Wound Assess 01.10.10

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,Documentation &

Management

HHC Health & Home Care

. , ,

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ec ves

List six elements to include when assessing anddocumenting wounds

escr e e our ssue ypes oun n e wounbed

Differentiate pressure ulcer stages as defined byNPUAP

Define surgical wound and stasis ulcer using theOASIS definition

Identify wound classification/etiology

List appropriate wound management that provide

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n ro uc on

Success Drives the care plan in motion

esponse o ems

Impact on reimbursement

Determines necessary resource utilization Quality Indicators depend on accurate/consistent

assessment Emergent Care for Wound Infection, Deteriorating Wound

Increase in Number of Pressure Ulcer

Improvement in Number of Surgical Wounds

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n ro uc oncon

Interventions

To discharge patient with patient or caregiver

To keep free of infection

To revent rehos italization

To prevent skin breakdown

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Two Primary Layers of the

n

< 1mm thickness, avascular

Regenerates on average every 28-30 days

Melanocytes produce and distribute melanin, the

brown pigment of skin

environmental antigens

Dermis innermost layer supports & nourishes epidermis

Collagen, fibroblast

Extra cellular matrix formation

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Anatom : Human Skin

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n ruc ure

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a or unc ons o e n

,

Thermoregulation & Excretion regulates

Sensation pain, touch, temperature andressure

Metabolism vitamin D synthesis inpresence of sunlight

Communication body image

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n s e ge

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Skin as We Age

Easily traumatized Decrease in sebaceous lands

Decrease in immune response

Chan es in thermore ulation

Less elasticity

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ypes o oun ea ng

. -

Edges approximated

owers r s o n ect on

Involves little tissue loss/defectHeals with minimal scarring

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ypes o oun ea ng

.

Chronic wounds e.g.: Pressure ulcers,

allowed to heal by production of scar

tissuea. Edges not approximated

b. Greater tissue loss

c. Higher risk of infection

d. Longer healing times

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ypes o oun ea ng

3. er ary e aye r mary n en on

(delay between injury and closure)

Surgical wounds left open for 3-5 days

Closed with sutures, staples or adhesive skin

Heals with more scar tissue than primary

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Three Phases of WoundHealing

Inflammatory Phase reactive phase 4-6 days of cellular infiltration

Phagocytosis neutrophil remove

necrotic tissue, macrophage ingestac er a, ac va e o re ease grow

factors

factors, blood vessels dilate

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Three Phases of Healingcont

4 - 24 days for normal non-infected wounds Fills the wound with connective tissue

granu a on

Contracts the wound edges (contraction)

Covers the wound with epithelium

Fibroblasts cellular proliferation, synthesizecollagen, release growth factors

An io enesis formation of new blood vessels

Granulation major tissue fills wound bed(connective)

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Proliferative Phase

phase last several weeks

buds or granule tissues ranu a on o ssue, ro as

stimulate the production of collagen

Margins pull together, decreasing thewound size

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Proliferative Phase

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Proliferative Phase Contraction

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Proliferative Phase

- ,

light purple from edges in full thickness wounds

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ree ases o ea ngcont

Remodeling collagen fibers rearrange,

Increase tensile strength

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Maturation Phase

emo e ng p ase

lasts 21 days to months

Process continues until

regained about 80% of

strength

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oun ea ng asca e

-

MaturationProliferative/

Fibroblastic

Remodeling

Granulation

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Wound Assessment, Documentation

& Management

Head to Toe SkinAssessment

Risk Assessment Identify Causative Factors,

- a en s ory

Type/Classification of

Wound

Nutritional and Hydration

Status

Wound Etiology

Location

Vascular Status

Environmental and

Appearance, Shape

Pain

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Whats wrong with this patient?

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Wound Location The wound location

should be precisely

identified

such as left or right,

medial or distal, and

location

Buttocks: sacral

coccyx, ischium,trochanteric, etc.

, ,Suprapubic, etc.

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Width side to side; greatest width

Depth from visible to the deepest area

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oun mens ons

,

sterile cotton tipped applicator into thedee est art of the wound bed ras the

applicator at skin level, and then measure the

applicator from its tip to your fingers

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Wound Base

Granulation red/pink and beefy appearance

Epithelial bridging

u

Slough yellow, tan

sc ar ac , rown

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ranu a on p e a za on

,

berry like red or pink

Epithelial tissue dry,deep pink to pearly

ink li ht ur le fromedges in full thicknesswounds or may form

wounds

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usc e, en on an one

Muscle pink to dark

red, firm, highly

muscles shiny white,

thin to thick, contains

muscle or muscle group

Bone

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Eschar and Slou h

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a s unne ng

extend in any direction from the wound and

abscess formation

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What is Underminin ?

intact skin along the wound margins

Space between the surrounding skin andthe wound bed

wound edge

May extend entirely around wound

Subcutaneous fat necrosis Usually indicates aerobic and anaerobic

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How to Measure Tunneling

n erm n ng

-

applicator gently to

centimeters

Describe the locationusing the face of a

clock, with 12 oclock

at the patients headand 6 oclock at the

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Wound Sha e & Ed es

Round

Crater-like

- Intact (or not)

Callous

Macerated Desiccated

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oun gescon

Fibrotic / firm

epibole

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Periwound Skin

Edema Pitting

on p tt ng

Induration

Er thema Periwound Pain

Maceration

asAbsence of hair

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er woun ncon

, ,

Presence of foreign bodies sutures, drain, , ,

metal, dirt, bone/metal)

Er thema redness irritation dermatitisdemarcated borders, red streaking. In darkskin, may appear purple or a gray hue or

eepen ng o e e n c s n co or Dry skin

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oun xu a eWOUND ODORWOUND ODOR WOUND DRAINAGEWOUND DRAINAGE

Clean or irrigate woundwith NS

Describe exudate: Amount

o e e presence orabsence of odor

o or

Types

Serous clear to straw Serosanguinous slightly

bloody

Sanguineous - bloody

Fibrinous composed offibrin and cells

Purulent thicker,opaque and colorful

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Wound Exudate haracteristicsExudate Type Color Consistency Significance

Sanguineous/ Red Thin, watery Indicates low blood vessel

Bloody grow or srup on o

blood vesselsSero-sanguineous Light Thin, watery Normal during

red to

pink

inflammatory and

proliferative phases of

healing.Serous Clear,

light

color

Thin, watery Normal duringinflammatory and

proliferative phases of

healing.Seropurulent Cloudy,

yellowThin, watery May be first signal of

impeding wound infection

to tan

Purulent/pus Yellow,tan or

Thick, opaque Signals wound infection;ma be associated with

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easur ng a n

wound or periwound area

s e pa en o ra e e pa n on a sca e o

0-10, with 0 indicating no pain and 10 severe

7 to 10 is mitigating pain

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Classification of Wounds b :

ACUTECHRONIC

sua y rauma orsurgery

Heals quickly through awell orchestrated process

Healing not timely ororderly

3 phases of healing withlimited local care

onger ea ng me ueto

Pressurehours)

Inflammatory (0 to 3

Inflammation

Poor nutrition

ays

Proliferative (3-21days)

Poor circulation

Ma re uire active wound Maturation (21 days-

1.5 years)

treatment to heal

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Pressure Neuropathic - diabetic

Venous insufficiency

Arterial

Dehisced Surgical Wound

Others: Malignancy,

Vasculitis, Fistula,Pyoderma Gangraenosum

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oun ass ca on y ep

- -

epidermis and possiblepartial loss of dermis

-

destruction extendingthrough the dermis to

Shallow wounds

No granulation tissue

involve the subcutaneous

layer and possibly muscle

erma repa r w

epithelial tissue

tissue

Wound contraction

partial-thickness Epithelialization

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urg ca oun omp ca ons

-

Wound Dehiscence acute wound failure,woun srup on, a om na woun

separation

ccurs y e an ay pos opera ve

About half are associated with infection

, ,

Hypoproteinemia, Hypertension, DM

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urs ng ssessmen

Assess incision site for any signs and symptoms ofinfection

Heat Elevated WBC

Purulence ncrease ra nage assess ress ng or s gns o ooz ng

Odor

Changes in wound appearance and surrounding tissue

easure woun nc s on

Wound Care Sheet use to document progress andnon progress of wound status

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M1340 Does this patient have

a Surgical Wound?

Yes, patient has at

surgical wound

Surgical wound knownbut not observable due

to non-removable

Cast or dressing per

physician order

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What is a Surgical Wounds &

What is Not?

Central line sites Sta led or sutured

Surgery to the mucosalmembranes,

incisions

Wound with drains

Gynecological surgicalprocedure via vaginal

Medi-port sites

Implanted infusion

PICC line

access devices I & D with excision

Debridement orplacement of skin graft

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(Observable) Surgical Wound

Most problematic largest, most resistant totreatment, or an infected surgical wound

Identifies the degree of healing Newly epithelialized incision well approximated, complete

e ithelialization Fully granulating no s/s of infection, no dead space, no

avascular tissue

,

edges open Not healing - >25% avascular tissue, closed edges,

,

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an an n erven ons

surgery

surgery

Pain relief as needed Provide information to patient/caregiver related to

wound healing process and signs and symptoms of

woun comp ca ons n ec on

Provide emotional support related to reason for

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urg ca oun n a s

Surgical Wound Post Removal of

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Surgical Wound Post Removal of

e en on u ures onTherapy

Surgical Wound 3 weeks VAC

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Surgical Wound 3 weeks VAC

erapy

S i l W d 4 k t

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Sur ical Wound 4 weeks ost

VAC

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ressure cers

Compression mechanical injury o ssue compresse e ween wo ar

surfaces

impaired, decreasing the supply of oxygen and

Injury External Factors:Pressure

ShearFriction

Maceration

Pressure Points

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Pressure PointsSUPINE POSITION SITTING POSITION

Occiput Scapula Sacrum Heels

. . . .

LATERAL PRESSURE

Ischium 8%

ElbowTrochanter Knee

6%

Malleolus 6.1%

..

Piper B. Mechanical Forces: Pressure, Shear, and Friction. In Bryant & Nix (Eds.)Acute and Chronic Wounds:

Current management concepts (3rd Ed.) Mosby. 2007

Braden Scale For Predicting Press re

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Braden Scale For Predicting PressureUlcer Risk

, ,

activity, mobility, nutrition, friction & shear

Four Severity: 1. completely limited, 2. very limited,

3. slightly limited, 4. no impairment

The intensity and duration of pressure

Sensory perception, mobility, activity Tissue intolerance for pressure

Moisture, nutrition, friction/shear

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rogress on o ressure cer

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this patient assessed for Risk of

0 - No assessment conducted [ Go to M1306 ]

1 - Yes, based on an evaluation of clinical factors,

e.g., mobility, incontinence, nutrition, etc., without

2 - Yes, using a standardized tool, e.g., Braden,

Norton, other

Alwaysanswer #2

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M1302

(M1302) Does this patient have a Risk of

Developing Pressure Ulcers?

0 - No

1 - Yes

Remember!

A score of 18 & below

requires intervention

to prevent pressure

ulcers

62

If Patient High Risk, Did Intervene

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g ,

mp emen Restorative Nursin

Incontinence Management (skin care, moisture barrier, absorbent

pads or diapers, offer bedpan/urinal, increase water intake) Bladder/Bowel Training

Pressure Ulcer Prevention/Management Turning & Positioning, Prevent Friction and Shear

Pressure Reduction Support Surface

Improve Mobility

Transfer/Positioning

Moist Wound Healing Wound Bed Preparation

Nutrition

M1306 - Does this patient have at least one

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designated as unstageable ?

Depth must be visible to accurately stage

Answer No or (Go to M1322)

, , ,

Select NO if

Stage 2 pressure ulcer has healed and

There are no other pressure ulcers

Remember! Stage 3 and 4 can never be considered fully healed.They may be closed, the wound surface is covered with new

.

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- -

Pressure Ulcerthat is present at discharge

-

2 - Developed since the most recent SOC/ROC assessment:record date pressure ulcer first identified:

_ __ /__ __ /__ __ __ __

month / day / year

NA - No non-e ithelialized Sta e II ressure ulcers are resent atdischarge

65

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age ressure cer

dermis presenting as a

shallow open ulcer with a

Without slough

An intact or open/rupturedserum- filled blister

Can only heal by the

epithelialization

process of regenerationof the epidermis across

M1308 Current Number of Unhealed (non-

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(

ep e a ze ressure cer a ac age(Enter 0 if none; excludes Stage 1 pressure ulcers)

Column 1

Completed at

SOC/ROC/FU & D/C

Stage Description- Unhealed pressure ulcer Number CurrentlyPresent

a. Stage II----

b. Stage III----

c. Stage IV----

d. 1 Unstageable: Known or l ikely but

unstageable due to non-removable dressing or

----

device

d. 2 Unstageable: Due to coverage of wound ----

d. 3 Unstageable: Suspected deep t issue

injury in evolution----

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age ressure cer

loss

be visible but bone,

tendon or muscle are

not exposed

Slough may be present

ay nc u e unne ng

and undermining

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age ressure cer

loss with exposedbone, tendon, or

muscle

Slough or eschar may

be present on some

parts of the wound bed

undermining andtunneling

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ns agea e ressure cer

loss in which the baseof the ulcer is covered

by slough (yellow, tan

gray, green, or brown)

,brown, or black) in the

wound bed

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uspec e eep ssue n ury

bruising

Blood-filled blister dueto damage ofunderlying soft tissue

from ressure and/orshear

Painful, firm, mushy,,

cooler as compared toadjacent tissue

Suspected Deep Tissue Injury

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Evolution Pressure related

injury to

subcutaneous tissueunder intact skin

,have the appearanceof a deep bruise

quickly

May lead todevelopment of

age or

pressure ulcer, evenunder optimaltreatment

Black J. Adv.in Skin & Wound Care 2005;18(8):415-421

M1308 at Recertification and

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sc arge

Step Two If there is a wound in column1

If present at SOC or ROC include that wound in

column 2 If after SOC or ROC do not include in column 2

Step Three If there is a 0 in column 1 then

make sure there is a 0 in column 2


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ep e a ze ressure cer a ac age(Enter 0 if none; excludes Stage 1 pressure ulcers)Column 1 Column 2

omp e e a

SOC/ROC/FU & D/C

omp e e a

Stage Description- Unhealed pressure ulcer Number Currently Present Number of those listed in

Column 1 that were present

on admission (most recent

SOC/ROC)

a. Stage II0 0

b. Stage III0 0

c. Stage IV1 1

d. 1 Unstageable: Known or likely but

unstageable due to non-removabledressing or device 0 0d. 2 Unstageable: Due to coverage of

wound bed by s lough and/or eschar

d. 3 Unstageable: Suspected deep tissue

injury in evolution 1 0

Directions for M1310, M1312 and M1314

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If the patient has one or more unhealed (non-epithelialized)

Stage III or IV pressure ulcers, identify the Stage III or IV

width) and record in centimeters. If no Stage III or Stage IV

pressure ulcers, go to M1320

75

Length Head to Toe Width Side to Side

-

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(Observable) Pressure Ulcer:

0 Newly epithelialized

1 Fully granulating

3 Early/partial granulation

4 Not healing

NA No observable ulcer

Identifies the degree of closure visible in themost problematic observable pressure ulcer,s age or g er

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Pressure Ulcer Post Surgical

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e r emen

Pressure Ulcer Post

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y roge ress ng x a ee

M1322 Current Number of

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age ressure cers

blanchable rednessover a bony

,2 pressure ulcer statusof healing is non-

prom nences

Difficult to detect in

individuals with dark

ea ng

skin tones

May not have visible

differ from surroundingarea

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cenar o s. . .

Negron still has one stage 2 PU that was presentat SOC. A fully epithelialized stage 3 at SOC isnow a s age . nswer urrenNumber of Unhealed Pressure Ulcers.

2. How would you complete M1308 Current Numberof Unhealed Pressure Ulcers if Mrs. Negron now

implications does this have for our patient? Ouragency quality measure?


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omp e e a

SOC/ROC/FU & D/C

omp e e a

Stage Description- Unhealed pressure ulcer Number Currently Present Number of those listed inColumn 1 that were present


SOC/ROC)

a. Stage II1 1

b. Stage III0 0

c. Stage IV1 1


unstageable due to non-removabledressing or device 0 0

.





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omp e e a

SOC/ROC/FU & D/C

omp e e a

Stage Description- Unhealed pressure ulcer Number Currently Present Number of those listed inColumn 1 that were present


SOC/ROC)

a. Stage II1 1

b. Stage III0 0

c. Stage IV1 1


unstageable due to non-removabledressing or device 0 0d. 2 Unstageable: Due to coverage of




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M1300 SOC/ROC Was the patient assessed for

Risk of Developing Pressure Ulcer? oes e p ys c an or ere

plan of care including interventions to prevent

M2400 Transfer/Discharge Were the following

-

ordered POC and implemented?

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rocesses easure n

Care Plan

me y are

Assessment

mp emen a on

Education

Prevention

Care Planning

Care Coordination

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ommun ca on

Report of Assessment Findings Parameters

Change in Condition/Status

Lab work test results

-outcomes during past 60 days

Verbal Orders Change of treatment, medications, additional discipline

including visit frequency, duration and interventions

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ressure cer anagemen ,

friction and shear Support surface

Lift sheet, overhead trapeze

Turning and positioning, maximize mobility

Incontinent care, bladder/bowel training

Moisture barrier

u r on ro e n, ncrease ca or e, supp emen

with multivitamin (Vit A, C & E), zinc

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oun anagemen r nc p es

Pressure, Shear, Friction Moisture

Circulator Im airment

Neuropathy

Provide Systemic Support to Reduce Existing

and Potential Cofactors

Nutritional and Fluid Support

Control of Systemic Condition Affecting Wound Healing i.e., blood glucose

Wound Management

t

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r nc p escont.

Prevent and Manage Infection

Remove Nonviable Tissue (debridement)

Eliminate dead space

Eliminate or Minimize Pain

TIME Princi les of Wound Bed

P ti

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Preparation

T Tissue nonviable or deficient

I Infection or inflammation

M Moisture imbalance

w u - v

Treatment Options: Moist

W d E i t

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Wound Environment

loosely Debridement,

HydrocolloidHyperbaric, Topical

Antimicrobial Agents,

Foam ,

Dermal Graft

Negative Pressure Wound Therapy

Management of Lower

E t it Ul

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Extremity Ulcers

Venous Insufficiency 85% of lower limb ulcer

Arterial Insufficiency

Diabetic/Neuropathy

Vascular Anatomy of the

ower x rem y

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ower x rem y

rich blood to the foot, then return the O2de leted blood back to the heart Superficial veins

Deep veins

Communicating veins

Arterial and/or venous system canma unc on

Recognizing and evaluating pathology

enous as s cers

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enous as s cers

veins leads to venous

hypertension venous blood does not

completely leave theveins

Fluids leaks from thevessels and formsedema in the tissue

we ng

Development of ulcers inankle or calf

Signs and Symptoms of

enous nsu c ency

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enous nsu c ency ,

palpate due to edema

Temperature normal warm

Capillary refill normal

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cers

Above malleolus Edema

Weeping lesions

Irregular wound edges

Shallow de th

Pain relief with elevation

enous cer anagemen

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enous cer anagemen

Ambulation

Ulcer care to maintain moist wound environment

Compression to reduce pressure differential andmaintain capillary function

o s , gvar s g suppor o mo era e compress on UNNA boot non-elastic compression

2 layer wrap 20-25 mm Hg

4 layer wrap 40 mm Hg (profore)

No compression for arterial insufficiency, CHF,

r er a cers

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r er a cers

OCCLUSION OFARTERIES

(arteriosclerosis

or atherosclerosis)

Known as PAD

Intermittent claudication

Characteristics of Arterial

cers

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cers ,

Small, Round, Shallow Depth

Pain with leg elevation

Absent or diminished pulse

cera on or gangrene o e ower ex rem y

ABI

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an ever y o

applied n e rac a n ex

Using Doppler:

Ankle Arterial BP

Brachial Arterial BP

= ABI


r er a nsu c ency

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r er a nsu c ency

Cramping or Aching Sensation in Calf Associated with Walking

Relieved with Rest

Femoral and Pedal Pulse Present

Dela ed Ca illar Refill >3 seconds

Skin Pallor when Leg Elevated >1 minute


r er a nsu c ency

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r er a nsu c ency

Pain with Elevation

Wound/Ulcers on Tips of Toes, Toes, Foot, Rarely

Above Calf

Ulceration or Gangrene

ABI

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r er a cer anagemen

revascularization

Moisturize dry skin, Do not apply between

toes Avoid trauma

Wound care moist wound healing ifade uate blood flow

- europa c cer

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europa c cer ,

autonomic changes, motor changes er p era vascu ar sease

Plantar

Usually granular

Minimal drainage

Callous wound edges Boundin ulses


a e c europa y

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a e c europa y

pale color, delayed capillary refill or may be normal

Diminished hair distribution

Warm or cold to touch

Sensory Changes loss of sensation

- Autonomic Changes absence of sweat/oil

production Ingrown or thickened toenails

Dry cracked areas, fissures

, , ,flat foot, Charcot degeneration

arco r ropa y

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arco r ropa y

No Pain on Ambulation Edematous and Warm

X-ray with Abnormality

Rocker Bottom Foot

R/O Osteom elitis

Bone biopsy MRI is more accurate but ex ensive

Very Important to Listen to

a en oroug s ory

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a en oroug s ory

Where is the pain?

Do you have swelling in your legs?

What factors aggravate or relieve pain?

Describe the pain: Aching? Burning? Constant? Intermittent?

Neuropathic Ulcer

Management

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Management

Off-loading

Patient education

Total contact casting

Hyperbaric oxygen Growth factors

a en uca on

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Avoid chemical, mechanical and thermal trauma

Wash, dry well, especially between toes

, Avoid temperature extremes

Avoid walking on hot surfaces (beach, sidewalk)

a en uca on

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,

Avoid chemical agents (corn, callus remover

Avoid adhesive tape

Do not cut own calluses/corns

,

Wear stockings or socks with shoes -

a en uca on

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NO bathroom surgery

Notify MD ASAP if blister or ulcer develops

,sheepskin, heel protectors

Keep tetanus current

ummary: ey o n s

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y y

Aggressive treatment of infection

Dee debridement

Pressure relief

Patient education

Glucose control

Collaboration Nutritionist, MD, Podiatrist, PT

ons er a erna ve erap es

Topical avoid harmful agent

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REMEMBER:

for successful management of

patients with lower extremity

What is To ical O2

Therapy?

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py

providing pure oxygen directly to the wound

Oxygen is delivered directly to the surface of

e woun Topical Oxygen Therapy provides a natural,

sa e an non nvas ve a erna ve or woun

healing that can be administered in any

Topical Oxygen Wound

erapy

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One-time Use, Portable

90 Minutes Per Treatment

3 Days Rest Re eat C cle Until Wound Is Healed

Documents

Wound Assess 01.10.10