Assessing and Correctly Identifying Wounds...None-dry wound bed Scant-wound is moist. Dressing will...

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We bring advanced wound care, clinical excellence, and servant leadership to you…

Assessing and Correctly

Identifying Wounds

Wound Care Plus, LLC @woundcareplusllc @mywoundcareplus

Statement of Disclosure

• Chief Executive Officer and Founder for Wound Care Plus, LLC

• Educational Speaker and Negative Pressure Wound Therapy Expert

• Editorial Member for Kestrel Wound Source (www.woundsource.com)

• Long Term Care/Long Term Acute Care Advisory Panel (Inception 2012)

• Professionals Dedicated to Quality Wound Care (Inception 2013)

• Invited Expert for the American Medical Directors Association for Pressure Ulcers and Other Wounds

Workgroup Revision to LTC Standards (2014)

• Principal Investigator for Clinical Research Trials Santyl vs. Hydrogel (www.clinicaltrials.gov)

• Principal Investigator for Clinical Research Trials Allevyn Life Non-bordered (www.clinicaltrials.gov)

National Publications

• Clinical Competencies for Long Term Care Collagenase Santyl (2015)

• Quality Assurance and Performance Improvement Clinician’s Resource Guide (2016)

• Transitions of Care Clinician’s Resource Guide (2016)

• Debridement: Clinician’s Resource Guide (2016)

• PICO Single Use NPWT System: Clinical Competency for Long-term Care Providers (2016)

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Source: CMS’s RAI Version

3.0 Manual Page M-1

“It is imperative to determine

the etiology of all wounds

and lesions, as this will

determine and direct the

proper treatment and

management of all wounds”

Source: CMS’s RAI Version 3.0 Manual Pages:

M-9

M-11

M-13

M-16

M-21

2. For the purposes of coding; determine that the lesion being assessed is primarily related to pressure and that other conditions have been ruled out. If pressure is not the primary cause, do not code here.

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Malignant Lesions

Calciphylaxis

Discoid Lupus Skin Lesions

Sarcoidosis Lesions

Surgical Wounds

Venous Insufficiency Ulcers

Arterial Ulcers

Pyoderma Gangrenosum Typical (Classic) Atypical Peristomal Pustular Bullous Vegetative

Majorlin’s Ulcer Acanthosis Nigricans

Digital Sclerosis

Bullosis Diabeticorum

Necrobiosis Lipoidica Diabeticorum

Diabetic Dermopathy

Eruptive Xanthomatosis

Disseminated Granuloma Annulare

Diabetic Ulcer

Trauma

Pemphigoid Bullous Cicatricial Gestationis

Sweet’s Syndrome

Skin Tears

Burns

Vasculitis

Collagen Vascular Diseases

Necrotizing Infection

Pemphigus Radiation Necrosis Ulcer

Neuropathic Ulcer

Source: The Physician’s Guide to The Wound Institute

Page 26: Treatment Algorithm

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Undermining

Tunneling

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Stable Eschar-Do Not Touch • Dry • Firmly Adherent • Eschar Intact • Peri-wound has no erythema,

no fluctuance, no bogginess, no maceration, no warmth, no redness, no induration or swollen tissue

Unstable-Consider having specialist remove • Drainage • Edges peeling or lifting up • Eschar does not cover the entire wound • Peri-wound may have erythema,

fluctuance, bogginess, temperature or color changes, maceration, warmth or redness, induration, or swollen tissue

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Stable Eschar Body’s Perfect Band-Aid

Unstable Eschar Something’s brewing

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Fungating

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Tumor

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Purulent-opaque, milky and sometimes green, yellow or brown

Sanguineous-reddish, thin and watery

Serous-clear, amber, thin and watery

Serosanguineous-clear, pink, thin and watery (blood-tinged)

Commons Types

Drainage Amount None-dry wound bed

Scant-wound is moist. Dressing will have no more than a drop or two of drainage present or dressing may be dry

Small-minimal amount of drainage covering less than 25% of the dressing

Moderate-wound is wet and drainage covers 25-75% of the dressing

Large (Copious)-wound has significant fluid that may fill the wound and drainage will cover more than 75% of the bandage. Peri-wound may shows signs of maceration

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Demarcation/Demarcating

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Epibole or Epiboly

Erythema

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Hemosiderin Staining

Heralding Sign

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Hypergranulation Tissue

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Induration

Maceration

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Rubor

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Laboratory Draws

MRI Scan

CT Scan

X-ray

Venous Ultrasound

Arterial Ultrasound Ankle-Brachial Index

Tissue Cultures

Punch Biopsy

Wedge Biopsy

pH Testing

Debridement

Pressure Mapping Arteriogram

Venogram

Transcutaneous Oxygen Monitoring

Diagnosis of Exclusion

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Questions?

Martha R. Kelso, RN, HBOT, CEO, WCP

(888) 256-3814

martha.kelso@mywoundcareplus.com

Martha R Kelso facebook.com/MarthaRKelso @MarthaRKelso