Basics of Wound Care/ Assessment and Documentation

What are different types of wounds?

venous (VLU), diabetic (DFU), pressure (PI), arterial, trauma, surgical, burn

Why is it important to know the type of wound?

guides decision making for POC: What topical treatments will support healing? What supportive measures are needed? What strategies will help prevent complications? What is the predicted healing timeline?

What are some questions to ask when obtaining an initial wound history?

When did you first notice the wound? How did it begin? How have you been treating the wound? Is the wound causing pain? Please describe. Do you have any underlying conditions that may be contributing to the wound development or failure to heal?

What are important impairments, contextual factors, and comorbidities that we should be hyperaware of when collected a wound history?

limited mobility due to neurologic or MSK disorders, DM or diabetic neuropathy, trauma/ falls, PAD, incontinence, altered nutritional status, medications such as steroids, chemotherapeutic drugs, psychosocial barriers- financial constraints, lack of emotional or physical support

What are the steps to prepare for wound treatment?

gather supplies, position the patient, remove existing dressing (if present), cleanse wound

What types of supplies should one gather to prepare for wound treatment?

wound cleansing products (saline, gauze), measuring guide, cotton swab, flashlight/ headlamp

How should one position the patient in preparation for wound treatment?

to promote comfort and allow for visualization of the wound, make sure supplies are within reach and determine if you will need assistance

What should one observe/ note when removing existing dressings?

the condition of dressing: saturated? type of drainage? odor? dislodged or intact?

What are the elements of a wound assessment?

location, position, dimensions, depth, sinus tracts/ tunneling and undermining, wound base, wound edges, drainage, odor, periwound skin, pain, physical assessment beyond the wound edge

How should wound location be documented?

using specific anatomical terms

What are words/ directions used to describe the position of the wound?

proximal, distal, superior, inferior, anterior, posterior, medial, lateral

Define proximal.

nearer to the trunk

Define distal.

further from the trunk

Define superior.

near the head

Define inferior.

further from the head

Define anterior.

nearer the front

Define posterior.

nearer the back

Define medial.

near the midline

Define lateral.

further from the midline

What dimensions of a wound are measured? When and how often should they be measured?

length, width, and depth; initial eval and at least weekly

How should one document if the wound shape is irregular and difficult to describe?

drawing/ tracing

What are different measurement methods?

clock, greatest length and width

What is the unit of measurement for wound documentation?

centimeters

What are the steps for measuring wound depth?

place the cotton swab at the base of the wound, align the thumb and forefinger against swab at skin level, remove from wound and compare to measuring device

Define sinus tract/ tunneling.

one directional area of depth or connection between the surface of the wound and underlying abscess or organ

Define undermined area.

sweeping area of separation from wound edge

What are the 4 types of wound bases?

slough, eschar, granulation, epithelium

Describe a slough wound base.

moist devitalized tissue or debris. Appears whiteish, yellow, or tan. It can be firmly attached or loose. Composed of liquifying tissue, fibrin, WBCs, bacteria.

Describe an eschar wound base.

necrotic tissue is hard or soft in texture; usually black, brown, or tan

Define nonviable or devitalized.

a generic term that refers to all dead tissue (eschar and slough)

Describe a granulation wound base.

vascularized connective tissue that fills wound deficit; may be red or pink and has cobblestone texture

Describe an epithelium wound base.

areas of resurfacing, typically from wound edges or “islands” extending from follicles. Appear pearly white or pink.

How should you document a wound with more than one type of tissue present?

document by percentage

What is friable tissue?

bright red tissue that is soft, easily bleeds, or lifts off; often sign of infection

Define granulation tissue.

the moist tissue which fills an open wound as it heals, the color is pink or beefy red, often has a cobblestone or berry- like appearance

Describe a clean, non- granulating wound base.

tissue may appear pale pink or red and smooth without cobblestone texture of granulation tissue

T/F All red or pink tissue is granulation tissue.

false

Describe an epithelial island wound base.

occurs as the epidermis regenerates across the wound surface; characterized by smooth pink tissue that eventually closes the wound

Describe an underlying structures wound base.

wound bed may expose underlying structures such as tendon, muscle, bone

What are the different types of wound edges?

epithelial migration from edges, undermining separation, epibole, callous, maceration

Describe epithelial migration from edges.

ideally, wound edges are attached, moist and flush with wound base

Describe undermining separation of wound edges.

areas of separation between the wound base and edge

Describe epibole wound edges.

rolled edge preventing epithelial resurfacing

Describe callous wound edge.

calloused edges are found on pressure- bearing surfaces such as plantar diabetic foot ulcers

Describe maceration wound edges.

after extended exposure to moisture, skin becomes overhydrated and appears pearly white with soft texture

T/F It is normal to see hyper/ hypo pigmented skin around the edges of a wound during healing.

true

What are terms used to describe the volume of drainage?

none, scant/ min, mod, large, copious

What are characteristics of drainage?

serous, serosanguinous, purulent, sanguineous (bloody)

What are some causes of wound odor?

anaerobic bacteria, tumor, necrotic tissue/ debris

What two things should be documented when describing odor?

intensity and quality

What things should be noted/ observed with regards to the periwound skin?

integrity (maceration, dermatitis, erosion), tissue texture, color (erythema, pallor, ecchymosis), edema, induration (hardness), temperature

How often should you assess pain with wound care?

each dressing change

What factors of pain should be documented?

characteristics (burning, stinging, stabbing, aching), intensity using rating scale, factors that reduce or exacerbate pain (analgesic use- type, frequency, and response)

What are things that should be assessed beyond the wound edge?

circulation (peripheral pulses, temp, hair growth, color, varicosities), neuro status (sensation, strength), weight, activity (gait/ posture, endurance), structural deformities, edema, other (footwear, support surfaces)

What are potential causes for venous leg ulcers?

LE edema, family hx of varicose veins, past DVT

Where are venous leg ulcers usually lcoated?

lower legs above ankle, medial or lateral aspect

Describe the appearance of a venous leg ulcer.

irregular border, shallow, pink/ red base, highly exuding

Describe the appearance of the skin surrounding a venous leg ulcer.

brown pigmentation (hemosiderin staining), dermatitis (dry, flaky, itchy), edema, fibrotic (hard, woody) texture

What are some potential causes of a diabetic foot ulcer?

DM, peripheral neuropathy, foot deformities

Where is the usual location for DFU?

pressure points on plantar surface of foot, toe tips

Describe the appearance of DFU.

distinct edges, can be deep- probing to underlying structures, nonviable tissue in base

Describe the skin surrounding a DFU.

callouses, foot deformities (charcot, hammer toes)

What are potential causes of pressure injuries?

impaired mobility, incontinence, acute illness or complex surgical intervention

What is the usual location of PI?

bony prominences, areas of friction/ shear

Describe the appearance of PI.

varies based on stage

Describe appearance of skin surrounding PI.

varies based on location and stage

What two things does frequency of assessment depend on?

care setting and patient condition

How often should you assess wounds in acute care?

daily

How often should you assess wounds in long term care?

weekly

How often should you assess wounds in home care?

with each dressing change

What are factors that would trigger an immediate reassessment?

change in patient condition, any patient transfer, significant change in condition of wound

What are some questions to ask at each assessment?

Have you noticed any changes with your wound? pain, pertinent issues (blood glucose control, activity level, appetite/ oral intake), ability to comply with plan (activity recommendations or restrictions, wound treatments, meds)

What are local signs of wound deterioration?

pain develops or increases, edema develops or worsens, poor tissue quality (friable, mottled, pale), increased nonviable tissue (slough), drainage changes or increases, foul odor, surrounding (advancing) erythema or induration, healing stalls

What are causes of wound deterioration?

biofilm or infection, impaired perfusion, malnutrition, difficulty adhering to treatment plan, contributing factors

What are typical signs of infection?

erythema, edema, induration, heat, pain, purulent drainage, odor, fever

What are covert (subtle) signs of infection?

poor quality/ friable granulation tissue, low- level chronic inflammation (erythema and induration), increased exudate/ moisture, elevated blood glucose levels, failure of appropriate antibiotic treatment, recurrent slough formation, delayed healing despite optimal wound management and supportive measures

What signs of infection require assessment and referral to PCP?

advancing erythema and fever

Define and describe the appearance of dermatitis.

inflammation of epidermis and dermis; often misdiagnosed as cellulitis; scaling, crusting, weeping, erythema, erosions, intense itching

Define and describe the appearance of cellulitis.

diffuse acute inflammation and infection of the skin and subcutaneous tissues that signifies a spreading infectious process; fever, mild leukocytosis, pain and tenderness, erythema, inflammation, may have history of immunosuppression

Why would you culture a wound?

identify bacteria that could be contributing to infection, guides antibiotic therapy

When would you culture a wound?

wound shows s/s of infection or impaired healing

What are types of wound cultures?

tissue, needle aspiration, surface swab culture

List the steps of surface swab culture Levine’s Technique.

1) cleanse the wound with normal saline 2) do not use an antimicrobial wound cleanser 3) moisten swab with normal saline 4) swab a 1 cm area with force 5) don’t culture necrotic (non- viable) tissue! 6) promptly transport to lab

Define a partial thickness wound.

depth does not extend beyond dermis

Define full thickness wound.

depth extends through the dermis to the subcutaneous tissue and may involve underlying structures

What are pros and cons to wound classification via partial/ full thickness?

pro: useful for all wound types

cons: lack of detail and must identify structures

What is the grading system for pressure injuries?

NPIAP Pressure Injury Stages

What is the grading system for DFU?

Wagner DFU GS

What is the grading system for venous leg disease?

CEAP System

What is the grading system for surgical site infections?

ASEPSIS scoring system

What is the grading scale for skin tears?

Payne- Martin Classification System for skin tears and international skin tear advisory panel (ISTAP)

T/F Grading systems can be used interchangeably and are not etiology specific.

false

What are signs of improvement in chronic wounds?

wound bed red and moist, edges adherent to base and epithelialization occurring from margins, size decreasing, base filling in (depth decreasing), and tunnels smaller, pain decreasing or absent, drainage decreasing, no odor, patient feels better, more active

What are signs of normal wound improvement?

less nonviable tissue, less surrounding erythema, increased granulation tissue, less drainage/ odor, decreased dimensions, less depth/ undermining, adherent (attached) edges

Why do we document wound care?

guides care- status and progress toward outcomes, creates medical record for regulatory and legal purposes

When do we document wound care?

admission (baseline info to use as baseline for future assessments), at time of dressing change, post- debridement, with significant change in condition, transfer or discharge

How should we document wound care?

wound- specific forms, progress notes, combination of both, photography

What should be included with wound photography in documentation?

patient ID, date, ruler for scale, patient consent, consistency (same camera, distance from wound/ magnification, light source, pre or post debridement or both), ensure photos are stored in a secure manner

What are legal and regulatory considerations in documentation?

CMS regulations, joint commission, IHI, NDNQI, NQF, institutional policies and procedures, job scope, practice privileges

What are documentation requirements?

no blanks on forms, use of approved abbreviations, legibility, progress note for unexpected findings, photo documentation per facility policy and procedure, person that completes the assessment must be the person completing documentation