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Harmony Healthcare International, Inc.

Copyright © 2012 All Rights Reserved 1

Wound Assessment and Documentation It’s about the WHOLE patient, not just

the Hole IN the patient

HARMONY UNIVERSITY The Provider Unit of

Harmony Healthcare International, Inc. (HHI)

Presented by:

Kim Steele RN, WCC, RAC-CT Regional Consultant

Housekeeping

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A Little About Me

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Contact Information for Questions

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Objectives

Name main components and functions of skin

Identify wound types and the common characteristics of each – chronic and acute

Describe phases of wound healing

Cite three potential issues that can complicate wound healing

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Objectives

Determine causative factors related to wound etiology

Identify key issues to describe and document when assessing a patient’s wound and properly documenting on the whole wound

List three characteristics of three common wound types


Objectives

List three key components of overall assessment

Name at least seven wound details that need to be assessed and documented

Know the four key pieces to good wound documentation

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Why it matters

The patient

Cause – knowing is fixing

Treatment – using the correct one

Effect – is it working

10/31/2012Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 6



Why it matters

Regulations

Clinical standard of practice

Not documented = not done. How will it hold up to audit? How will it hold up in court?


Patient History

Often overlooked

What to consider

How long wound has been there

Treatment history

Overall wound history

Professionals involved in treatment


Patient History

Co-morbidities

Diabetes

Coronary Artery Disease

Cancer

Systemic factors

Cognition

environmental




Skin – The Basics

Did you know?

Skin is the largest organ

We shed and re-grow our outer skin about every 27 days

Each square inch of skin cells contains 20 feet of blood vessels


Skin – The Functions

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Thermoregulation

Circulation and sweating

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Protection

External elements

Prevents excessive loss of fluids and electrolytes

Immunological response

Production of sebum

Contains melanin





Holds

Controls

Retains

Expression

Metabolism


The Layers

Epidermis – the external surface

Made up mostly of dead cells

Avascular

Keratin if formed from older cells. This provides the tough waterproof covering


Epidermis

Three cells to remember

Keratinocytes

Melanocytes

Langerhans




Between the Layers

Basement membrane – junction between epidermis and dermis


Epidermis

Functions

Provides a barrier

Prevents water loss

Repels water


The Layers

Dermis – supports and nourishes epidermis




Dermis

Made up of proteins like collagen and elastin

Cells are produced in bone marrow

Made up of four cell types


Dermis

Functions

Nourishes

Protects

Thermoregulation


Other Areas of Impact

Subcutaneous tissue

Fascia

Muscles

Ligaments and bones

Cartilage




Other Areas of Impact

Vascular System

Red blood cells (RBCs)

White Blood Cells (WBCs)

Platelets


Principals of Wound Healing

Partial thickness wound –wound is a partial thickness skin loss through the epidermis and into but not through the dermis

Healing phases

Epidermis repair

Dermis repair



Full thickness wounds – full thickness loss through the epidermis, dermis and into subcutaneous tissue. May involve the bone, tendon and muscle.

Three overlapping phases begin at time of injury





Full thickness wounds –healing phases

Defensive/Inflammatory

Proliferative

Maturation



Types of wound closure

Primary

Secondary

Tertiary


Potential Complications

Complications of healing – all wounds are placed in one of two categories of healing

Acute

Chronic





Complications

Impaired Inflammatory Phase

Chronic Inflammation

Hyper-granulation – epibole



Complications

Temperature – Changing a dressing results in decreasing the temperature of the wound for up to four hours

Hypoxia – Not enough oxygen to the affected area

Lack of moisture



Exudate – a good thing Five key roles:

Flushes

Brings collagen

Carries particles

Contains nutrients

Acts as lubricant




Components

Full Patient Assessment

Physical Characteristics


Step 1 – The Assessment

Assessment

Lab work – consider the following labs for a patient with a wound

A1C Hgb

Albumin

CBC

Cholesterol

Glucose

HCT and Hgb

Prealbumin

Total Protein

Total Lymphocytes



Presence of:

Undermining

Tunneling

Foreign bodies

Visible tendon, muscle, ligament, bone

Identify Anatomical Landmarks

Dermis, fascia, tendon, muscle, bone

Location: Sacrum, coccyx, ischium, etc.

Assessment



Assessment

Subjective Data - Critical

Cause of wound – MOST IMPORTANT THING TO KNOW

Treatment history

Wound duration

Systemic factors


Assessment

Environmental factors

Psychosocial

Frequency


Assessment

Frequency

Weekly

With any significant change in status

After a debridement




Assessment

Objective

The first steps

Measure wound

The clock face Body and feet

Length – width - depth


Assessment

Objective

Tunneling and Undermining

Other forms of documenting wound appearance

MDS coding


Wound Classifications

Partial Thickness

Full Thickness

Burns





Skin Tears – 3 categories

Category I

Category II

Category III



Bruises – go through multiple stages of healing

0 – 2 days

2 – 5 days

5 – 7 days

7 – 10 days

10 – 14 days

2 – 4 weeks



Staging – for pressure ulcers only

Six classifications

Stage I

Stage II

Stage III

Stage IV

Unstageable

Deep tissue injury




Wound Base Assessment and Evaluation

Tissue Type – describe percent and location

Granulation

Hypergranulation

Slough

Eschar


Wound Base Assessment and Evaluation

Tissue type

Epithelial

Muscle

Tendon

Fascia

Bone


Wound Assessment and Evaluation

Tissue Adherence

Non-adherent

Loosely adherent

Firmly adherent





Tissue Color

Red

Pale pink

Purple

Black or brown

Yellow

Grey



Tissue Color

Green

White

Drainage

Purulent

Sanguiness

Scant

moderate

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Wound edges

Smooth

Rounded

Raised

Appearance

Tunneling

Undermining

Sinus Tract





Odor

Presence of foreign bodies

Surrounding tissue – must be evaluated and documented on



Definitions

Excoriation

Denuded


Assessment

Preparation

Body position

Cleaning the wound

Physical characteristics

Identify the body part and location




Assessment

Tissue Damage – know the difference

Staging

Partial thickness

Full thickness

Tissue adherence

Non-adhered

Loosely adhered

Firmly adhered


Assessment

Color – what does each color mean?

Red

Pale pink

Purple

Black or brown

Yellow, grey, green

white


Assessment

Exudate – is it always a bad thing?

Serous

Sanguinous

Serosanguinous

Purulent

Odor – assess after the wound has been cleaned. Use descriptor words




Assessment

Foreign bodies

Staples

Sutures

Drain tubes

Hardware

Anything that is not part of the body


Assessment

Wound edges

Do not confuse with periwound tissue

How do they look?

Acknowledging different issues in different areas

Periwound – also called surrounding tissue

Proper assessment


Assessment

Periwound

Assessment

Palpation

Amount of tissue to consider

What the eye sees




Documentation

General Tips

Risk assessment

Tools, forms and checklists

Assessment findings

Interventions

Not the treatment Nursing


Documentation

Treatment

Details

Effect

Changes

Dietary supplements

Procedures

Adverse reactions


Documentation

Wound Specific

Venous ulcers

Arterial ulcers

Diabetic ulcers

Pressure ulcers

Surgical wounds

Other issues – lesions, cellulitis, infection




NAME THAT ULCER



What is it?


Pressure Ulcer Stages

Stage I




What is it?



Suspected Deep Tissue Injury


What is it?





Stage 3


What is it?



Stage IV




What is it?


Eschar Tissue

Eschar Tissue: Thick, leathery, frequently black or brown, necrotic (dead) or devitalized tissue that has lost its usual physical properties and biological activity. Eschar may be loose or firmly adhered to the wound.


What is it?




M0700:

Granulation Tissue

Slough Tissue


What is it?


M1030

Venous Ulcers




What is it?


M1030

Arterial Ulcers

Things to Remember

Sebum

Keratin

Melanin

Moisture

Temperature

Exudate




Things to Remember

Types of wounds

Partial thickness

Full thickness

Phases of Wound Healing


In Summary

Knowing the basics of skin, how it works and the basics of wound healing will help in determining wound type, appropriate treatment and accurate documentation


In Summary

We can’t properly treat any issue, especially wounds, if the details are not documented. Leave the reader with a clear and concise visual picture. Take credit for all that is being done. As licensed practitioners, we are being held to a much higher standard than ever before. Show them what you know!




References

Ayello,E. (April 2012) Comprehensive programs for preventing pressure ulcers. Advances in Skin and Wound Care (volume 25 number 4 April 2012). www.woundcarejournal.com

National Pressure Ulcer Advisory Panel (NPUAP). (2009) Prevention and treatment of pressure ulcers: quick reference guide. www.npuap.org


References

Wound Care Education Institute. (2008) Skin and wound management course. www.wcei.org

American Medical Director Association. (2009) Pressure Ulcers in the long term care setting: current clinical standard of practice. www.amda.org



Questions/Answers

Harmony Healthcare International

1 (800) 530 – 4413

[email protected]

Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc.

http://www.woundcarejournal.com/

http://www.npuap.org/

http://www.wcei.org/

http://www.amda.org/




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