wound assessment and documentation
DESCRIPTION
Wound AssessmentTRANSCRIPT
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Wound Assessment and Documentation
Dot Weir, RN, CWON, CWS Osceola Regional Medical Center Kissimmee, Florida
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Treat the Whole Patient….
• Complete history and physical exam • Review of systems • Family history • Surgical history • Medications
• Rx and OTC • Allergies
• Social history • Smoking / alcohol history
Not just the “hole” in the patient…
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Risk Factors for Healing Challenges - Intrinsic
• Nutrition and hydration • Medications
– Steroids – ASA – Anticoagulants – Chemotherapy
• Infection • Incontinence • Immobility
– Use of calf muscles
• Co-morbid disease states • Diabetes • PAOD • Inflammatory diseases • Anemia • Hyper- or hypotension • COPD • SCI • CVA • Renal disease • Age • Past radiation
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Imperative…
• KNOW • THE
• DIAGNOSIS!
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Degree of Tissue Destruction
• Wound type specific • All not universally utilized • Can present barrier to consistency in
documentation
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Wound Specific Grade/Staging Systems
• NPUAP/EPUAP Staging/Grading – Pressure Ulcers
• Wagner Scale – Diabetic Foot Ulcers (DFU’s) • UT Diabetic Wound Classification – DFU’s • CEAP – Venous leg ulcers • Tissue Loss (partial / full) – Universal • Payne-Martin & STAR – Skin Tears
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Partial Thickness
• Loss of epidermis and down into but not through the dermis • Abrasions • Skin tears • Blisters • Skin graft donor sites
• Split thickness
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Full Thickness
Through the dermis, extending down to subcutaneous tissue, muscle, may have exposed structure
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Stage 2
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IAD / MASD
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IAD / MASD
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Skin Tears
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Skin Tears
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Skin Assessment
• Temperature • Normally warm to touch
• Warmer could indicate inflammation • Coolness could indicate vascular issues
• Color • Intensity
• Pallor • Rubor
• Hyper- or hypo-pigmentation
Practice Nursing 2013, Vol 24, No 1
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Skin Assessment
• Moisture • Dry (Xerosis) or moist • Hyperkeratosis (flaking, scales) • Eczema • Dermatitis, psoriasis, rashes
• Turgor • Dehydration vs. effects of aging
Practice Nursing 2013, Vol 24, No 1
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Skin Assessment
• Integrity • Presence of open areas and
appropriate classification • Skin Tears
• Skin or epidermal skin stripping injuries
• Most commonly caused by friction and/or shear
• Avulsive tissue injuries • Full thickness trauma wounds
Practice Nursing 2013, Vol 24, No 1
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Skin Tear Assessment Tools Payne-Martin
•Payne RL, Martin MLC. Defining and classifying skin tears: need for a common language. Ostomy Wound Manage. 1993;39(5):16-26.. LeBlanc K, Baranoski S. Skin tears: state of the science: consensus statements for the prevention, prediction, assessment, and treatment of skin tears. Adv Skin Wound Care. 2011;24(9)(Suppl 1):2-15. STAR Skin Tear Classification System available at: http://www.silverchain.org.au/assets/files/STAR-Skin-Tear-tool-04022010.pdf. Accessed on: November 15, 2011.
Payne-Martin Skin Tear Classification System Category I Skin tears without tissue loss
A. Linear type (no tissue loss, resembles an incision) B. Flap type (epidermal flap covers the dermis to within 1 mm of skin
tear edge) Category II Skin tears with partial tissue loss
A. Scant tissue loss type (≤25% epidermal flap lost, covers > 75% of the dermis)
B. Moderate-to-large tissue loss type (≥25% epidermal flap lost, >25% dermis exposed)
Category III
Skin tears with complete tissue loss
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STAR Classification System
18
STAR Classification System Category 1a
A skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap color is not pale, dusky or darkened.
Category 1b A skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap color is pale, dusky or darkened.
Category 2a A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap color is not pale, dusky or darkened.
Category 2b A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap color is pale, dusky or darkened.
Category 3 A skin tear where the skin flap is completely absent. •Payne RL, Martin MLC. Defining and classifying skin tears: need for a common language. Ostomy Wound Manage. 1993;39(5):16-26.. LeBlanc K, Baranoski S. Skin tears: state of the science: consensus statements for the prevention, prediction, assessment, and treatment of skin tears. Adv Skin Wound Care. 2011;24(9)(Suppl 1):2-15. STAR Skin Tear Classification System available at: http://www.silverchain.org.au/assets/files/STAR-Skin-Tear-tool-04022010.pdf. Accessed on: November 15, 2011.
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Location
• Document in reference to head, front or back
• Commonly used terms • Proximal, distal • Superior, inferior • Medial, lateral • Anterior, posterior • Dorsal, plantar
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Location
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Location
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Wound Dimensions
• Two dimensional (Length x Width) • Three dimensional (documented as
Length x Width x Depth) • Specialized digital cameras • Planimetry • Tracings
X
=
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Length and Width
• Longest axis for length, perpendicular line to that for width
•Clock or head to toe: line closest to 12-6 for length, 3-9 for width
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Depth
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Location and Dimensions: Implications
• May assist in identification of wound type • Proper identification and tracking of wound
progress • Appropriate support management • Appropriate coding for debridement and
advanced biologicals
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Undermining
• Tissue loss parallel to the skin surface
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Undermining
Head / 12 o’clock
Feet / 6 o’clock
9 o’clock
3 o’clock
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Undermining
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Visual Documentation
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Tunneling / Sinus Tracts
Tissue loss into depths of the wound
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Tunneling / Sinus Tracts
• Tissue loss into depths of the wound
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Undermining and Tunneling: Implications
• Assessment of healing • Awareness to prevent premature closure • Effective choice of dressing materials and filling
of space • Assessment of need for further debridement /
surgical exploration
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Wound Edges: Open
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Migrating Edge
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Wound Edges: Closed, or Unattached
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Epiboly
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Wound Edges
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Wound Edges: Implications
• Assessment of healing • Potential for healing!
• Exposure of viable edge for migration
• Assessment of need for further debridement, excision of edges
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Exudate - Amount
• None • Scant/small • Moderate • Large • Copious • When was last
dressing changed?
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Exudate - Color
• Green, yellow, blue-green, gray, red, tan…….
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Exudate - Character
• Serous, serosanguinous, sanguinous, purulent
• Opaque, clear, cloudy • Liquefying necrotic tissue • Dressing residue
• Hydrocolloids
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Exudate
• Assessed while considering surrounding tissue condition and odor
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Exudate Amount, color, character: Implications
• Evidence of infection • Color may be indicative of particular bacteria
• Distinguish between treatment residue and actual purulence • Liquefying necrotic tissue
• Enzymatic or autolytic debridement • Biological products incorporating
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Odor
• Presence • Absence
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Odor: Implications
• Increasing bacteria • Need for increased frequency of dressing
changes • Quality of life impact
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Tissue Types
• % Necrotic tissue
• % Granulation tissue
• % Other structure
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Tissue Types
• Eschar • Slough • Fibrin • Granulation tissue • Epithelium
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Eschar
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Slough
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Fibrin?
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Granulation
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Granulation?
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Hypergranulation Tissue Ultrasound
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Antimicrobial Foam
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Silver Nitrate
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Epithelium
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Exposed Structures
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Vessels: Know the Neighborhood
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Tissue Types: Implications
• Decision making related to wound bed preparation
• Decision making related to topical treatment • Assessment of improvement vs. worsening of
wound, blood flow, bacterial balance
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Peri-wound Evaluation
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Peri-wound evaluation: Implications
• Evidence of inflammation/infection • Evidence of failure of dressing to manage
moisture effectively • Evidence of need for education related to care
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Excoriation
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The Power of Photographs
• A picture is worth a thousand words
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Issues Around Photography
• Competence of the photographer • Concern related to legal implications
• potential for litigation vs. potential for $$ lost • Argument related to the ability to alter a
digital image • Don’t download: print only • Upload to secure site
• Write it into the hospital policy
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Components of Photography Policy
• Competencies on file • Date documented in the
wound • Don’t rely on date stamp
• Size comparator in photo • Photograph all wounds • Consider arrival /
discovery and then re-photograph at discharge
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Summary
• Accurate and repeated wound assessments are the driving force behind treatment decisions
• Utilization of a system that monitors changes over time will enable analysis of healing or non-healing • Prognostic indicators • Treatment plan can be adjusted accordingly