Any wound that does not heal within three months is considered a chronic wound. Chronic wounds are detained in one or more phases of healing. If these wounds ever heal, they may take years to do so, causing patients severe physical, mental, emotional, and financial stress, and placing a financial burden on the healthcare system.
Consultations are an important first step in providing access to appropriate treatments and specialists. Since many immobile, hospitalized patients are prone to developing chronic wounds, many wound care consultations now take place through telehealth applications. This less costly alternative to an in-person consultation refers to contact between a patient and a healthcare provider through electronic communications such as audio, video, and other telecommunications. It is an especially helpful option for patients in long-term care settings as it enables nurses with specialized wound knowledge and skills to provide support to nurses directly caring for patients, which improves the chance for wound healing.
Proper wound assessment can have a significant impact on patient outcome. When evaluating a chronic wound, a full physical examination of the patient must be done focusing on the patient’s height, weight, and skin characteristics. Trends in a patient’s weight must be noted as adequate nutrition is essential for wound healing. Skin color, texture, turgor (elasticity), and temperature must also be evaluated. Healthy skin will feel smooth and firm, have good turgor, and lack erythema (redness.)
The wound’s circumference and depth, along with the condition and location of the wound bed, must be documented weekly and should take place after wound cleaning and debridement. Wound depth must be classified as partial (does not penetrate the dermis) or full (involves tissue below the dermis) thickness.
The surrounding skin and tissue must also be carefully inspected. Any compromised skin near a wound is at risk for breakdown, making preventive measures a necessity. The color, amount, and odor of exudate (drainage) in the wound, as well as undermining (space between intact skin and wound bed) and tracts (channels extending from one part of the wound to another) must also be checked. Pain level should be evaluated by the patient utilizing the pain scale designated by the healthcare facility they are in.
It should not be assumed that a foot wound is a diabetic foot ulcer without ruling out other causes that can include venous ulcers (caused by improper functioning of venous valves, usually of the legs), ischemic ulcers (caused by arterial insufficiency), vasculitic ulcers (caused by inflammatory destruction of blood vessels), and malignancies.
A full examination and documentation of findings must be completed prior to a diagnosis of a foot wound. This ensures that the proper treatment plan is established. Foot ulcer evaluation should include assessment of neurological status, vascular status, and evaluation of the wound itself. This includes vital information such as wound size, shape, location, depth, base, and border, as well as signs of infection and deterioration.
Neurological status can be checked by using 10-gram monofilaments. This is an effective method of testing for the presence or absence of "protective sensation." Patients are deemed to have lost their protective sensation if they cannot feel a 10-gram monofilament pressed against their skin. As a result of this lack of sensation, their foot is now "at risk." This means the patient is more likely to damage their foot without feeling it. However, it is also necessary to test for vibratory sensation since approximately 10% of high risk patients can feel a monofilament, but have lost their vibratory perception. This can be done using a 128-Hz Tuning Fork. Both of these tests can be performed fairly quickly in any office setting. There are more in-depth analyses that can be performed in a neurological laboratory. These include using a vibrometer (a device designed to more accurately measure vibratory sense), assessing temperature sense, performing nerve conduction studies, and checking position sense and balance.
Vascular assessment is also an essential component in the evaluation of diabetic ulcers. This includes checking pedal pulses, the dorsalis pedis on the dorsum of the foot, and the posterior tibial pulse behind the medial malleolus. Patients with a non-palpable pedal pulse should seek further testing at a noninvasive vascular laboratory. The capillary filling time must also be assessed by pressing on a toe until the skin blanches, then timing the skin while it restores its color. A prolonged capillary filling time is considered anything greater than 5 seconds.