Wound Assessment and Documentation

Dot Weir, RN, CWON, CWS Osceola Regional Medical Center Kissimmee, Florida

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…

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

Imperative…

• KNOW • THE

• DIAGNOSIS!

Degree of Tissue Destruction

• Wound type specific • All not universally utilized • Can present barrier to consistency in

documentation

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

Partial Thickness

• Loss of epidermis and down into but not through the dermis • Abrasions • Skin tears • Blisters • Skin graft donor sites

• Split thickness

Full Thickness

Through the dermis, extending down to subcutaneous tissue, muscle, may have exposed structure

Stage 2

IAD / MASD

IAD / MASD

Skin Tears

Skin Tears

Skin Assessment

• Temperature • Normally warm to touch

• Warmer could indicate inflammation • Coolness could indicate vascular issues

• Color • Intensity

• Pallor • Rubor

• Hyper- or hypo-pigmentation

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Skin Assessment

• Moisture • Dry (Xerosis) or moist • Hyperkeratosis (flaking, scales) • Eczema • Dermatitis, psoriasis, rashes

• Turgor • Dehydration vs. effects of aging

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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

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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

STAR Classification System

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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.

Location

• Document in reference to head, front or back

• Commonly used terms • Proximal, distal • Superior, inferior • Medial, lateral • Anterior, posterior • Dorsal, plantar

Location

Location

Wound Dimensions

• Two dimensional (Length x Width) • Three dimensional (documented as

Length x Width x Depth) • Specialized digital cameras • Planimetry • Tracings

X

=

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

Depth

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

Undermining

• Tissue loss parallel to the skin surface

Undermining

Head / 12 o’clock

Feet / 6 o’clock

9 o’clock

3 o’clock

Undermining

Visual Documentation

Tunneling / Sinus Tracts

Tissue loss into depths of the wound

Tunneling / Sinus Tracts

• Tissue loss into depths of the wound

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

Wound Edges: Open

Migrating Edge

Wound Edges: Closed, or Unattached

Epiboly

Wound Edges

Wound Edges: Implications

• Assessment of healing • Potential for healing!

• Exposure of viable edge for migration

• Assessment of need for further debridement, excision of edges

Exudate - Amount

• None • Scant/small • Moderate • Large • Copious • When was last

dressing changed?

Exudate - Color

• Green, yellow, blue-green, gray, red, tan…….

Exudate - Character

• Serous, serosanguinous, sanguinous, purulent

• Opaque, clear, cloudy • Liquefying necrotic tissue • Dressing residue

• Hydrocolloids

Exudate

• Assessed while considering surrounding tissue condition and odor

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

Odor

• Presence • Absence

Odor: Implications

• Increasing bacteria • Need for increased frequency of dressing

changes • Quality of life impact

Tissue Types

• % Necrotic tissue

• % Granulation tissue

• % Other structure

Tissue Types

• Eschar • Slough • Fibrin • Granulation tissue • Epithelium

Eschar

Slough

Fibrin?

Granulation

Granulation?

Hypergranulation Tissue Ultrasound

Antimicrobial Foam

Silver Nitrate

Epithelium

Exposed Structures

Vessels: Know the Neighborhood

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

Peri-wound Evaluation

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

Excoriation

The Power of Photographs

• A picture is worth a thousand words

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

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

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