Section: CME Category: Wound Care

Wound Assessment and Documentation

Pamela Scarborough, PT, DPT, MS, CWS, CCEEAA

Pamela Scarborough PT, DPT, MS, CWS, CCEEAA discusses staging of different types of wounds as well as reviewing assessment and documentation of wounds.

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Goals and Objectives
  1. Define staging and differentiation of chronic wounds
  2. Review the unique characteristics to assess different types of wounds
  3. List techniques to properly document wounds
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    Pamela Scarborough Pamela Scarborough has nothing to disclose

  • Lecture Transcript
  • TAPE STARTS – [00:00]


    Unidentified Female Speaker: So we're going to talk about the wound assessment and it was interesting. I was reading an article by a podiatrist that I thought was very interesting, so podiatrist, I want you to know that I'm honoring what this podiatrist said in her article, was that she felt as if the professional podiatry needed more education on the wound assessment. Now, this is what this podiatrist said, would any of the podiatrists in here agree or not? True?

    Unidentified Male Speaker: I'll give it to him.

    Unidentified Female Speaker: You give it to him, all right. So they should, all right.

    Unidentified Male Speaker: They don't listen at our place.

    Unidentified Female Speaker: They don't listen at your place, all right. So I have no faculty disclosures that I need to tell you about. These are the objectives. I'm not going to read them and we're going to get right into the wound assessment and talk about this. Care setting, who's in home health? Anybody in home health? You have to use the oasis. Who's in long-term care? Anybody in long-term care? I'm in long-term care. You have to report using the MDS. Who's in acute care? You're probably going to be using some type of electronic medical record.

    Who is in outpatient? Who's doing outpatient? You probably have your own electronic medical record or maybe you're using a paper system. So the care setting can be a driver for how often you have to do the wound assessment. Usually, we do it once a week. How many of you do a wound assessment once a week? If you're in home health, if you're in long-term care, you actually do, and how many of you do the wound assessment each time your resident or your patient comes to your office? So again, it could be care setting-specific on frequency.

    So generally, we do it on a weekly process, but we're looking at doing the wound status maybe of with each dressing change, which often they do in acute care, and what we're looking for is, is this wound improving or is it deteriorating? That is what our wound assessment should be showing us. We should also do a wound assessment when the patient's condition changes. Maybe it's not the wound that's changing but they have an acute, mild congestive heart failure. Well, how is that going to affect my wound? And then, we have to document according to our policy or our protocol, which is going to be care setting-specific.

    [02:06]

    So here's some of your wound-specific grading or staging systems. Tissue loss, we're going to talk about these two at the top, tissue loss, partial and full thickness, which is a universal methodology. You have your National Pressure Ulcer Advisory staging system for pressure injuries, ulcers. Then, you have your Wagner's scale, your University of Texas Diabetic wound classification, your CEAP for venous insufficiency leg ulcers. And then, there's several different systems and the one I happen to like the best is the International Skin Tear Advisory Panel for skin tears.

    The care setting I made, and we have as many skin tears, if not more than we have pressure ulcers, so we really have to understand skin tears also. So when we're looking at partial thickness and full thickness, this works for all ideologies of wounds. It doesn't matter what the ideology is. Our partial thickness wounds, these are wounds that extend through the epidermis, the first layer of the skin, and can go down to the dermal tissue but doesn't go through it.

    These are your stage two pressure injuries, your skin tears, blisters, split thickness skin graph. So these are just some examples of partial thickness wounds. Full thickness extend through the epidermis and dermis can go down to the subcutaneous tissue, and can go all the way down to muscle bone and joint. So these are our stage three and four pressure ulcers, your arterial wounds. It can be your diabetic foot wounds. All of these could be full thickness wounds. And this is universally accepted and people are going to understand what you're talking about if they're in wound management.

    Then, I'm going to fly, and I have a question for you. How many of you want me to go through the staging system really quickly? And the reason I'm saying this, there are more mistakes staging than almost anything else we do in documentation. Anybody who wants to go through the staging system or do you want me to skip it? You tell me. I see a couple of hands. All right, we're going to fly through the staging system.

    Do you ever get heal pressure ulcers that you have to care for, podiatrists? You got to know the staging system to be able to do it well. Stage one, pressure injury. Is intact skin, so it's intact, there's only two injuries on pressure that are intact, stage one and deep tissue pressure injury.

    [04:05]

    Those are the two that have intact skin. Intact skin with a localized area of non-blanchable erythema or redness. In darker skin tones, the pressure injury may appear with persistent red, blue or purple hues. The presence of blanchable erythema are changes in sensation, temperature or firmness, may perceive visual changes. Color changes, intact skin may also indicate a deep tissue pressure injury. So here is a stage one on a light-skinned individual and here is a stage one on a darker-skinned individual. Very difficult to see, we have to respect darker skin tones and look at them differently to be able to help our patients and residents. Stage two, pressure injury, now I'm using the word injury and ulcer, and I'm interchanging them.

    CMS, the Centers for Medicaid Medicare Services, tells us in long-term care what we're supposed to write, and they don't care about the fight that Jim just mentioned about pressure ulcers and pressure injuries. They don't say, "We don't care what words you use. You can use pressure ulcer, pressure injury, bedsore, decubitus. We don't care." Please don't use the bedsore and decubitus. That will really date you. Use pressure ulcer, pressure injury. Those are the things to use.

    So you'll see me going back and forth between ulcer and injury, because CMS doesn't care what we say. There's still a fight going on two years later about these words and CMS is not going to get in our internal fight. Stage two pressure injury. This is a partial thickness loss of skin with exposed, they are mispresenting as a shallow open ulcer. The wound bed is viable. It's pink and red, and some people think that pinkness or redness is granulation tissue. You have to be able to differentiate granulation tissue from dermal tissue. This is a very visual discipline and that's why I want to send this stuff to you in color, so that you'll be able to see what we've been talking about.

    Moist, it may also present as intact, are open ruptured blister. Now, but blister for a stage two has to be clear. If it has blood in it, it's a deep tissue pressure injury and not everybody understands that nuance. Adipose, that is not visible and deeper tissues are not visible. Granulation tissues, slough and eschar are not present.

    [06:07]

    We see this mistake over and over, and over again. They call it shallow deep full thickness wound – pardon me, with dermal tissue in it. They think it's red and they're calling it granulation tissue, because they don't know the difference between granulation and dermal tissue. Then, it says slough and eschar, these are not present in a stage two. Look at this. This is one of the biggest mistakes with stage two pressure ulcer. This stage should not be used to describe moisture-associated skin damage, including uncouthness, associated dermatitis, intertriginous dermatitis, which is inflammation of the skin folds, medical adhesive-related skin injury, and traumatic wounds such as skin tear burns and abrasions.

    Stage three pressure ulcer. This is a full thickness loss of skin with the subcutaneous fat. Now, NPUAP says the subcutaneous fat is visible. I don't necessarily agree with that and CMS didn't necessarily agree either. They changed the definition for our purposes in long-term care and they used the words maybe visible, instead of is, and I have to tell you, I agree with CMS. Maybe visible is visible in the ulcer and granulation tissue, and epiboly. Epibolys are rolled edges. Everyone in here if you have pierce tears, you have epiboly. You get wounds like that where you have those rolled edges and somebody has to open those rolled edges so the keratinocyte, the cell that covers over the top of the wound, can move again.

    Slough and eschar may be visible but do not obscure the depth of the tissue loss. The depth of tissue damage varies by anatomical location. Areas with significantly adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon ligament, cartilage, and our bone are not exposed, and you have to take those glove fingers sometimes and put them in your wounds to determine, do we have a stage three or do we have a stage four? And sometimes it's going to take palpating in the wound to figure that out.

    [08:02]

    If slough and eschar obscures, if you cannot see the bottom of the wound bed, then you're going to call it an unstageable pressure ulcer or pressure injury. Stage four pressure ulcer is a full thickness skin and tissue loss when exposed, are directly palpable. Fascia, muscle, tendon, ligament, cartilage are bone in the ulcer. Slough and our eschar may be visible. Epiboly, those rolled edges, remember pierced ears. Undermining and/or tunneling often occur. The depth varies by anatomical location. Again, if slough or eschar obscures, you cannot see at all the bottom of the wound bed, then this is an unstageable pressure injury.

    Now, note the wound base does not to be – need to be completely free of necrotic tissue. If you can see the wound base, you can have a wound 90% covered with eschar, but you see a tendon. That's not unstageable. If you see that tendon, what stage does that make it? Stage four, absolutely. This is a huge mistake that we see happening all the time in every care setting. Unstageable pressure ulcer injury. Full thickness skin and tissue loss with the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured. You cannot see because of slough or eschar.

    Stable eschar, and there's a difference between stable and unstable eschar, and you want to figure it out, is this stable? Is it unstable? Because you're going to treat them differently depending where they are on the body. Stable eschar is dry. It's adherent. It's intact without erythema or fluctuance. That's not flatulence. That's fluctuance, two different things, fluctuance, flatulence, which means squishy saggy baggy, should only be removed after careful clinical consideration and consultation with the resident physician, nurse practitioner, physician assistant. It is your practitioners that are going to help you make that decision or clinical nurse specialist, if allowable, under State license, your law.

    Now, if not slough or eschar is removed, you're going to have a stage three or four pressure ulcer.

    [09:58]

    If the anatomical depth of the tissue involved can be determined once you take that necrotic tissue out of there, then we're supposed to reclassify the stage from unstageable to whatever it is. Is it a stage three? Is it a stage four? The pressure ulcer again does not have to be completely debride – or free of all slough or eschar for reclassification of that stage to occur. And on the right, you could see some examples of that.

    Deep tissue pressure injury, we use to call these bruises, and then we got these horrible f-tags in long-term care because they turn into full thickness wounds. Thank goodness, we finally got this. So this is intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of the underlying soft tissue. This area may be preceded by tissue that's painful, firm, mushy, baggy, warmer, cooler, as compared to the adjacent tissue. These changes often proceeds, skin color changes, and discoloration may appear differently and darkly pigmented skin.

    We have to use more than just our eyes oftentimes when we're looking at dark skin. This injury results from intense and a prolong pressure and shear forces at the bone muscle interface. The wound may evolve rapidly to reveal the actual extent of the tissue injury or may resolve without tissue loss. We have found that 40% of the deep tissue pressure injuries, if you have good blood flow, you're going to – they'll resolve, 40% of them, but you have to have good blood flow for that happen.

    And there is a machine in the exhibit hall that will help with this. I think it's [MISS] [11:29]. Does anyone seen the MISS unit? And it will help with the tissue pressure injuries to help resolve them so they don't open up. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia muscle or underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue pressure injury opens and 60% of them are going to open, open, you want to reclassify the ulcer to the appropriate stage.

    And do not use deep tissue pressure injury to describe, and the reason they put this here, and the NPUAP put this here, is because this is what we're doing over and over, and over.

    [12:02]

    People who did not know how to stage well, do not use deep tissue pressure injury to describe vascular, traumatic, neuropathic or dermatologic conditions. So this is just looking at the evolution of a deep tissue pressure injury on the heel where it demarcates itself and declares itself. So this is how it came in, that's how it ends up. And in long-term care, if we don't catch this on admission, we end up owning this and we get an f-tag for it. F doesn't mean failure but in some ways, it does.

    Medical device-related pressure injury. This is a new definition for my care setting, specifically, and it's going to be a very important definition. A medical device-related pressure ulcer injury results from the use of devices designed and applied for diagnostic or therapeutic purposes. The result of pressure injury generally conforms to the pattern, shape of the device, the injury should be staged using the staging system. We are mandated to stage medical device-related pressure injuries in my care setting.

    What calls it on right over there? What do you all see? Bed pan, TED hose, and somebody with severe arterial insufficiency. I hate TED hose. They are truly a problem because they're not used correctly or appropriately. Mucosa membranes. Mucosa membranes, pressure ulcer injuries are found on the mycosis. Where in the mycosis? Here, right? Here, right? Here, right? There, right? It can be in any of those places. With a history of a medical device and used at the location of the injury.

    Due to the anatomy of the tissue, these ulcers cannot be staged. Mucosal injuries, take your tongue. Run it around the inside of your mouth. Now, rub your face. You have no epithelial tissue in your mouth. So the structure, the anatomical structure is different, which is why we can't correlate it to a pressure ulcer injury. And then, we have some coding directions for long-term care about the mouth when we have a mucosal pressure ulcer.

    [14:07]

    In long-term care, you are mandated. You are mandated by the Federal government what you have to document and we're going to go through some of this together. And there are some validated tools. There is something called the PUSH tool, Pressure Ulcer Scale for Healing, that the National Pressure Ulcer Advisory put out. And this tool helps you look at, is this wound getting better or is it getting worse, simply by looking at it on a graph. And you measure your length, your width, and your exudate amount and the tissue type.

    And then, there's another system that's been validated, the BWAT system, for Barbara Bates-Jensen, that's the Bates-Jensen wound assessment tool, that looks at 13 areas, and again, use plot to score of were the things are getting worse or getting better. And many of you, you either have, how many of you have – let's do it this way. How many of you are still using a paper system instead of an electronic system? Anybody still using a paper system? No? Okay, everybody is using some type of an electronic medical record.

    So this is just looking at what the PUSH toil looks like. That's how you designate your information and this is the BWAT tool. These are some of the electronic medical records for wounds, for the wound assessment and our monitoring system. Now, some of these are looking at an imaging device and others, of these, are some of the electronic medical records. Does anyone see your electronic medical record in this list? Raise your hand if you see your record in here, your electronic medical record, anybody?

    No, really? Because this is almost all of them. So you got something different maybe that your hospital or your group built for you. So we want to look at the location and we were looking at the location. Please be specific. Don't say, "On the right buttocks." What does that mean? My right buttocks goes from here to here. We want to know exactly where it is. Use your boney landmarks. Use your proximal, distal, anterior, posterior, medial, lateral, superior, inferior, dorsum of the foot, the plantar surface of the foot, not the top of the foot, not the side of the foot.

    [16:02]

    Which side? Is it the medial malleolus or the lateral malleolus? We need to use our words to describe it. So want to be very specific when we're describing the location of these wounds, and use your boney landmarks. We have to do dimensions. We are going to do our length, our width, which in general, overestimates the wound. And then, we also want to do depth in many situations. Is anybody using specialized cameras? Anybody using specialized cameras for your area, getting the area or getting the dimensions?

    There is that. There is planimetry and then there's tracings also. And care setting is also going to tell you how to measure wounds. How many of you measure your wounds from the longest length to the widest width perpendicular to that? Show me. Who does measures your wounds like that? That's really how I prefer to measure my wounds. I am mandated by the Federal government to measure head-to-toe the longest area and then side to side. Three to nine, that's it. That's how I have to measure. Don't like it, doesn't matter, that's what I have to do.

    And then, we're going to measure the depth, and we all know how to measure our depth. Undermining and sinus tracts, undermining, is an area parallel to the skin surface? Tracts are called sinus tracts or sometimes are called tunneling, and their narrow areas, they can have – go into an area and you could have an exit or you might not have an exit. And we want to assess, measure and document to help you figure out what you need to do with that undermining and tunneling.

    So here's some undermining that you see and the undermining is going from 12:00 to 3:00. You want to document that. What is the extent of my undermining? Where is that tunnel or where is that sinus tract? I've got one here at 6:00 and I've got one up there at about 11:00. So where is it on the clock? What do wound edges looks like? Are they attached? Are they well-defined? Are they unattached? It makes a difference.

    [18:01]

    Do they have rolled edges, the epiboly? It makes a difference. Are there regular wound edges? Are they hyperkeratotic? Do you have callous around the wound edges? All of these makes a difference and needs to be documented. Do we have epiboly? That's those rolled edges. All of this has epiboly and once you have epiboly, the keratinocytes think they're finished and this wound is going to stay open. What do you all do? What do you do when you have epiboly? Guys, call out. What are the things you do? Do you cut it?

    Anybody silver nitrate it? Most of you cut it? I'm hearing noise over here. So you got to want to open your edges and there's several different methodologies for doing that, depending on your licensure and your skillset. Wound drainage, how much is there? What's the color? What's the consistency? Does it smell? So here's your amount, non-scant, moderate, large, copious. You can see some poorly managed exudate there. When was the last dressing change?

    That kind of tells us what's going on with the drainage is, when was the last dressing change? You want to look at the character. Is it serous? Is it serosanguinous? Is it sanguineous? Is it seropurulent? Or is it purulent? So we want to describe all of this related to our exudate. And what color is it? What if it's green? What do you think when you see green and it has that fruity smell? Yeah, we think pseudomonas. So color can be important also. So describe what you see.

    Now, this is from the Association for the Advancement of Wound Care and is a methodology for quantifying wound exudate. For instance, Heather might think something has moderate exudate, but when I look at it, I think that's a copious. It's very subjective when you're doing your exudate and recording it is very subjective. I'm not going go through this with you but this is something that you might want to use to help everyone begin to quantify their exudate a little more consistently.

    [20:04]

    Odor, you have to smell your wounds. That was the part that was the grossest to me about wound care, still to this day, is the odor that makes me nuts. Anybody else feel that way? Am I the only person that feels that way about the odor? I think the women have it harder than men. For some reason, we have a better able to smell things than men. I don't know why that is.

    Tissue types, what kind of tissue do you have in that wound? Do you have epithelial tissue that's trying to cover over the top of the wound? Do you have that beautiful granulation tissue? Do you have slough, and then what kind of slough? Jim is going to talk about that later. Or do you have eschar and is that eschar, is it – what is the word I want to use? Is it stable or unstable? Thank you very much. Gosh, somebody listened. Whoa, I am so impressed.

    And then, Jim is going to talk about this later, about the different types of slough, which makes a difference. The slough makes a difference. It's not just slough. There are different types of slough. What's going on in my wound base? Do we have an exposed tendon? Do we have a foreign object? Do we have hyper granulation tissue? It all makes a difference. You may say that you have a tendon but whether or not it's been damaged or not, is going to determine how you're going to write your plan of care.

    Structures, you want to recognize structures such as your bone, tendon, fascia, vessels because it's important. There is the potential for migrating infections or osteomyelitis in many instances. We want to be sure we keep these structures moist to prevent them from drying out and protect them from injury also. So here are some structures. Here, you can obviously see a bone or my thing you go. There's our bone. Here, we're tapping the bone. Now, somebody if they're just looking at this, they might think, "Oh, that's bone." That's slough right here, "Ohm there's some bone." Don't assume that. It's collar bone but if I tap on it, it's soft. It has characteristics of a tendon.

    [22:01]

    So if you just look and don't get into something like tapping, you're going to miss what you have here. And taking care of that tendon is absolutely critical at this point. Fascia, this is your connective tissue. You know, your fascia goes from all the way from the top of your brain to the tip of your toe, which is one continuous track. When we have infections that are going along our fascial planes, that's what they're doing, they're running down the fascial planes. So do you have fascia? Do you have tendons that are exposed?

    No, it's in the neighborhood. I'm not going to show it right now. We're kind of a little bit short on time but here's a vessel. We need to be very careful even if you're – you're going to have to be careful of doing negative pressure here, to be careful and protect that tendon. And right here, if I run the video, you'll see a tendon. They were getting ready to put on negative pressure in that where's clinic, and the medical assistant came to doc and said, "Doc, come look at this." And what this is, it's a pulsating artery.

    And they were getting ready to put negative pressure on without protecting the artery. So you have to know what's in the neighborhood. So you look at your periwound examination, what's going around the edges? You want to look at the structure and quality. You want to look at the periwound, the color. Is there edema? Is it indurated or fluctuant? Is it hot? What's the temperature? Do we have epithelial edges or the edges attached, unattached? Do we have epiboly? Do we have callous?

    So here's maceration of course, super hydrated skin. When we look at our edema related to the periwound area, if you have this erythema and edema, and increased temperature more than three centimeters beyond the edge of the wound, the literature tells us you probably have an infection. I work with people who really have a hard time. I work with LBNs and LPNs, and they're really having hard time understanding where they need to go related to, is this infected or is it not infected?

    [24:02]

    So I have to teach some of the simpler ways for them to figure this out. You want to look at your epithelial edges, are they migrating? Do you have islands of epithelial? This probably means these islands in the middle here, probably mean you have a hair follicle that is intact and those keratinocytes are coming up that hair follicle. That's a very good thing to have. And then these edges, you can see these edges have already been migrating, and here's some epithelial tissue right here about a cell thickness, and then they get thicker and thicker, and start climbing on top of each other and get thicker and thicker.

    Do we have excoriation? Please use your words appropriately. Excoriation means scratches. And if you have somebody that has excoriation and they're having scratches, they're telling you they're having pain and/or inflammation. So why are you having scratches? It probably hurts or burns. Or is it denuded? That's a different word. That means that that tissue has been pulled off, denuded. So these are two different words used differently.

    And then, you want to look at your wound pain. Do you have chronic wound pain? Do you have cyclical wound pain? Do you have non-cyclical wound pain? We have to document this. Chronic wound pain is when you're not moving the patient and they are still having pain. You're not manipulating them. You're not turning them and they're still having pain. It can be continuous or in a minute. Cyclical wound pain is, and the most common cyclical wound pain recorded in the literature, is from dressing changes.

    And the most pain that people have in wound care is from dressing changes, unless of course they're having neuropathy. So how many of you pre-medicate your patients before you do a dressing change? Anybody in here pre-medicate before you do a dressing change? Absolutely. The patient should not suffer during your dressing changes. If they do, you have a problem and you're not providing care at the level that should be provided.

    And then, there's non-cyclical wound pain, something that's done more sporadically, and I use the example of debridement. Maybe you debride on Monday but you don't need to debride it again until the following Thursday. So it's more cyclical. I'm sorry, more non-cyclical.

    TAPE ENDS [0:26:03]