A view from the coffee room…use your four basic senses when assessing patients and chronic wounds

We all carry along excellent medical examination tools constantly. Maybe you remember from pre-clinical physiology courses that human has five basic senses: sight, sound, smell, taste, and touch. Regarding examining the patient and assessing a patient with chronic wounds, I suggest that you use only four of your basic senses and discard taste, although our early colleagues made diagnostics by tasting e.g. urine for diabetes¹. So, lets stick with our four senses.

This is my take on examining the patient with a chronic wound and assessing the wound itself –  the person and the wound.

The examination of the patient with a chronic wound begins when the patient enters the room. Inspect how the patient moves, briskly walking without any walking aids, with walking sticks or crutches, with the help of a rollator walker, in a wheelchair or on a stretcher. Also note how the patient moves to the examination table, easily or with help of others. On the examination table note if the patient can breathe easily lying supine or do you need to lift the backrest to ease the breathing. Why this is important, with a single glance, you can assess patients’ reserves for further treatment.

Next, employ your hearing. History taking is one of the core skills in medicine and surgery also and is taught in medical school², with lists and memory tricks. It is important to ask the right questions, however, it may be more important to learn how to listen. Patient-centred communication associates with adherence to treatment^3,4, although these two references are old, they are still valid. Simple open question like, why do you think the wound is not healing, may reveal something that is not written in the electronic patient records, as electronic patient records tend to hold biomedical information but collecting psychosocial information may be lacking⁵. Listen how the patient breathes, is there difficulty of breathing, short sentences, or long sentences, is there wheezing or coughing. I know, this goes to the territory of internal medicine.

Check, Phase 1 completed, we proceed to the wound assessment.

It is easiest to start with smell. Rule of thumb is that infected and wounds with necrotic tissue smell bad and when I say bad, I mean really bad. To give you an  idea of the wound smell, I introduce you to odour assessment scoring tool⁶, in which wound odours are classified in four-step system. The extremes are 1. strong odour evident when entering the room from 1.8 to 3 metres with wound dressings on the wound to 4. No odour even when removing the dressing. Malodorous wounds, in the classification 1, are typically fungating malignant wounds or pressure ulcers with acute infection. It has been clinical belief that it is possible to distinguish bacteria by the odour. One of the most characteristic odours is Pseudomonas aeruginosa, the odour is sweet, grape-like and fruity⁷. This empirical belief has been recently shown to be real^8,9

Ok, this is a bit difficult, because now you should be doing four things almost simultaneously, location of the wound, wound dressings, periwound tissue and wound bed. Starting with the location, note the precise location of the wound and pay special attention to the position on top of the bony protrusion. Wound location gives valuable aetiological clues. Venous leg ulcers typically locate in the medial side of the lower leg between the lower calf and the medial malleolus. Arterial ulcers locate typically over bony prominences, heel, malleoli, or tip of the toes. The third important subgroup of chronic wounds is diabetic wounds, that locate below the ankle, frequently in the forefoot.

I like to observe myself what the wound dressings look like, and sometimes, this requires dumpster diving. The colour of wound exudate, the amount – a lot or just a little, is the exudate only in the primary wound cover or in the secondary dressings, and don’t forget the smell.  

Take a close look at the periwound area. Note oedema or the lack of it, is the skin shiny, how about the nails and hair growth, if diminished that nay implicate peripheral arterial disease¹⁰, the colour of the skin, redness might imply to infection, white wound edges are always an indicator of excess wound exudate and the use of wrong dressings that are not absorbable enough. 

Wound bed observation is important, and I cannot underline this enough. Correct identification of wound bed tissues leads to more successful wound outcome. Use a systematic approach to assess the wound bed, tissue type, colour of the discharge, odour, tunnelling, and exposed structures. Previous literature contains classifications to do this systematically^11,12, just to mention few.

Glove up for the next step. I suggest that you start by assessing the skin temperature, use you’re the back of the hand or fingers to detect temperature differences. Warmness may indicate infectious processes and coldness to inadequate arterial blood supply. Palpate the periwound area, is there oedema and if yes is it pitting or non- pitting edema. Palpate distal pulses, at least dorsalis pedis and posterior tibial. If you can’t palpate them, think is it you or does the patient have problems in the arterial circulation.

By now you should have collected enough information for your clinical diagnosis and probably have come up with further tests to validate your hypothesis. The most important issue with successful wound care is the correct wound diagnosis, and treatment of underlying conditions. This is the contribution of us doctors to wound care – proper diagnosis and treating the patient.