This document provides an overview of wound assessment techniques. It discusses assessing the patient's history, examining the wound itself using techniques like TIME (tissue, infection, moisture, epithelial edges) and PQRST (provocation, quality, radiation, severity, time) for pain. The document outlines investigating further with tests and making a diagnosis. It also discusses implementing a treatment plan using wound bed preparation principles to manage tissue, infection, moisture and epithelial edges. The goal of wound care is a healed wound through this assessment and treatment cycle approach.

1. WOUND ASSESSMENT
AS SIMPLE AS ABC
ABDUL MANAN BIN OTHMAN
BSc (Hons) NPD Northumbria UK, CCWC (Mal)
Assistant Medical Officer
National Wound Care Committee
Wound Care Clinician
Kota Tinggi District Health Office
email: pppabdulmanan@yahoo.com

2. DISCLAIMER
• The contents presented in these slides are the
opinions of the speaker
• Treatment modalities mentioned are for
scientific discussions only and are not
recommended for off-label recommendations
• If there are any products mentioned, it is for the
purpose of the topic discussion only.

15. WHAT…..WHEN
WHO…WHERE
…HOW..

16. Wound bed
preparation
Care Cycle
Start with
the patient
Identifying
wound
aetiology
Perform
TIME
assessment
Agree goals
Treat &
evaluate
TIME
interventions
Healed
GOAL IN WOUND CARE CYCLE
No
YesPrevention

17. WOUND ASSESSMENT
• Age (extreme of age)
• Disease and co-morbid (DM,
malignancy)
• Obesity
• Medication (steroid,
chemotherapy)
• Nutrition
• Impaired blood supply
(arterial and venous ulcer)
• Lifestyle (smoking)

18. H.E.I.D.I

19. H-HISTORY
• Medical
• Surgical
• Pharmalogical
• Social
• HOPWI

20. •Once you have your story it’s time to
use your senses:
•HEAR
•SEE
•SMELL
•TOUCH

21. E-EXAMINATION
• The patient as a whole- systemic
• Focus on the wound
• Pain- PQRST
• TIME assessment

22. PAIN IN PQRST
• P-Provokes/ Palliates
>what causes pain?
>what makes it better
>Worse
Q- Quality
>What does it feel like
>Is it sharp
>Dull/Stabbing
>Burning
>Try to let patient describe the pain

23. • R-Radiates
> Where does the pain radiate
> Is it in one place
> Does it go anywhere else
S- Severity
> How severe is the pain
> Scale 1-10
> Wong baker faces

24. • T- Time
> Time pain started
> How long did it last?

25. I-INVESTIGATION
• What bloods??
• X-rays
• Scan??
• Ultrasound
• C&S
• HPE
• Tissue Analysis
• That require to help you make your diagnosis

26. D-DIAGNOSIS
• Stage what of PI
• Wagner Stage for DFU
• Venous Ulcer
• Arterial Ulcer
• Surgical Wound
• Burns how many %
• Traumatic Wound
• PAD
• PVD
• Cancerous / Malignancy

27. I-IMPLEMENTATION
• Start planning
• Cleansing solution
• Primary Dressing
• Secondary Dressing
• Compression
• Emollient/ barrier

29. WOUND
PICTURE
• W- Wound or ulcer location
• O- Odor assess before and during
dressing
• U- Ulcer category, stages, PI , DFU, Burn
• N- Necrotic Tissue
• D- Dimension of wound- shape, length,
width, depth, drainage color

30. • P- Pain score – 0-10
• I- Induration –( surrounding tissue, hard
or soft)
• C- Color of wound bed- red, pink,
yellowish, black
• T- Tunneling
• U- Undermining- clock references
• R- Redness or discolorationin
surrounding skin
• E-Edge of skin-loose or tightly adhered?

31. T.I.M.E WB
PREPARATION
• A tool during wound assessment to
identify barriers to healing
• Implement a plan to remove barriers and
promote healing

32. HISTORY OF
TIME
• Originally developed from Plastic Surgery Team-
1977,Philadelphia.
• Concept and framework to prepare wound bed before
split skin graft- also called Wound Bed Preparation
• Later extended into chronic wound management
• Proposal of Wound Bed Preparation concept in year
2004 to EWMA – emphasizing on debridement,
moisture balance and bioburden

35. T.I.M.E
4 main components of wound bed preparation:
1) Tissue Management
2) Control of Infection & Inflammation
3) Moisture Imbalance
4) Advancement of Epithelial Edge of the
wound

36. TRIANGLE OF
WOUND
ASSESSMENT
(TOWA)

37. TRIANGLE OF WOUND
ASSESSMENT (TOWA)
WOUND
Wound bed
Wound edge Periwound skin
 Tissue type
 Exudate
 Infection
 Maceration
 Excoriation
 Dry Skin
 Hyperkeratosis
 Callus
 Eczema
 Maceration
 Dehydration
 Undermining
 Rolled

38. •Position
Document from
World Union
Wound Healing
Societies, 2016

39. Adapted from small teaching of Dr Wan Zuraini, KK Telok
Datok, Kuala Langat

40. Adapted from small teaching of Dr Wan Zuraini, KK Telok
Datok, Kuala Langat

41. Adapted from small teaching of Dr Wan Zuraini, KK Telok
Datok, Kuala Langat

42. 2017
M.O.I.S.T
A CONCEPT FOR THE TOPICAL TREATMENT OF
CHRONIC WOUNDS
Dissemond J, et al. J Dtsch Dermatol Ges.2017.

43. T.I.M.E
CONCEPT AS A WOUND BED
PREPARATION

44. Source: International advisory board of wound bed preparation 2003

45. 1) TISSUE
MANAGEMENT
• Pathology : defective matrix, non-viable tissue and cell debris
impairs healing
• Plan: Episodic or continuous debridement
• Effect of actions: restoration of wound base and functional
extracellular matrix proteins (chronic ->acute wound)
• Clinical outcomes : Viable wound base

46. TISSUE TYPES
• Necrotic eschar
• Slough
• Granulation
• Hypergranulation
• Poor quality granulation
• Epithelium

47. HOW TO IDENTIFIED
VIABLE/ NON VIABLE
•4C FORMULA
-COLOUR
-CONSISTENCY
-CONTRACTION
-CIRCULATION

48. •non viable muscle/ tissue can be
identified by its dark color, its
mushy consistency, its failure to
contract when pinched with
forceps, and the absence of
bleeding from a cut surface

49. DEBRIDEMENT???
Process of removal of non
viable tissue and
contaminants from a wound to
promote healing.

50. METHOD OF
DEBRIDEMENT
• B- Biological debridement
• A- Autolytic debridement
• S- Surgical debridement
• U- Ultrasonic debridement
• H- Hydrostatic debridement
• M- Mechanical debridement
• E- Enzymatic debridement
• C- Combination

52. •CROSS HETCHING
ESCHAR??????
#########
#####
##########

60. 2) CONTROL OF INFECTION
& INFLAMMATION
• Pathology : high bacterial count/prolonged inflammation -> ↑
cytokines & protease activity, ↓ growth factor activity
• Plan: -remove foci of infection (local/systemic)
- antimicrobials/antiinflammatory
• Effect of actions: low bacterial count & controlled inflammation
• Clinical outcomes : bacterial balance and reduced
inflammation

62. PATHWAY OF WOUND
INFECTION

63. Contamination

64. Colonization

65. O2
O2
O2
pH
pH
pH
pH
O2
Critical colonization

66. Infection

67. BIOFILM
• Community of microorganisms encased
within an extracellular polymeric matrix,
which accumulates at a surface.
• It has been estimated that biofilms are
associated with 65 percent of nosocomial
infections.
• Play a significant role in a large number of
infections in humans.
• due to the intrinsic resistance of these
structures to antimicrobial agents and host
defense mechanisms, wound with biofilm
cannot be treated effectively with
antibiotic.

70. 3) MOISTURE
IMBALANCE
• Pathology: dessication & excessive fluid- slows epithelial
migration and margin maceration
• Plan: moisture balance dressing, compression , negative
pressure dressing.
• Effect of actions: restored epithelial migration and avoidance
of maceration
• Clinical outcomes : moisture balanced for wound healing

75. WOUND ASSESSMENT
SEQUENCE FOR EXUDATIVE
WOUND MX
1. Assess the patient
2. Assess the region of
the wound
3. Assess the current
dressing
4. Assess the exudate
5. Assess the wound
base and edge
6. Assess the
periwound skin
7. Manage exudate
and related problems
(World Union of Wound Healing Societies 2007)

76. 4) ADVANCEMENT OF
EPITHELIAL EDGE OF THE
WOUND
• Pathology : non-migrating keratinocytes, non responsive
wound cells, abnormal protease activity and ECM
• Plan: reassess cause (T.I.M, extrinsic factor) and consider;
debridement, skin grafts, biologic agent
• Effect of actions: migrating keratinocytes and responsive
wound cells
• Clinical outcomes :advancing epithelial edge

78. SURROUNDING
SKIN?????

79. Peri Wound Skin Classification
Grade Type Description
0 Normal skin
1 At risk skin
2
(Exudate Centred)
A Dessication
B Maceration
C Allergy
3 Inflammed
4 Infection
5 Atypical
Dr. Harikrishna K.R.Nair 2015

80. Source: International advisory board of wound bed preparation 2003

81. WOUND
COLOUR
MODEL

82. Black–necrotictissue
Red–granulation
tissue
Yellow-slough
Exudate–moderate
(purulent)withodour
Pink–Epithelialtissue
Edges-undermining
Size12x8x1cm
Site–sacralregion

84. LETS START
THE
ASSESSMENT

89. DOCUMENTATION
• CONSENT- DEBRIDEMENT
• GENERAL ASSESSMENT- ADOMNIL
• LOCAL ASSESSMENT- SIZE, SHAPE, DEPTH, WIDTH
• TYPES OF WOUND- STAGES…GRADE….
• PHOTO CONSENT
• PROGRESS NOTE
• NUTRITIONAL STATUS
• MEDICATION
• PLAN OF DRESSING AND CHOICE OF DRESSING
• CENCUS/ RETEN

92. TAKE HOME MESSAGE
• Accurate holistic assessment of the patient and
the wound will provide an understanding of
primary treatment objectives resulting in
improved patient outcomes and reduced costs.
Practitioners involved in wound care need to
ensure they have the essential skills required to
plan, implement and evaluate care on an
individual basis .

93. BE CREATIVE!!!

94. • People are often unreasonable and self-centered
FORGIVE THEM ANYWAY..if you are kind, people may
accuse you of ulterior motives..BE KIND ANYWAY…if
you are honest, people may cheat you.. BE HONEST
ANYWAY…if you find happiness, people may be
jealous..BE HAPPY ANYWAY..the good you do today
may be forgotten.. DO GOOD ANYWAY…give the
world your best and it may never be enough…GIVE
YOUR BEST ANYWAY…for you see, in the end it is
between YOU AND GOD…it was never between you
and them anyway…….
• Mother Teresa

95. ‘WOUND
HEALING WITH
PASSION’
-LEARN -HELP -HEAL

96. • Dear ocean,
Thankyou for makingus feel
tiny, humble,inspired, and
salty……allat once
Be kind and have courage
Manners makethman…

97. THANK
YOU
Abdul Manan bin Othman
Assistant Medical Officer
Wound Care Clinician
Bsc Hons Nursing Practice
Development, Northumbria
University, CCWC(Mal).
pppabdulmanan@yahoo.com
+60132634113

98. THANK
YOU

99. WOUND
CLEANSING

101. WOUND DRESSING
SOLUTIONS
•Non Antiseptic Solutions
•Antiseptic Solutions

102. • Wound cleansing is a process of
removing inflammatory
contaminants from the wound
surface
• These contaminants can impede
healing and increase risk of
infection

103. • The contaminants are:
Necrotic tissues
Excess exudates
Foreign objects
Infected tissues

104. NON-ANTISEPTIC SOLUTIONS
• Commonly used non-antiseptic
solutions are:
Normal Saline
Water for irrigation

105. Normal Saline
• Preferred cleanser for most types of wounds (physiologic and
safe).
• Less effective in dirty and necrotic wounds.
• Not advisable in MRSA and Pseudomonas infected wound.
(peter et al 2008)
• Once the container is opened, it should be used within 24 hours.
Water for irrigation
• Less physiologic compared to normal saline but still safe to be
used.
• Can be used in MRSA and Pseudomonas infected wounds.

106. ANTISEPTIC SOLUTIONS
• Antiseptic solutions are used to clean the
wound which are dirty and infected.
• Commonly used antiseptic solutions are:
 Chlorhexidine gluconate 1:200 in Aqueous
solution
 Super-oxidized solution
 Polyhexamethylene biguanide (PHMB) solution

107. Chlorhexidine gluconate 1:200 in Aqueous
solution
• Effective against Gram positive bacteria, fungi
and also enveloped viruses.
• Less effective against Gram negative bacteria.
• Has both bactericidal and bacterostatic action.
• Readily available in healthcare setting.

108. Super-oxidized solution
• Good bactericidal, virucidal, fungicidal and
spongicidal.
• Also blocks the inflammatory process.
• May help in biofilm removal.
• Two components in this solution are oxidized
water and chlorine.
• The oxidized water is broken down into oxygen,
ozone and other oxidized species.
• Costly.

109. Polyhexamethylene biguanide (PHMB)
solution
• Helps to soften and remove the slough.
• It can remove and reduce the biofilm
formation.
• Less painful.
• Costly.

110. • These solutions besides painful on application also
cause harm to the normal tissues if used as dressing
solutions (cytotoxic), however a short term use may be
permissible
 Povidone iodine
 Hydrogen peroxide
 Sodium hypochlorite
 Acetic acid
 Eusol

111. TYPES OF WOUND
DRESSING MATERIALS

112. MODERN DRESSINGS

113. FILM

115. HYDROGEL

117. HYDROCOLLOID

119. CALCIUM ALGINATE

121. FOAM

123. HYDROFIBER

125. SILVER

126. ROLE OF
DRESSING

127. ROLE OF DRESSING
• To achieve a wound bed that is sufficiently
moist for healing, but that does not cause
problems such as maceration, whilst treating
underlying contributory factors, enhancing
patient quality of life, encouraging healing ,
adressing exudate- related problems and
optimising healthcare resource use.
• World Union of Wound Healing Societies 2007

130. • Regular comprehensive assessment and
documentation
• Documented improvement of the wound
and progress
LEAD TO

131. • Healthy or improving periwound skin
• Healthy wound bed with no sign of
infection
• Reduced dressing change requirements
• Lack of reduction in wound odour
• Reduction in or lack of wound pain

132. SIGNS OF LACK OF
PROGRESS
• The patients quality of life is not improving
• The periwound skin remains unhealthy
• The wound bed shows signs of increasing bacterial
load
• There is soiling outside the dressing
• The patient has made adjustments to accommodate the
exudate
• Dressing changes are very frequent
• Wound odour is uncontrollled
• Wound pain is continuing

133. I.A.D
MARSI

136. TAKE HOME MESSAGE
• Accurate holistic assessment of the patient and
the wound will provide an understanding of
primary treatment objectives resulting in
improved patient outcomes and reduced costs.
Practitioners involved in wound care need to
ensure they have the essential skills required to
plan, implement and evaluate care on an
individual basis .

137. BE CREATIVE!!!

138. • People are often unreasonable and self-centered
FORGIVE THEM ANYWAY..if you are kind, people may
accuse you of ulterior motives..BE KIND ANYWAY…if
you are honest, people may cheat you.. BE HONEST
ANYWAY…if you find happiness, people may be
jealous..BE HAPPY ANYWAY..the good you do today
may be forgotten.. DO GOOD ANYWAY…give the
world your best and it may never be enough…GIVE
YOUR BEST ANYWAY…for you see, in the end it is
between YOU AND GOD…it was never between you
and them anyway…….
• Mother Teresa

139. ‘WOUND
HEALING WITH
PASSION’
-LEARN -HELP -HEAL

140. • Dear ocean,
Thankyou for makingus feel
tiny, humble,inspired, and
salty……allat once
Be kind and have courage
Manners makethman…

141. THANK
YOU
PPP Abdul Manan bin Othman
Assistant Medical Officer
Wound Care Clinician
Bsc Hons Nursing Practice
Development, Northumbria
University, CCWC(Mal).
pppabdulmanan@yahoo.com
+60132634113