Assessment and Documentation Issues in Wound Care
A complete wound assessment and accurate documentation of that assessment are two crucial elements of effective wound care. The initial and ongoing assessments provide the information on which the subsequent plan of care is based. Documentation provides a record and an evaluation of the wound status, on which changes in this care plan are based. This article will discuss integral components and facets of each of these elements.
A complete wound assessment evaluates at least four key components; nutrition, wound etiology, wound appearance and pain.
Proper nutrition gives the body the tools it needs to heal. It is important to remember that a serum albumin is affected by hydration status, renal function, and infection (It is not reflective of the present condition). A prealbumnin blood level is an accurate measure of nutritional status.
The etiology of for example a chronic ulcer is often overlooked. However, it is logical that if the etiology is not controlled the wound will not fully resolve. To assess the wound etiology it is important to understand the characteristics of different types of ulcers. Pressure ulcers usually develop over a bony prominence and are therefore circular in shape.
Arterial ulcers are usually painful, oftentimes appear on the distal/lateral extremity, and present with a pale or necrotic wound bed with minimal exudate. The affected extremity is usually cool, absent of hair growth, has diminished or absent pulses, and thickened toenails.
A venous ulcer is usually located on the medial aspect of the leg, within the gaiter area, and has a high volume of exudates if infected or just beginning wearing compression hose. The surrounding skin is often edematous and evidence of hemociderin staining (a brownish discoloration of the skin caused by the breakdown of the red blood cells in the tissue layers) may be apparent.
A diabetic ulcer is often related to poorly controlled blood sugar leading to decreased foot sensation and as a result of peripheral neuropathy. Neuropathy can result in unnoticed skin irritation, perhaps from ill-fitting shoes, which may lead to an ulcer. Foot care education and properly fitting shoes are important issues in preventing and resolving diabetic foot ulcers.
An assessment of the ulcer involves its appearance, the wound location and size, the wound bed tissue, the wound edges, the periwound skin, and wound exudate. The size is determined by measuring the longest length from 12 - 6 o’clock and longest width from 3 - 9 o’clock, measuring from wound edge to wound edge. The product of these numbers gives a wound area. Depth, undermining and tunneling can be measured by using a cotton probe. The optimal time interval between wound measurements is approximately 7 days in out-patient settings. More frequent measurement is unlikely to demonstrate clinically relevant differences in wound dimension. Devitalized tissue on a wound bed should be debrided. The exception is an uninfected arterial ulcer covered by dry, intact eschar. A clean bed can be with or without granulation tissue. An agranular, friable wound bed (one that may bleed easily) can indicate a high bacterial load that must be controlled before granulation occurs. Granulation tissue is composed of new capillary buds that should be supported by moist wound healing techniques. Moist wound healing has been shown to encourage healing with less pain and scarring. Wound edges should be open to allow for epithelial migration (not rolled or hardened). Erythema and induration of the periwound skin is common in the inflammatory phase but can indicate infection if it is accompanied by increased drainage, size, pain, or odor. Periwound tissue that is macerated indicates poorly controlled exudate, which could impair wound healing. If drainage strikes through the dressing then dressing absorption is inadequate. Moisture seepage could facilitate bacterial spread from either the wound or the environment.
Wound pain is a relatively new consideration in wound care. Most of the research on patient pain was performed in the 1990’s. However, recent research (Wounds 2003; 15(12): 381-389) indicates that moderate pain was experienced 80% of the time by individuals with pressure ulcers. Pain is an issue related to patient well-being and is always subjective. “Pain is whatever the experiencing person says it is, existing whenever the person says it does (McCaffery, 1968). The most common pain assessment tools are the 0-10 Pain Intensity Scale and the Faces Pain Rating Scale. All patients should be assessed for pain associated with their ulcers on an ongoing basis. Measures should then be taken to eliminate or control this pain such as covering wounds, repositioning, changing support surfaces, and/or providing analgesics or topical anesthetics ( e.g. during debridement) when appropriate.
Wound documentation also should include at least all four key components of your wound assessment. In the out-patient setting weekly documentation should minimally include a reassessment of wound appearance. Photographs are often used to supplement written documentation but they can provide an inaccurate representation of the wound, they are an added expense and are largely unnecessary in the presence of clearly written documentation. The size of the wound should be recorded L x W x D in centimeters. The face of a clock can be used to provide additional accuracy to the description of wound characteristics, such as “1cm tunneling at 3 o clock”. The terms used in documentation should represent objective data. Avoid words like “huge” or “deep”. Avoid diagnostic terms such as “infected”. Instead use the objective descriptors seen in the wound such as “perierythema” or “induration”. Infection can only be objectively determined by a wound biopsy. Wound bed descriptors should be specific such as “eschar” or “yellow slough” or “granular”. “Black” is not specific. This could mean an eschar or a hematoma. It is also important to document the percentage of tissue on the wound bed, such as “50% yellow slough”. The amount and the type of exudate (serous, serosangenous, sangenous, purulent) should also be documented. Wound care practitioners are often following several ulcers simultaneously, making it difficult to recall individual wound progression. Accurate, objective documentation provides a timeline of the wound progression on which to base changes in ulcer care.
An accurate depiction of the wound is also important legal protection. Ambiguity can be risky. Your documentation is legal evidence of the quality of the wound care you provide.
In conclusion, we have seen that the environment of the patient may cause profound difficulties in wound healing. Identifying and understanding these co-morbidities will help you bring in important interventions and gain more realistic expectations for the healing process.
This article was written by Jennifer Hurlow GNP, CWOCN
Quirino J, de Gouveia Santos, et al. Pain in Pressure Ulcers Wounds 2003; 15 (12): 381-389.
McCaffrey M Nursing Management of the Patient with Pain Philadelphia, PA: JB Lippincott, 1972.