I. Acute
A. Acute surgical: clean or contaminated after surgery
B. Traumatic wound: clean or contaminated
II. Chronic ulcers
A. Arterial: ischemia associated with various types of arterial occlusive disease
B. Venous: related to disorders that affect venous blood return to the central circulation
C. Diabetic: associated with excessive and prolonged elevations in glucose levels and peripheral neuropathy in diabetic patients
D. Pressure: underlying tissue damage due to prolonged pressure or shearing that results in decreased blood and oxygen to capillaries of soft tissue beds
KEY FACTORS IN DELAYED HEALING
I. Excessive tissue load/pressure
II. Decreased tissue perfusion and oxygenation
III. Urinary or bowel incontinence
IV. Infection
V. Systemic diseases such as diabetes mellitus
VI. Inadequate or poor nutrition
VII. Necrotic tissue
VIII. Immunosuppression
IX. Drugs such as steroids
X. Deficiencies such as in proteins, vitamins, and minerals
I. Specific to diminished arterial or venous flow or varying combinations, depending on areas involved
A. Pain and tenderness
1. Arterial: claudication
2. Venous: lower legs and feet “heavy” and “sore” after prolonged standing
B. Neuropathy
1. Arterial and diabetic ulcers: “numbness and tingling”
C. Arterial, venous, diabetic ulcers: patient report of poor wound healing
D. Stated “foot problems” or trauma
II. Applicable pressure ulcer risk assessment tools, such as the braden or norton tools (subjective and objective combinations)
GENERAL PHYSICAL EXAMINATION GUIDELINES FOR WOUND ASSESSMENT
I. Acute or chronic etiologic factors as underlying cause
II. Specific anatomic location (see next section, Wound-specific Physical Examination Findings)
III. Length and width in centimeters
IV. Depth of tissue destruction
A. Superficial
B. Partial thickness
1. Extension through epidermis and partially into dermis
C. Full thickness
1. Extension through epidermis and dermis and some subcutaneous layer involvement
2. Muscle and bone may be involved
D. Undermining and tunneling
1. Depth and direction
E. Sinus tracts
V. Color of wound: red-yellow-black classification system for wound healing by secondary intention
A. Red
1. Granulation tissue clean and healthy
2. Color is pink to beefy red
B. Yellow
1. Exudate present
2. Debridement and cleaning needed
3. Color is beige, creamy or whitish yellow, or yellow-greenish
C. Black
1. Eschar present, indicating necrotic tissue
2. Debridement and cleaning needed
D. Mixed combination of two or more colors
VI. Color, amount, and consistency of drainage
VII. Presence of foul odor, indicating infection
VIII. Appearance and temperature of surrounding skin and tissue
A. Presence of erythema, maceration, induration, or edema
IX. Calluses (typically on plantar surface of foot)
X. Wound classification system, such as the Wagner Ulcer Grade Classification System of Staging or the National Pressure Ulcer Advisory Panel
XI. presence of pain
WOUND-SPECIFIC PHYSICAL EXAMINATION FINDINGS
I. Arterial and diabetic ulcers
A. Typical locations
1. Toes and below ankles (general arterial disease)
2. Plantar surfaces of feet (diabetic ulcers)
B. Pulse volume is diminished or absent
C. Shiny, cool lower extremities
D. Leg hair is sparse or absent
E. Feet and lower legs near ankle are cool
F. Ankle-brachial index of less than 0.5 (arterial); may exceed 1.0 for diabetic patients
G. Toenails are thickened
H. Deep ulcers with smooth wound margins, small amount of drainage, cellulitis and necrosis (large amount of callus surrounding ulcer [diabetic ulcer])
I. Wound classification system, such as the Wagner Ulcer Grade Classification System of Staging or the University of Texas (UT) Classification System
II. Venous ulcers
A. Typical location
1. Lower legs, above ankle
B. Varicosity noticeable
C. Edema of lower legs or feet
D. Warm lower extremities and feet
E. Superficial, ruddy, granulating ulcer with irregular margins; moderate to heavy drainage
III. Pressure ulcers
A. Typical locations: bony prominences (sacrum, heels, occipitus)
B. Ulcer description in terms of general assessment of wound and a wound classification system for pressure ulcers, for example, the classification description by stages according to the National Pressure Ulcer Advisory Panel
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1. Stage I
2. Stage II
a. Partial-thickness loss
3. Stage III
a. Full-thickness loss
b. Clinically appears deep, crater-like, with or without underlying adjacent tissue
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