Assessing and Documenting Chronic Wounds



Assessing and Documenting Chronic Wounds





Stated simply, a chronic wound is an insult or injury to the skin that has failed to heal. A patient with a chronic wound usually has a host of factors that impede the healing process and ultimately lead to generalized discomfort. Chronic diseases— such as diabetes, vascular insufficiency, and various autoimmune diseases—can inhibit proper wound healing and affect the overall condition of the patient’s skin, including its moisture level and texture.

To achieve successful skin and wound healing, the clinician must meticulously follow every step of skin and wound management, including assessment, planning, implementation, evaluation, and documentation. Clinicians are responsible for assessing the patient’s skin, wounds, and management modality (dressing, drug, or device); implementing wound care orders; selecting and changing the management modality; and preventing infection during procedures. Identifying and addressing systemic factors in wound healing also are important for successful outcomes.


ASSESSMENT

Performing a comprehensive patient assessment is the essential first step toward healing the chronic skin condition or wound. Once the clinician has assessed the patient, identified any underlying conditions affecting healing, performed a complete assessment of the patient’s nutritional status, performed the proper tests to provide an accurate diagnosis of the underlying problem, assessed the patient’s knowledge of the disease, and documented all factors that affect the learning needs of the patient, a complete skin and wound assessment can be completed.

The assessment is set in motion with a one-on-one discussion between the patient or caregiver and clinicians who have cared for the patient’s skin and wound. Understanding the patient’s past and current family, social, and medical history may provide important insight into why the wound isn’t healing.

Clinical interventions will vary according to the assessment.



CHECKLIST


Obtaining a history

A thorough review of the patient’s medical history, laboratory tests, medications, and diet can help the clinician determine the cause of the skin condition or wound. Chronic wounds, for example, can be caused by a multitude of different diseases. Primary causes include pressure, chronic venous insufficiency,
lower-extremity arterial disease, and diabetic neuropathy. To obtain a patient’s history, follow these steps:



























[check mark] Review the patient’s medical history, which details allergies, laboratory studies, radiologic studies, vascular studies, medications, past illnesses, surgical procedures, and other pertinent facts related to the patient’s illnesses and problems. Ask about allergies to foods or medications, including topical skin and wound care products. Also, ask the patient if his skin’s appearance changes with the seasons.


[check mark] Review the patient’s family history, paying particular attention to the history of parents, siblings, grandparents, and natural children, and detailing the age and general health of living relatives, the death and cause of death of all deceased family members, and any chronic diseases that occur in the immediate family. This information will alert you to the presence of inherited or congenital conditions or diseases.


[check mark] Review the patient’s social history, including age-appropriate information regarding past and current activities, such as marital status, living arrangements, current employment and occupational history, sexual history, level of education, and use of drugs, alcohol, or tobacco. Ask about other social factors that may influence the patient’s activities of daily living.


[check mark] Ask about the patient’s bathing routines and about the different soaps, shampoos, conditioners, lotions, oils, and other topical products he uses routinely. Any such products may lead to changes in skin, appearing as xerosis, pruritus, wounds, rashes, or a change in skin color.


[check mark] Obtain a list of past and current medications and dressings, including all medications and dressings that have been used, have been effective, or have failed.


[check mark] Review previous treatments, dressings, drugs, and adjunctive modalities (such as physical therapy, skin replacements, and growth factors) and determine their effectiveness.


[check mark] Review all laboratory, radiology, and vascular studies that have been performed.


[check mark] Review the patient’s nutritional status and supportive therapies. For the patient who has a wound, obtain the following information:


[check mark] Review all clinician consultations related to specialty management programs for skin and wound care.


[check mark] Review (if indicated) all support surfaces and positioning devices used to manage the patient’s tissue load.


[check mark] Review (if indicated) any use of devices, such as compression stockings, custom shoes or braces, and assistive devices.


[check mark] Assess the patient’s knowledge of the disease, and document all factors that affect learning needs.


This comprehensive patient assessment will provide the clinician with the four W’s she needs to know for skin and wound care:



  • When did the skin condition or wound occur?


  • Who has taken care of the skin condition or wound?



  • What strategies have been used to facilitate healing of the skin condition or wound?


  • What documented findings (e.g., written information, laboratory test results, and vascular or radiology test results) can be reviewed to support the care of the skin condition or wound?

Answers to these questions will provide the clinician with a strong foundation upon which to manage the patient’s skin and wound. An incomplete assessment may delay the skin- or wound-healing process.


Performing a physical assessment

Differential assessment of the skin condition or wound is essential to understanding its cause and development. First, assess the patient’s skin temperature, dryness, itching, bruising, and changes in texture of skin and nail composition. Also, assess the skin for color and uniform appearance, thickness, symmetry, and primary or secondary lesions. (See Identifying primary and secondary lesions, page 18.)

Examine the patient’s nails for changes in thickness, splitting, discoloration, breaking, and separation from the nail bed. Question the patient about changes in his nails, which may be a sign of a systemic condition.

Document all the findings of the skin assessment. Note, too, any presence of a skin condition: erythema, itching, scratching, skin weeping, skin blistering, bruising, primary lesions, secondary lesions, and open wounds.



CHECKLIST


Performing a wound assessment

After completing the patient assessment and physical assessment, a comprehensive wound assessment is the next important step. The wound assessment helps define the status of the wound and helps identify impediments to the healing process. A clear understanding of skin anatomy is essential for assessing and classifying the wound and defining the level of tissue destruction. (See chapter 1.) A detailed assessment of the patient’s wound status includes, but isn’t limited to, the following parameters:

























[check mark] Location. Anatomic location describes the lesion and the nearest bony prominence or another anatomic landmark. Detailing the wound’s location is imperative for accurate documentation and consistent care by each provider working with the patient.


[check mark] Size (length, width, depth, undermining). Accurate wound measurements can assist the clinician in designing an appropriate care plan. Size includes length, width, and depth. Consistent vocabulary and units of measure are essential when documenting or describing the wound. (See Measuring wound depth, page 20.)


Color and type of wound tissue. Wound bed description and wound color provide a consistent approach in defining the tissue in the base of the wound. Descriptors such as granulation tissue, slough, and eschar are typically used to define tissue type. Tissue color also has been used to distinguish viable from nonviable tissue and is another descriptor that assists in the management process.


[check mark] Exudate or drainage amount and type. The amount of wound exudate or drainage is assessed and described with each dressing change. The number of dressingchanges needed per week can help in estimating the amount of exudate present. Large amounts of exudate may indicate an infection and a barrier to healing.


[check mark] Odor. Odor helps define the presence and type of bacteria in the wound and is assessed only after the clinician has cleaned the wound.


[check mark] Periwound skin condition. Periwound skin is assessed for color and temperature. Inflammation or erythema may indicate wound infection or dermatitis. Assessing the periwound skin for maceration or denuded tissue is also important. Macerated periwound skin should prompt the clinician to assess the topical wound dressing for its ability to manage exudate. Macerated or denuded periwound skin is also a concern when the clinician needs to anchor a dressing.


[check mark] Wound margins. The condition of the wound margins can provide the clinician with information about the wound’s chronicity or healing ability. Newly formed epithelium along the wound edge, commonly flat and pale pink to lavender in color (termed the edge effect), indicates stimulated healing.


[check mark] Pain. The presence, absence, or type of pain may indicate infection, underlying tissue destruction, neuropathy, or vascular insufficiency.


[check mark] Adjunctive therapies. Adjunctive therapies and support—such as negative-pressure wound therapy, support surfaces for bed and chair, and rehabilitation services—play a vital role. The patient’s wound should define the level of therapy needed.


[check mark] Patient knowledge of the disease and wound management. The educational needs of the patient must be evaluated on an individual basis, beginning with the nonjudgmental assessment of the patient’s knowledge relevant to the care plan. An experienced clinician should direct the educational activities.


[check mark] Dressing management. A moist wound-healing environment requires a proper dressing. Considerations for choosing proper primary and secondary dressings are based on wound characteristics, including size, undermining or tunneling, and amount of exudate. (See Measuring wound tunneling, page 21.)






Identifying primary and secondary lesions

These guidelines will help you differentiate between primary and secondary lesions.


Primary lesions

Primary lesions are those present at the onset of the disease.






























Bulla

▪ A vesicle larger than 5 mm in diameter


Cyst

▪ An elevated, circumscribed area of the skin filled with liquid or semisolid fluid


Macule

▪ A flat, circumscribed area


▪ Brown, red, white, or tan in color


Nodule

▪ An elevated, firm, circumscribed, and palpable area


▪ Can involve all layers of the skin


▪ Larger than 5 mm in diameter


Papule

▪ An elevated, palpable, firm, circumscribed lesion


▪ Generally less than 5 mm in diameter


Plaque

▪ An elevated, flat-topped, firm, rough, superficial papule


▪ Larger than 2 cm in diameter (papules can coalesce to form plaques)


Pustule

▪ An elevated, superficial area that’s similar to a vesicle but filled with pus


Vesicle

▪ An elevated, circumscribed, superficial, fluid-filled blister


▪ Less than 5 mm in diameter


Wheal

▪ An elevated, irregularly shaped area of cutaneous edema


▪ Solid, transient, and changing, with a variable diameter


▪ Red, pale pink, or white in color



Secondary lesions

Secondary lesions are the result of changes over time caused by disease progression, manipulation (scratching, rubbing, picking), or treatments.















Crust

▪ Slightly elevated


▪ Variable size


▪ Consists of dried serum, blood, or purulent exudate


Excoriation

▪ Linear scratches on the skin, which may or may not be denuded


Lichenification

▪ Rough, thickened epidermis


▪ Accentuated skin markings caused by rubbing or scratching (e.g., chronic eczema, lichen simplex)


Scale

▪ Heaped-up keratinized cells


▪ Flaky exfoliation


▪ Irregular


▪ Thick or thin, dry or oily


▪ Variable size


▪ Silver, white, or tan in color


A thorough wound assessment includes:



  • condition of the skin around the wound


  • status of the wound (whether acute or chronic)


  • amount of wound exudate, if any


  • presence or absence of necrosis


  • appearance of the wound, such as whether it is red, yellow, or black


  • evidence of possible infection or lack thereof


  • degree of cleaning and packing required


  • nature of the dressings needed


  • management of the drainage.


Additional qualifying factors for wound management


Body measurements

To ensure accuracy, patient stature (height and weight) must be measured by the clinician rather than reported by the patient.

If standing height can’t be measured, knee height calipers may be used. These calipers measure the length of the lower leg from the bottom of the foot to the


top of the patella, and a mathematical formula is then used to determine the patient’s height.



Measuring wound depth

To properly evaluate healing, the clinician must measure the wound initially and regularly during treatment. One method is to use a sterile, flexible applicator and follow the procedure below.




image



Measuring wound tunneling

The clinician should document both the direction and depth of tunneling, as outlined below.


Direction of tunneling

To determine the direction of tunneling, perform the following steps:



  • Put on gloves and gently insert the applicator into the sites where tunneling occurs.


  • View the direction of the applicator as if it were a hand of a clock (12 o’clock points in the direction of the patient’s head).


  • Progressing in a clockwise direction, document the deepest sites where the wound tunnels (e.g., 3 o’clock).


Depth of tunneling

To measure the depth of tunneling, perform the following steps:



  • Insert the applicator into the tunneling areas.


  • Grasp the applicator where it meets the wound’s edge.


  • Pull the applicator out, place it next to a measuring guide, and document the measurement (in centimeters).

Other body measurements—such as triceps skin-fold measurement, mid-arm circumference, and mid-arm muscle circumference—have limited usefulness in most wound care settings.

Any changes in the patient’s weight, as well as a history of the weight change, need further evaluation to provide information about the patient’s normal weight. Interview family members if the patient is unable to provide a history because of illness or mental deficiency.


Laboratory tests

Laboratory tests help evaluate the patient’s nutrition and hydration status. A complete nutritional assessment includes an evaluation of both a standard multiple analysis and a complete blood count as well as protein stores, electrolyte and fluid balance, renal function, liver function, glucose levels, anemias, and immune status. It also may include other specific nutritional laboratory values, such as prealbumin, folic acid, vitamin B12, ferritin, and transferrin levels, along with lymphocyte count. The accompanying table indicates the levels of mild, moderate, and severe depletion for common protein status laboratory values. (See Markers of malnutrition below; see also chapter 5.) Many laboratory assays, such as albumin, are affected by hydration status. It’s important to repeat laboratory tests after a patient has been rehydrated.


Nutritional assessment

Performing a complete assessment of nutritional status is critical to making sure the patient’s diet is optimal for supporting the healing process. In 2009, the European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel published “Prevention and Treatment of Pressure Ulcers.” These guidelines summarize evidence-based practices for pressure ulcer prevention and treatment.








Markers of malnutrition









































Marker

Normal value

Mild depletion

Moderate depletion

Severe depletion


Percent of usual body weight

100%

85%-95%

75%-84%

< 75%


Albumin (g/dL)

≥3.5

2.8-3.4

2.1-2.7

< 2.1


Prealbumin (mg/dL)

16-30

10-15

5-9

< 5


Transferrin (mg/dL)

> 200

150-200

100-149

<100


Total lymphocyte count (mm3)

2,500

<1,500

<1,200

< 800


From Whitney, E. N., et al. (1998). Understanding normal and clinical nutrition (5th ed.). Reprinted with permission of Brooks/Cole, a division of Thomson Learning: www.thomsonrights.com. Fax (800) 730-2215.

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Jul 5, 2016 | Posted by in NURSING | Comments Off on Assessing and Documenting Chronic Wounds

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