amount is scored from 0 (none) to 3 (heavy). Tissue Type is assessed and scored from 0 (closed) to 4 (necrotic tissue).

In order to ensure consistency in applying the tool to monitor wound healing, definitions for each element are supplied at the bottom of the tool. Step 1: Using the definition for length x width, a centimeter ruler measurement is made of the greatest length (head to toe). A second measurement is made of the greatest width (side to side). Multiply these two numbers to obtain square centimeters and then select the corresponding category for the size on the scale. Record the patients score. Step 2: Estimate the amount of exudate after removal of the dressing and before applying any topical agents. Select the corresponding category for none, light, moderate or heavy. Record the patients score. Step 3: Identify the type of tissue present in the wound bed. If there is ANY necrotic tissue, it is scored a 4. For the PUSH Tool, necrotic tissue refers to eschar and not slough. If there is ANY slough, it is scored a 3, even though most of the wound may be covered with granulation tissue. Granulation tissue is represented by a score of 2. If there is evidence of epithelial tissue, the score is 1. Once the wound is closed, the score becomes 0.
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Step 4: Add up the scores of the three elements to determine a total PUSH Tool score. Step 5: Transfer the total score to the Pressure Ulcer Healing Graph. Changes in the score over time provide an indication of the changing status of the ulcer. If the score decreases, the wound is improving or healing. If the score increases, the wound is deteriorating.
Example: Mrs. JM PUSH Tool Scores at Admission: L x W = 12.2 or 9 Moderate Drainage = 2 Slough = 3 Total = 14

Example of the PUSH Tool in Use Mrs. JM was admitted to the hospital with a Stage IV pressure ulcer. The wound is located on her coccyx and measures 3.4 x 3.6 x 2.0 cm. There is a moderate amount of drainage and the majority of the wound bed is covered with granulation tissue. However, approximately 25 percent of the wound is covered with a thin layer of slough. Without knowing anything else about Mrs. JM, the PUSH Tool can be completed for monitoring the condition of her wound. Her hospital stay includes a nutritional consult with dietary modifications and working with a physical therapist to increase her mobility. Mrs. JM receives a thorough assessment and is placed on a bladder program for incontinence. With prompted voiding, she remains continent. Wound care includes topical dressings that manage the wound condition. After one week, the wound measures 2.8 x 3.1 x 1.8 cm with slough covering approximately 10 percent of the wound bed. A moderate amount of drainage remains. After another week and the addition of an antimicrobial dressing, the wound measures 2.5 x 2.8 x 1.0 cm with no slough. A moderate amount of drainage remains. By week four of treatment, the drainage has decreased to light and the slough has been removed to reveal an adequately granulating wound bed with evidence of epithelialization at the wound edges. The wound measures 2.2 x 2.4 x 0.8 cm. The following week, the wound measures 1.6 x 1.8 x 0.2 cm. There is no drainage and the wound bed is granulating nicely with evidence of epithelialization. Mrs. JM is discharged and a home health agency is assisting her. They continue to use the PUSH Tool to document the

Example: Mrs. JM PUSH Tool Scores at Discharge: L x W = 0.8 or 3 No Drainage = 0 Closing = 1 Total = 4 5

progress of the wound. After one week the wound is almost completely closed and measures 0.8 x 1.0 x 0.1 cm with no drainage. Mrs. JMs wound is completely closed after week two with the home health agency.

Wagner Scale for Diabetes

The Wagner Scale is designed specifically for the patient with diabetes mellitus. It gives the clinician the ability to assess the foot based on the degree of involvement with skin and wound issues. It is a grading system from 0 to 5, with 5 being the worst possible situation.
Grade 0 ulcers have intact skin. Grade 1 ulcers are superficial. Grade 2 ulcers are deeper, and may extend to tendons or bones. Grade 3 ulcers contain an abscess or osteomyelitis. Grade 4 ulcers have gangrene of the forefoot. Grade 5 ulcers have gangrene of a major portion of the foot.

This scale provides the clinician with a mechanism to describe the degree of damage and gangrene when communicating with other clinicians.

Wagner Scale for Diabetes Grading System

Grade 0 (Zero) The patient has diabetes. There are no signs of any damage or ulceration on the feet. It is appropriate to evaluate the patient annually with the SemmesWeinstein monofilament to determine if there are any changes in sensation. The patient has developed a superficial ulcer. The ulcer does not involve any deep tissue or full-thickness tissue destruction. The patient should be able to close this wound with appropriate management of the diabetes, wound care and offloading pressure. The patient should be reassessed every 3 months The ulcer involves deep tissue destruction that may involve muscle, bone or tendon. Aggressive treatment is necessary to prevent complications such as amputation. The aggressive management of diabetes mellitus includes off-loading and prevention of osteomyelitis. Again, additional assessment for other wounds is necessary. The ulcer involves gangrene or a deep tissue abscess. There is potential for the loss of a limb. Diabetes control as well as aggressive topical wound care is necessary. The ulcer involves gangrene of the forefoot. Limb salvage is the goal of treatment. The ulcer involves gangrene of a major portion of the foot. The possibility of limb loss increases.

Grade 1

Grade 2

Grade 3

Grade 4 Grade 5 7

Semmes-Weinstein Monofilament Exam

Testing for protective sensation, such as the feeling a person gets when a blister forms or when stepping on a small pebble, is one of the best ways to screen for neuropathy. You can test quickly and reliably with the Semmes-Weinstein Monofilament Exam (SWME). This test uses a single, calibrated, untwisted 5.07 (10 gram) nylon monofilament (similar to a strong Fishing Line). It is usually mounted on a plastic or cardboard holder, and is standardized to deliver a 10-gram force when pushed against an area of the foot. Monofilament Exam Instructions:
1) 2) 3) 4) 5) Explain the procedure to the patient. Position the patient in a comfortable position, for ease of performing the exam. Demonstrate the use of the monofilament on the patients hand so that he or she will know what to expect. Hold the probe by the plastic or cardboard handle. Apply the monofilament perpendicular to the skin. Use sufficient force to cause the monofilament to buckle or bend, using a smooth, not jabbing, motion. Ask the resident to respond with a yes each time he or she feels the monofilament touching the skin. Touch the monofilament to the appropriate areas as indicated on the following documentation illustration. Apply the monofilament along the margin of a callus, ulcer, scar, or necrotic tissue. DO NOT apply the monofilament ON the lesion. Record the results on the documentation form by placing a dot () in the circle if the patient felt the monofilament, and a dash () in the circle if the patient did not feel the monofilament.

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Testing Sites Illustration 8

Place the tip of the monofilament perpendicular to the skin, bend and release.

Sussman Wound Healing Tool

The Sussman Wound Healing Tool (SWHT) was developed by Sussman and Swanson in 1997 specifically to measure pressure ulcer wound healing. The focus of the tool is to track a change in tissue status and wound measurement, assess whether the wound is healing, and track the impact of physical therapy technologies for wound healing. The tool contains two forms that are completed together. Part I of the SWHT assesses ten variables that address wound tissue attributes. The attributes are classified as not good for healing or good for healing.
The attributes that are not good for healing include: Hemorrhage Maceration Undermining/tunneling Erythema Necrosis The attributes that are good for healing include: Adherence at the wound edge Granulation tissue Appearance of contraction Sustained contraction Epithelialization

The scoring system is simply marked with a 1 if the attribute is present or a 0 if the attribute is absent.

The second part of the SWHT evaluates the wound depth and location, and measures the phases of wound healing. The depth and undermining are assessed at various points in the wound bed and recorded. The location of the wound is based on orientation such as left and right and anatomical markers such as C for coccyx and H for heel. The phases include inflammation, proliferation, epithelialization and remodeling. To obtain a copy of the Sussman Wound Healing Tool contact Aspen Publishers, Inc.

Bates-Jensen Wound Assessment Tool (formerly known as the Pressure Sore Status Tool)
The Pressure Sore Status Tool (PSST) was developed by Barbara Bates-Jensen to enhance communication between healthcare clinicians regarding pressure ulcers. The tool is now known as the Bates-Jensen Wound Assessment Tool. Thirteen assessment parameters are measured on a scale of 1 to 5. Two additional parameters are measured in a simple check system. The wound location is assessed, recorded and marked on a body diagram. The shape of the wound is described by its overall pattern, such as round or oval and linear or elongated. The tool will help you track individual categories as well as an overall score. Once the numbers are recorded and the scale is complete, a total is calculated using all thirteen parameters and then placed on a linear chart. The total ranges from 1 (Tissue Health) to 13 (Wound Regeneration) to 65 (Wound Degeneration). Data is collected on a routine basis, usually weekly. Results are compared to previous assessments and treatment plans may be adjusted accordingly.

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BATES-JEN SEN WOUND ASSESSMEN T TOOL

Instructions for use
General Guidelines: Fill out the attached rating sheet to assess a wounds status after reading the definitions and methods of assessment described below. Evaluate once a week and whenever a change occurs in the wound. Rate according to each item by picking the response that best describes the wound and entering that score in the item score column for the appropriate date. When you have rated the wound on all items, determine the total score by adding together the 13-item scores. The HIGHER the total score, the more severe the wound status. Plot total score on the Wound Status Continuum to determine progress. If the wound has healed/resolved, score items 1,2,3 and 4 as =0. Specific Instructions: 1. S i z e : Use ruler to measure the longest and widest aspect of the wound surface in centimeters; multiply length x width. Score as = 0 if wound healed/resolved. 2. D e p t h : Pick the depth, thickness, most appropriate to the wound using these additional descriptions, score as =0 if wound healed/resolved: 1= tissues damaged but no break in skin surface. 2= superficial, abrasion, blister or shallow crater. Even with, &/or elevated above skin surface (e.g., hyperplasia). 3= deep crater with or without undermining of adjacent tissue. 4= visualization of tissue layers not possible due to necrosis. 5= supporting structures include tendon, joint capsule. E d g e s : Score as = 0 if wound healed/resolved. Use this guide: Indistinct, diffuse = unable to clearly distinguish wound outline. Attached = even or flush with wound base, no sides or walls present; flat. Not attached = sides or walls are present; floor or base of wound is deeper than edge. Rolled under, thickened = soft to firm and flexible to touch. Hyperkeratosis = callous-like tissue formation around wound & at edges. Fibrotic, scarred = hard, rigid to touch. U n d e r m i n i n g : Score as = 0 if wound healed/resolved. Assess by inserting a cotton tipped applicator under the wound edge; advance it as far as it will go without using undue force; raise the tip of the applicator so it may be seen or felt on the surface of the skin; mark the surface with a pen; measure the distance from the mark on the skin to the edge of the wound. Continue process around the wound. Then use a transparent metric measuring guide with concentric circles divided into 4 (25%) pie-shaped quadrants to help determine percent of wound involved. N e c r o t i c T i s s u e T y p e : Pick the type of necrotic tissue that is predominant in the wound according to color, consistency and adherence using this guide: White/gray non-viable tissue = may appear prior to wound opening; skin surface is white or gray. Non-adherent, yellow slough = thin, mucinous substance; scattered throughout wound bed; easily separated from wound tissue. Loosely adherent, yellow slough = thick, stringy, clumps of debris; attached to wound tissue. Adherent, soft, black eschar = soggy tissue; strongly attached to tissue in center or base of wound. Firmly adherent, hard/black eschar = firm, crusty tissue; strongly attached to wound base and edges (like a hard scab). ! 2001Barbara Bates-Jensen

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N e c r o t i c T i s s u e A m o u n t : Use a transparent metric measuring guide with concentric circles divided into 4 (25%) pie-shaped quadrants to help determine percent of wound involved. E x u d a t e T y p e : Some dressings interact with wound drainage to produce a gel or trap liquid. Before assessing exudate type, gently cleanse wound with normal saline or water. Pick the exudate type that is predominant in the wound according to color and consistency, using this guide: Bloody = thin, bright red Serosanguineous = thin, watery pale red to pink Serous = thin, watery, clear Purulent = thin or thick, opaque tan to yellow Foul purulent = thick, opaque yellow to green with offensive odor E x u d a t e A m o u n t : Use a transparent metric measuring guide with concentric circles divided into 4 (25%) pie-shaped quadrants to determine percent of dressing involved with exudate. Use this guide: None = wound tissues dry. Scant = wound tissues moist; no measurable exudate. Small = wound tissues wet; moisture evenly distributed in wound; drainage involves < 25% dressing. Moderate = wound tissues saturated; drainage may or may not be evenly distributed in wound; drainage involves > 25% to < 75% dressing. Large = wound tissues bathed in fluid; drainage freely expressed; may or may not be evenly distributed in wound; drainage involves > 75% of dressing. S k i n C o l o r S u r r o u n d i n g W o u n d : Assess tissues within 4cm of wound edge. Dark-skinned persons show the colors "bright red" and "dark red" as a deepening of normal ethnic skin color or a purple hue. As healing occurs in dark-skinned persons, the new skin is pink and may never darken. P e r i p h e r a l T i s s u e E d e m a & I n d u r a t i o n : Assess tissues within 4cm of wound edge. Non-pitting edema appears as skin that is shiny and taut. Identify pitting edema by firmly pressing a finger down into the tissues and waiting for 5 seconds, on release of pressure, tissues fail to resume previous position and an indentation appears. Induration is abnormal firmness of tissues with margins. Assess by gently pinching the tissues. Induration results in an inability to pinch the tissues. Use a transparent metric measuring guide to determine how far edema or induration extends beyond wound. G r a n u l a t i o n T i s s u e : Granulation tissue is the growth of small blood vessels and connective tissue to fill in full thickness wounds. Tissue is healthy when bright, beefy red, shiny and granular with a velvety appearance. Poor vascular supply appears as pale pink or blanched to dull, dusky red color. E p i t h e l i a l i z a t i o n : Epithelialization is the process of epidermal resurfacing and appears as pink or red skin. In partial thickness wounds it can occur throughout the wound bed as well as from the wound edges. In full thickness wounds it occurs from the edges only. Use a transparent metric measuring guide with concentric circles divided into 4 (25%) pie-shaped quadrants to help determine percent of wound involved and to measure the distance the epithelial tissue extends into the wound.
! 2001 Barbara Bates-Jensen

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2001 Barbara Bates-Jensen. Used with permission.

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References:

Anna and Harry Borun Center for Gerontological Research. The Bates-Jensen Wound Assessment Tool page. Available at: borun.medsch.ucla.edu/modules/ Pressure_ulcer_prevention/puBWAT.pdf. Accessed January 29, 2007. Bates-Jensen BM, Vredevoe DL, Brecht M-L. Validity and reliability of the pressure sore status tool. Decubitus. 1992;5(6):20-8.

Sussman C, Swanson G. Utility of the sussman wound healing tool in predicting wound healing outcomes in physical therapy. Advances in Wound Care. 1997;10(5):74-77. Woodbury GM, Houghton PE, Campbell KE, Keast DH. Development, validity, reliability, and responsiveness of a new leg ulcer measurement tool. Advances in Skin & Wound Care. May 2004;17(4):187-196.

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