The periwound is as important as the wound. As clinicians, we should carefully assess the wound bed, but we need to remember also to assess the periwound and surrounding skin. The periwound should be considered the 4cm of surrounding skin extending from the wound bed. Chronic wounds may manifest any of the following characteristics, depending on wound type: erythema, induration, epibole, ecchymosis, hyperkeratosis, and changes in shape.^1,2

Five-Step Periwound Assessment

1. Temperature
2. Location
3. Shape
4. Color
5. Wound depth

The temperature of the periwound can be a good indicator of whether active infection is present or to determine whether there is normal blood flow. The back of the hand is most accurate.^1,2 The periwound is helpful in identifying partial- or full-thickness tissue. Partial-thickness wounds do not penetrate the dermis, are shallow, and heal by re-epithelialization. There is no granulation in a partial-thickness wound. Scabs, abrasions, and serous-filled blisters are types of partial-thickness wounds. Full-thickness wounds extend below the dermis. At this level of tissue destruction, you will see granulation and possible devitalized tissue (slough, eschar). Measure the deepest point of tissue loss with a cotton-tipped applicator.³

Document skin condition and abnormalities that may indicate underlying health conditions or previous wounds. This would include any dermatitis, hyperkeratosis, hemosiderin staining, reactive hyperemia, scars, and abnormalities. Make note of dryness or cracking of the periwound or surrounding skin. Poor skin turgor signals dehydration. Managing moisture-associated skin damage is important in preventing further skin breakdown. Zinc oxide barriers and absorbent dressing types are just a few ways of managing exudate. Go an inch larger with foam dressings, to maximize moisture absorption.^1,2 Using liquid dressings such as skin prep can help protect periwound skin from moisture and adhesives and can lessen friction forces.⁴ If the periwound skin is not at an optimal moisture balance, skin becomes compromised, leading to further skin breakdown. Keep in mind that measuring periwound breakdown can be helpful in validating a larger dressing size for reimbursement and painting that picture of healing progress.⁵

Wound edges and margins are particularly important for identifying a possible cause of the wound. Location, shape, and color indicate many factors in the cause.³ Epiboles, for instance, are rolled and indicate a chronic wound because the epithelial cells are unable to migrate across the resurfacing of the wound. Undermining predicts that there is shearing or a gravity force involved, which may be caused by positioning while sitting up in a chair or bed.⁵ You want to measure not only the wound size, but also any undermining, tunneling, and periwound impaired skin. Thorough and detailed documentation helps paint the "whole" picture of the wound assessment. Wound dressings play a major role in wound healing. Selecting a dressing can be simplified by identifying wound depth and exudate. Remember to consider pain as well. Look at each patient as a "whole," not only the "hole" in the patient.

Conclusion

Periwound breakdown can delay healing, worsen wound progress, and possibly cause pain. As clinicians, we should think not only of the wound bed preparation, but also of protecting and treating the periwound. Using the appropriate dressing size, using preventive protective barrier techniques, and balancing moisture levels within in the wound bed will help prevent periwound breakdown.

References

1. Meyers, B. Wound Management: Principles and Practice. 2nd ed. Upper Saddle River, NJ: Pearson Prentice Hall; 2008:56–7.

2. Bryant R, Nix D. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St. Louis, MO: Elsevier Mosby; 2011:117.

3. Morgan N. Measuring Wounds. Wound Care Advisor. Available at: http://woundcareadvisor.com/measuring-wounds/. Published July 11, 2012. Accessed March 14, 2018.

4. Lawton S, Langoen A. Assessing and Managing Vulnerable Periwound Skin. World Wide Wounds. Available at: http://www.worldwidewounds.com/2009/October/Lawton-Langoen/vulnerable-s…. Published October 2009. Accessed January 12, 2018.

5. Slachta PA. Caring for Chronic Wounds: A Knowledge Update. Wound Care Advisor. Available at: https://woundcareadvisor.com/caring-for-chronic-wounds-a-knowledge-upda…. Accessed March 14, 2018.