Chronic Wound Care Ch13 22

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Wound Care Processes-From PatientAssessment to Healthcare Delivery Systems


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Wound Assessment and DocumentationLia van Rijswijk, RN, MSN, CWCN;Jo Catanzaro, MSN, RN, CWOCN

ObjectivesThe reader will be challenged to:. Evaluate commonly assessed wound characteristics. Explain the rationale for assessing different wound characteristics. Analyze the purpose of wound assessment in your clinical practice

lntroduction1f, ppreciation .rf the r'vound healing pr-ocess, factors

!\ that nral affect it. and rhe nurrrber oi dcvicesI \available to manase rvounds has increased dra-rnatically during recent years. However, a significant por-tion of rvor.rnd-healing knowleclge is based on the resultsoflaboratory studies, rvhile data about the clinical effec-tivencss of nrost u,ound care products rcmain limited.C)ne of the nranv reasons for this relativell, slow clinicalprogress is the challenge of wound assessment. Manycommonly used wound assessnrent ternrs remain poorlydcfined, and knorvledge about the validity and reliabilityis lirnited. In acldition, r,vound assessnrent validiW and reii-ability str-rclies are ofteu conducted fron a rescarch, rathcrthcn a clinica[. perspectivc.

Slorvl,v but surelv, r.ve are starting to understand rvhichindiccs of u.ound hcaling Jr:c nort appropriate to evalu-ate." In addition, in clirrical practice, it is generallybeiieved drat it is better to regular\ assess usins the samcpossibly less-than-perGct tool than not to assess at a11.1Every plan of care and intenentioll as wc1l as the clini-

ciani abi1iry to dcterr.rrine the effectiveness of cale is bascdon a complete patient historr., assessntent, ancl regular- fol-lor.r,-up assessments.'This chapter rvi1l focus on the prac-

tical application of available research as it pertains to theclinica'l assessment and docun'rentation of nonsuturcd,mostly chronic u,-ounds.The assessmellt of pressule ulcersis revierved in Chapter 58, and the assessment of rvoundpain is revierved in Chapter 11 of this textbook.

AssessmentWhat it is andWhat it is NotVerbs commonly used to describe the process of follorv-

r-1p cal'c irrclucle assess, eualuate, fiortitor, or inspect. It isimportant not to Llsc them interchangeably, because theiruse aflects the levei of knowledge required to implenrentthe process. To monitor or inspect nleans to watch, keeptrack of, check, or closely vierv a person or condition.'Toevaluate, to determine the significance of an observationthrough appraisal and study, requires speci{ic skiils andknorvledge. Similarly, to collect, verify, and organize data(eg, to assess) is inrpossiblc lvithout specific skiils and anunderstanding of the condition involved.' For example,the plan of care for a home-bound patient may include 2visits per weck; once a week, the home health aide r'vrllchange the dressing ancl monitor the patient and wound

for signs of improvement, infection, or deterioration, andonce a n.eek, the registered nurse nill change the dressirrgand complete a rvound assessment to quantifi/ progess.

van Rijsrvijk L. Crtanzero J. Wound assessnrent lnd clocunrcutation. [n: Krasner DL, l{odehe:rvcr GT, Sibba]d I{G. eds. Chronic Wound Core:AClinicol Source Book for Healthcore ProFessionols. 4th ed. Malvcrrr, Pa; HMP (lorrrmunications. 2ltl)7:l1j 126.

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among healthcare professionals, may helpdesired outcome by stabilizing the seeminglytern of chronic wounds.

van Riiswijk and Catanzaro

Figure l. Clearly defined and realistic of care, aswell as assessment tools that improve

Wound Assessment and Documentation

unstable patterns may result in a desired outcome, provid*ing one does not lose sight ofit (Figure 1).

Outcorne and treatrnent eflbctiveness. In recentyears, considerable efforts have been made to discover andtest physical, chenrical, or biological rnarkers ofnormal orabnorrnal healing. 'While laboratory results have beenencouraging, information about the clinical value and util-iry of measuring these markers is limited.

For example, the ratio of tratrix metalioproteases(MMP, and tissue inhibitors of mltrix metalloproteases(TIMP, is known to change with the phase of the healingprocess, along rvith the amount, timing, and distribution ofthese chemicals. In a case series involving 4 patients withdilTerent qrpes of wounds, biopsies obtained every 2 weeksshowed that MMP-2 expression paralleled climcal woundimprovement.' However, in clinical practice, regular clinicalassessments and reassessntents are stil1 the only way to deter-mine lvhether the rvound is rnoving in the direction of thegoal of care or desired outcome.The effectiveness of inter-ventions, that is, their abiiiry to produce the decided, deci-sive, or desired effect, cannot be ascertained unless baselineassessnlent data are compared to follorv-up data. In addttionto monitoring the ellectiveness of the plan of care, regularreassessments may help motivare patients and caregivers.Systen'ratically gathered assessment and reassessment datarvi11 also help clinicians develop a treatnlent outcome data-base. The gathered data can be reviet'ed, analyzed, andcompared to outcomes reported in the literature to devel-op or rnodi$, wound care policies, procedures, and individ-ua1 patient care p1ans. Because "real world" experientialoutcome data is limited, this type of information is crucialwhen trying to develop care plans and pathu'ays.oe In sum-mary, wound assessment and reassessment policies and pro-cedures are a necessary and integral part of the individualpatient's plan of care as well as a tool to accumulate lnuchneeded outcome data on chronic wound care.''"'

Clinical Wound Assessment FrequencyAfter gathering the baseline or admission assessment

data, clinicians have to decide how often and rvhv ther.vound should be reassessed. Overall patient condition,wound severiry patient care environment, goa1, and plan ofcare alTect the reassessment and monitoring frequency andrationale (Figure 2). For example, when a patient has a sys-ternir: condition that has been shown to increase the risk ofinfection, the u'ound may require tnore frequent monitor-

ing and assessments. Dressing/treatment selection may alsobe affected by the reassessment frequency. For example, ar.vor:nd that needs to be reassessed daily should not be cov-ered with a dressing that is designed to remain in place fora number of days. A reasscssment rationale fbr Stage Ithrough Stage IV pressure ulcers has been reviewed else-

thetable pat-

Clinical Wound AssessmentGoal of care. The patient history and assesslnent

findirrgs are the foundation for developing the of careand patient care plan. It will help the cllnician nlne if a

needed, a patient history and assessmerrt will nrine iffre-quent turning is appropriate and Gasible nt follow-up assessments designed to monitor outcome( rvi1l deter-

rvound is inGcted, r'vhether rt can be surgicallywhich treatnent should be used. If pressure redi

r.rlne whether the wound is moving in theultimate outcorne, the goal of care.'

Developing a realistic and clearly definedparticularly important lvhen managing pachronic wounds because they often have aconcomitant conditions that may affect t

clearly defined, patients and caregivers may

couraged. Defining short-term as u,ell as lon

tion to developing realistic long-term andgoals of care, it helps to remember that eve

closed, and

ibutron is

of the

I of care isents with

mber ofhealing

hort-terrnseerningly

process or the plan of care. A chronicconsiderable burden to patients, caregivers,professionals.u If the goals of care are not rea lc or not

presents a

healthcare

dis-

m goals

of care may help. For exanple, the overali goa of care fora full-thrckness wound with necrotic rissue be coin-plete healing, but the short-term goal of care ould be toreduce pain and obtain a granulating rvound In addi-

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Wound Assessment and Documentation van Rijswijk and Catanzaro

Figure 2. Wound reassessment and monitoring frequency/rationale are affected by the overall patient condition, woundseverity, patient-care environment, goal of care, and plan of care.

where.t Since the reassessment frequency depends on thereassessment rationale, it is common for the frequencyinterval to change over time. During the first few weeks ofhome care, for instance,

morefrequent

skillednursing visits

may be needed for teaching purposes and to ensure thatcaregiver monitoring procedures are understood and fol-lowed. Similarly, during the first Gw weeks of outparientcare, more frequent assessments may be needed to assurethat the wound is responding well to care and that there areno allergic reactions to the dressing(s) or bandage(s) used.'W'hen a chronic rvound is progressing well, daily monitor-ing (even when the dressing is not changed) and regularassessment (at least weekly) are generally recommended."-"

The use ofrisk-assessment tools and procedures for panens

with Stage I pressure ulcers is discussed in Chapter 60.

Assessing the WoundGeneral wound classification. The first step in thepatient and wound assessment process is to classi$, thewound. For this purpose, 2 general categories commonlyare used. The first category is related to the cause (surgicalor nonsurgical) and whether the wound is chronic or acute

(Figure 3).A chronic wound has been defined as a woundthat has failed to proceed through an orderly and timelyprocess to produce anatomic and functional integriry or awound

thathas proceeded

through the repairprocess

with-out establishing a sustained anatomic and functional result.''Clinically, it is important to distinguish between these dif-Grent types of wounds, because generally, acute woundsheal more expediently than chronic wounds. Hence, thegoals of care are difFerent. Similarly, because superficial andpartial-thickness wounds can be expected to take less timeto heal and are less like1y to develop complications thanfull-thickness rvounds, the second general category is basedon initial wound depth." "'

Wound and skin variables that may affect healing alsohave been reconulended for inclusion when classifiingpatients who are at risk for or who have venous ulcers or

diabetic foot ulcers. For example, for venous ulcers, classifi-cation and grading includes clinical signs, etiologic classifi-cation, anatomic distribution, and pathophysiologic dys-function.'' Using this classification, patients presenting withlower ieg skin changes (eg, pigmentation, venous eczema,lipodermatosclerosis) and active ulceration of any depth

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Figure 3.Wounds are classified by cause and

rvould receive a chnical classification of ClasDiabetic foot ulcers can be classified basecl ontion of anatomical wound characteristicsdcpth), the presence ofinfection, ischemia, and

tion of ischemia and infection.'o'n Becausc tgoal of any classrficatior systenr is to guide cadict outcomes, the results of one stud-r,', r'vhichseverity scores of a diabetic foot r-rlcer classific(the Universiry of txas'Wound Classilicationpredict outcomes, are encoLlraging."' Regardclassification svstem used, inclusion ofthe avenous ulcer and drabetic foot ulcer variables the initialassessment is tecomrnended.'t''n

Choosing a wound assessrlent


Classifi cation Algorithm

o1994 Diane Krasner, Lia van Rijswijk

ncluding

lvi1I ahvays require the talcnts of a skilled professional.Before revierving the various r,vound assessment l.rethodsthat can be used, it is important to renlember that a reasonfor healthcare proGssionals'increased reliance on the use ofequipment and tests is their abiliry to qtlantiE/ observarions.Since conrmunication, including communicating r,voundassessrllent data, is such an integral part of achieving thegoal of care, standardization of the terninolory and tech-niclues used is crucial (Figure 1).

Reliability and validity. Re1iabi1it1. and validity areimportant clinical concerns. -When 2 or n.rore peoplernake the s:rme assessment, it is important that the assess-ments are similar. For example, rvith respect to u,oundmeasuren)ents, specifying lvhich position the paticrltshor-rld be in rvhen the nound is measured and rvl-richtape 1ne:]sure or tracing should be r-rsed rvil1 greatlyincrease reliability. The vaLdity of an assessment, its abil-

ity to assess u,hat it is supposed to, can be increased bychoosing the appropriate method. For erample, assessingrvound depth bl, looking at a photograph is not as valida) n'rcd\uring actual deptJr.

Qualitative and quantitative rr-rethods. A woundassessment method can be descriptive, quaiitative, or quan-

combina-

ultimateand ple-i.ate thetn systenl

stenr) cans of theentioned

Clinicalprimarilylost valuees.t When

nrents andv can110l

d woundassesslnent

6 (Co-6).conrbina-

wound assessrnent is not an exact science. Itrooted in clinical obsenation, a skill that hacompared to the use of instruments and machi

it cotres to skillful observation. available instrequipment may enhance the process, but treplace the adcpt cxamination of the clinician r 1ilte[Jrateand evaluate the significance of all the patientinformation obtained. in other rvords, theprocess, defined as collecting, verifiing, and zing data,

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titarive.The use of descriptive and qualitative mcthods (eg,the u,ound has improved, it is red, snralier than last week,the surroundrng skin is healthy, and the patient does notcomplain of pain) is often insutEcient for evaluating theoutcome of care. For the person who made the assessment,thrs chart entry nukes perfect sense and provides xn accu-rate description of the observations. Hor'vever, it does notprovide a complete picture for sonleone who has not seenthe rvound, and the resuitant documentation rvill not facil-itate continuity of care. If the same wound assessrnent isnrade using a conrbination of standardized descriptive andquantitative methods (eg, it includes pain and rvound meas-urcments as well as strndardized descriptions of the sur-rounding skin condition), the finclings are easier to under-stand by someone r'vho has not seen the rvound, thus facil-itating conrmunication and continuiry of carc.

Assessing wound depth. Neither wound depth northe appearance ofthe rvound bed can be accurately assessedif the wound contains loose debris, particulate nratter, ordressing resrdue.Therefore, wor-rnd cleansing is the first step

in the rvound-assessnlent process. For assessntent pllrposes,rinsing the rvound r'vith saline r,vill usually suffice. Howevelrvhen particulate matter is adherent to the rvouncl bed,higher prcssures (eg, pressures becween 4 and 15 pounds persquare inch) may be needed.""

If a u,ound is covered u.ith eschar, w-ound depth cannotbe assc'ssec1. In these instances, document "unable to stage"or"unable to asscss wound depth" and explain',vhy."'IA1so,the exact depth of rvounds rvith sinus tracts or tunnels maybe dillicult to assess because the bottom ofthe tunnel can-not be seen.These r.r,-ounds can be clas;ified as fu1l thickness(Table 1), and the amount ofrvound care product neededto filI the tract or tunnel can be used as a gauge for detcr-

rnimng the extcnt of tissues involved.

Stiaictiireainvolved

.,i:, ,..,.i. rr,.i..:ii.. ,r:r ,:,, ,..,: . :,9Qs.!,.!P{9n$. ..,. ., .,,

. : : .:: ,:,' rrr ,ir , r: . ..-:, ::iaaging System5r.. :,::.r:

. Epidermis Superficial wound(strotum corneum, Stage I pressure ulcer*gronulosum,spinosum, Grade 0 (or 0) diabeticond germinotivum) foot ulcer**

First-degree burn

. Epidermis Partial-thickness wound

. Dermis Shave biopsy Abrasionfion follicles, opocrine ond Skin graft donor siteseboceous glonds,blood and Stage ll pressure ulcedlymph vessels, nerve endings) Grade I (or l) diabetic

foot ulcer**Venousdisease: clinicalclassifi cation Class 6#*Second-degree burn

. Epidermis Full-thickness wound

. Dermis Punch biopsy. Subcutaneous tissue/ Penetrating woundsuper{icial fascia (fot, fbrous Stage lll pressure ulcer*ond elostic tissue, deeper Grade 2 (or l) diabetic footblood vessels) ulced*Venous disease:

clinical classi{ication Class 6wThird-degree burn

. Epidermis Full-thickness wound

. Dermis Dehisced surgical wound

. Subcutaneous tissue Stage lV pressure ulcerx

. Deep fascia/underlying Grade 3 (or ll/lll) diabeticstructures (muscle, tendon, bone) foot ulcer**

Venous disease: clinicalclassification Class 6***Third-degree (sometimescalled fourth-degree) burn

Exarnples of wo_tlnds; ''9. onr monly qsed:,wo,Und

Many woutrcls do not fit into sinLple depth categories *Notiono/pressure ulcerAdvisoryponelpressure ulcerprevolence,costondand contain areas of partial-thickncss and full-thickness riskossessment.ConsensusDevelopmentConferenceStatementDecubitus.dermal involvement.:3'when usinpr a :ressure ulcer o' foot I::;::"^!if,::"::i#:;*.;;:;:"i;:l:::::Jr'i;l:;"';i:;t;:;;.ulcer staging system, the stage cor:esponding tvith the *aWogner FW.The dysvosculot foot: o system for diognosis ond treatmenLdeepest area of rhe u.ound is docrmented. Similarly, , ;".1T,irI^ir'li!,'n!k','lt";!;"!l';::!;:l:;:'4,3.1r'ilij[,l:r,vound corrtaining areas of partial- a rd fu1l-thickness der- Ylanaze. 1997;43(2):44-53. **aBeebe HG, Bergon ll, Bergqvist D, et ol.nar invorvement is crassified as a full-thickness wound. :J',','JfXfl::-':,iXi'i;:",{:[;ffi:ii:i'!iii"i'!fi!trf*i.?1';l:::i

Staging.'Wound depth is an irnpcrtant sssessnlcnt Vari- Sur+. 1995;21:542-647. *The extent oftissue domoge connot be oscet'able, sincc it has a dir-ect effect on hou long the rvound may ':#":r!::r;l:,,*u^P

stosins del'nitions "suspected deep tissue iniurv" ond

take to heal. Hence, most clescriptive u,-ound-assessmentnethods, including staging systems, are based on depth.The involved." " The Pressure Sore Status Tool includes, amongrvork ofShea,t'rvith subsequent rrodifrcations, has resulted othels,5 pararneters rclated to depth, including tbe variablein the most coru:ionly used (and rccently revised) National "obscured by necrosis."t"Pressure Ulcer Advisorv Panel (NPUAP) stagrng and the Burn u'ounds are classified based on depth and area. ForEuropean Pressure lJlcerAdvisory Panel (EPUAP) classifi- example, partial-thickness rvounds ar.e classified as superficatiorl systen-N (Table 1).r*t' Other pressure ulcer staging cial or deep second-degr-ee burns, and wound area issystenm, such as the Yarkony-Kilk scalc and the Stirling defined as total body sur&ce area involved. ClassificationGrading S,vstem, are also based on the lcvel of tissue svstems for diabetic foot ulcers (eg, the'Wagner scale and

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van Riiswiik and Catanzaro Wound Assessment and Documentation

trr,ri.,i:11::::,i;riri:BgiilptioO,titrt::til

. Lengch (longest areaof tissue breakdown)and width (longestmeasurementdicular to the length)are measure( using adisposableguide/ruler calibratedin centimeters

. Record length, width,method of measure-ment, patientat time of as

Tracing . Disposable acetatesheeg measuringguide, or plastic bag

Horvever, thev al1 rely on the clinician's au,'ound depth, which nray not always be eAssessing the extent of dermal involvement can

held over the woundwhile tracing theedges with a perma-nent, fine tip marker;add location markera(eg.head, toes), date,patient number

. Clean the sheet orremoveside of plasticbag/measuring guide

. Attach tracing tochart and/orarea using 1.0-cm or0.5-cm gr"id paper*

. Record area, methodof obtaining andlatirng measurementPatient Position attime of

* Some freosuring guides incotporote o l.O-cm or O.S-cm

University of Texas diabetic wound classrficat

See Figure 4.

system)

also include a wound-depth assessment.rssr'T classi6ca-tion systenr all liave one major-advantage: t hey ardizethe ternrinologv used, thus facilitating

chronic rvound classification systems have been tested forreliabiliry and validiry and in practicc, the most u.ide11, uscdpressure ulcer staging systelns are not ve1'y accurate.'''t'""tt'Research results of pressllre ulcer assessment instrurnentshave been reviewed elsewhere,t'and recent research con-lirnrs that both the intrarater and interrater reliabiliry oftheEPUAP classification system, which is sinilar to theNPUAP grading systern, is 1ow among nonexpert nllrses.toFina11y, staging systems were not designed to capturechanges that occur during the healing process! and theyshould be used to facihtate adrnission diagnostic procednreson1y.''" Just as u,e do not change the admission assessment

. Good interraterand intraraterreliability

. Provides a clini-cally reliablerecord ofchanges inwound size overttme

. Easy

. Expense is

determined bymaterials used. Fast. Excellent inter-

rater andintrarater relia-bility

. Reliabilitydecreases withincreasingwound size

. Method may notbe suitable forresearch purposes

. May be difficultto see woundmargins

. lf transparencydoes not containgrid, tracing hasto be copied togrid paper tocalculate area

. Manual countingof squares ongrid paper maycause over- orunderestimationof actual area

. Tracings can bea valuable partof patientrecords andchanges inwound area caneasily be com-pared

nlcauon.to assess

y to do.

lar\ ditlicult because dermal thickness variespartlcu-

age (thinat birth and after the {ifth decade of life), sex thicker inmen than in women), and anatonical loca rangesfrom less than 1 nrm on the evelids to greater n J rnnron rhe back. Another lirmretion i. that, to drtc, y a feu'

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of a deep second-degree burn to a superficial second-degree burn rvhen it is healing, presstlre ulcers should notbe downstaged or backstaged as they heal.While cliniciansin some patient-care settings may be required to dorvnstagepressure ulcers for reirnbursement purposes, baseline andflollor'v-up depth assessments in the patient's chart shouldinclude a description of the tissues inr''olved andlor actualdepth

orvolunre measurenr.ent. The Pressure Ulcer Scale

for Healing (PUSH), developed to address the concern ofdownstaging, does not include rvound-depth inforn"ntron.Research indicates that the instrument may be valid, andalthough the PUSH scale is widely used, usets have suggest-ed additional improvements.'"''';

Describing the extent of tissue darnage.The previ-ously described staging difliculties also apply to describingthe extent of tissue damage. First, cliricians car-r tr.v to findmarkers of wound depth. For exanrple, islands of epitheli-um in the rvound bed n-Lay be indicative of a superdcial orpartial-thickness rvound (Table 1). When underlying struc-tures, such as fascia or tendon, are visible, the rvound

extends dou.'n through the dernris and can be classified asfu1l thickness. Second, it helps to remernber that dermalthickness ranges from approximlltely 1 Inm to '1 mm; thus,most rvounds that are deeper than 4 mm involve subcuta-neous tissue and can be classified as fuil-thickness rl'ounds.t'Finally, document if the rvound bed is irregulaq eg, "latcralaspect of lvound extends through subcutaneous tissue,proximal aspect of the wound contains dern-fs."

Measuring wound depth, undermining, and tun-neling. Wound depth is most commonly measured andquantified bv gently inserting a sterile swab into thervound. Find the deepest point and put a glovecl forefingeron the swab at skin level. Rentove the sr'vab and plece it

next to a measuring guide, calibrated in cencimeters.r" Thisrvound assessment method is not very useful fol partial-thickness or superficiai rvounds but can provide valuableinformation lor deeper rvounds.The presence or absence ofundermining, a space between the surrounding skin andwound bed, and tunneling also can be determined in thismanner. The depth of a tunnel or pocket of underminingcan be measured using the same technique as described forinound dcpth. The validiry and reliabiliry ol this rnethoddepends on clinician ski11s and documentation.

First, determine ifyou need assistancc to help the parientremain in the position reqr.rired to perform the assessmentand n'rake sure that 1-ou have ali the equipment (eg, ruler,pen, paper) at hand. Second, the r,alue of the measurenientfor evaluating change (reliabiliry) also depends on docu-menting how (patient position) and rvhere (eg, most lateralarea) in thc r.vound it rvas obtained. If tunneling or under-mining is present, record the percentage of the wound mar-gin involved and the location. If it is dilficult to describe

Figure 4. Using a 1.O-cm grid to determine wound size,count the crosspoints that fall completely within the ulcer.This ulcer measures l3 cm'. When using a 0.5-cm grid,count the crosspoints and divide the number by 4.

rvhcre the measurement was obtained, drarv a picture of thervound and mark the area or use a "c1ock" system. Forexample, for all assessment findings, the area of the rvoundclosest to the patient's head is l2 o'clock.There are no lim-itations on how' matr1, depth measurements can be made,

and it rnay be helpful to take 2 or 3 different measuremcntsin different areas to get a clear picture ofthe rvound dirnen-sions. Taking multiple measurements close together andrecording the average may improve accuracy. Insertion ofany object into the wound mav cause tl:auma, and if cottonsw:rbs are used, particles can remain in the rvound bed.These concerns hal.e led some experts to recot-rrnendassessing depth b,v gently inserting a gloved {inger instead ofa srvab." A variety of disposable w,ound probes with orwithout attached fbam tips and ruled ureasurenrent sticksare comnrerci:rlly available and, unlike cotton srvabs, rvillnot deposit particulates in the rt-ound bed.

Regardless of horv depth is nreasured, once a method has

been chosen for a particular r,vound, standardizing the pro-cedure is crucial to evaluate whether the wound is movingin the direction of the goal of care. High-frcquency ultra-sound has been used to assess skin and skin thickness andcan also be used to assess rvound depth and estimate rvoundvolume -"vhen more objective assessments are needed.tut"

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van Rijswijl( and Catanzaro

Figure 5. Wound assessment

Assessing wound area/size. Measuling a recording


Assessment Model

'1994 Diane Krasner and Lia van Rilswijk.

help c1i-infonnation about the progress of a u,-ound, the actualnumber obtaincd n'hen lnultipl_ving length and r.idthfi]e:lsurernents is :rccurare only if the u,ound has a regulargeonretlic shape.t" Second, lvhile excellent correlationshave been found betr'veen planirnetric R-ound area, rvounclrvidth, lcngth, r,r,idth x length, perincter. :rnd area based onthe fornrula fol an ellipse for snraller u,.ouncls (< 40 crn'),the accuracy of length x rvidth nleasurelnents and acetatetracings varies depending on thc srze of the $,ound."',t'Third, all rescarch related to the va1idit1,- and reliabiliry ofruler rneasurelrlents w:ls perlbrmed bv rncasuring thelongest rneasurement of the \\.ound (- length) follorved b,vthe longest nreasurerncrlt perpendicular to rhe lengtlr (=rvidth). Snrdy resr:1ts suggcst that this measlrrernent nlethodis rnuch more reliable and valid than other methods. includ-irrg the "ckrck" method (head-to-toe = length and srde-to-side = rvidth)." As rvith other assessnlents, paticnt positionat thc time of nreasurenrent, rccording hon the measllre-ments were obtained (src measuring ttound depth). xtdrnethod consistency a1'e itnportant. At this tinie, llteasllre-rnent of r.vound surface is considered suiEcient for thc rou-tine clinical docunrerrtatiorr of chronic lvound healing.t''t'A1so, it is encouraging to note th:rc assessirrg u,ound sizedoes not involve a significant amount o[time.'When feasibrlity rvas evaluated, rcscarchers found that using papcr tapcor a grid tr:lnsparency takes approxim:rtel1, 1 minute.s'

Whilc n-rost prxctical and valuable for assessing change or,'ertime in clinical scttings, measLlrelnents obtained using instru-ments, such as dreiral irnaging and computerized planirnetry,may be more :lccllrate. Research to develop ancl test ncrv

acute r'vounds have shou,.n that 1arge, deep r,r nds takenrore time to heal than small, dcep rvounds,sturlies of dcep chronic r.vounds llar.e also shorvru,-ound size atTects healing time."''' " Seco

the size of a w-ound upon admission are crucialricrans dcvclop the goal ofcare and patient-carcinitial rvound size rnay aflect tinre to healing.

u,-ound measurelrlents quanti$,- change in u.outo help ansu'er the question, "Is thc lvoun

rnc'thods I'rave advantages and disadrrantagesthcir accur:rcy depends to a large cxtcnt outhe clinician to precisely lintl thc rvound edge.p1e, it nr:ry take practice to scc neu.\ formedthe wound margins. Befirrc developing and inu,ound-rlcasurcn rent protocol, the follotving rrngs anil hrnitations shoulil be consiilerecl. First, itant to renembcr that all 2-dirncnsional ntcchniques provide an index of r.".ound area.

plan. First,Stuclics of

d clinicalthat irritial

, ongoingarea/ stze

healing?"

asLlrlng

Clinical studies ]rave shor,vn that a reduction ir ulcer arca

(epproxinratel,v 20%-lO')/o) after 2 l u,,eeks of t ntlsapredictor of healing for pressure ulcers, venous ulcers,and foot ulccrs in those rvith diabetes nr Lls.l!.lr.l;+)fherefore, if a r,vound is not getting srnallc-r after -4 ureeks

, and planftreatnrent, x re-evaluation ofthe patient, u,ouof care is generally reconrrnended.'t''"'

The most conulonly used techniques forr,r,ound area/size ir.r the clinical setting include pe lneas

sLlrenlentlrelnents or tracings (Table 2, Figurc ,l). Both r2), ancl

abilin, ofr exaltl*eliunr at

nentlng aarch lindis in-rpor-

sLlre1ne11t

cxample,vair-rable

Surrounding Skinfor: color, moisture suppleness.

Measure andlor

trace wound area.Measure depth.

Wound bedAssess for: necroticand granulation tis-

sue, fibrin sloughepithelium exu-

WoundAssessment

Assess for:condition of

everl though lcngth x lvidth calculatiols p

CHRONIC WOUND CARE, 4th Editron


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Wound Assessment and Documentation van Riiswijk and Catanzaro

w,ound rneasutement svstens for use rn specific cJirrical set-dngp or when conducting research is ongoing.t{5'to tn

Color photographs can also be used to rneasurc lvoundarea/size, as long as the wound is not on a curved suface.t-Pl-rotographs can be taken r'rsing a regular 35-nrm or digitalcamcra with a linear tneasurement scale next to thc w'oundand/or at a standard distance. Clinicians rvho possess theexpertise and skill ro take qualiry photographs and calculatervound area follou'ing projection r.vill 6nd that chrs methodcorrclates strongly rvith obaining tracinp." In addition, stan-dard photographs or digital irnagcs can be a useful addition to

the patient chart (see tlorumentatittn) and digital images can be

used for telemedicine.'While the reliabiliry arrd vaLidity of spe-cialty camer:rs with grid film have not been established,stereophotogrammetl'y, using a video camera ancl specialcompllter sofrware, has been found to be precise.o" Results ofa study to evaluate the validity and reliabiliry of a tool tomeasure and assess chronic r,vounds based on photographs are

encouraging and may heip r'vound care experts assess wounds

rvhen a be&ide assessment can llot be peformed.t"

Volurne. Wound volume can be calculated as follorvs:ar-ea x depth x (.).327; horvever, this rnethod is not exact.Indeed, variations of up to 40% ofvolutne have been foundrvhen this nlethod is used..r Other methods of measuritrgvolume (eg, using dental impression materif,ls or {illing elesion with saline) are nrore precise but also more expensiveand difijcult to peform irr routine clinical practice.Concerns about cast materials being used in wounds havealso been voiced. In deep wounds, excellent correlationsbet."veen r.vound volume and rvound circumference andbet-"veen ',vound area and circunference have beenfound.r'rd Some instrunrents, sttch as digital planimetrv sys-tems, also calculate rvound volume from a depth llreasure-

nrent obtained using a foam-tipped probe. ln sunrmar\r,obtaimng area measllrc'nrents has been found to provideclinically useful and valid inforrlation; u'hereas, the need tolnersure r'vound volume in clinical pracdce rernains thesubject of debate. In addition, rcgardless of the nrethod orcquipment used to measure wound size or r-olume, clinicalassessrnent and interpretation skills remain parantount.Results of one study sugsicst that the reliabiliry* of bothmanual and computerized s,-ound measurements (tracings)

increases u,hen the av'erage of3 repeated nleasures is used."Assessing the wound bed.After measuring tl're size of

the rvound, tl're appearance of the u'ound bed needs to beassessed and docutrented (Figurc 5). Simply notirlg the

prcsence or absence of granulation tissue, necrotic tissue,fibrin slough, etc is insufficient to monitor progrcssbecause this rnethod rvill not capture changes in thewound bed until they are complcte (eg, completelv fi-ec ofnecrotic tissue). Similarly, the red-ye11or,v-black system,which translates granulation tissue into red, fibrin slough

into yel1ow, and dried debris (eschar) irrto b1ack, rvi11 onlycapture Present or absenl changcs.While relarively easy toteach and use, limitations must be kcpt in rnind (eg, boneand tendon are also ye1lou., topicai treatments may discol-or a rvound, sutures may be black, and the presence offor-eign bodies has to be documented separately).u'To date,one study of 6 observers has found good inter-observeragreenlent using the 3-color niethod of assessing chroniclvounds.tt Many rvounds contain a conrbination of granu-lation and necrotic tissue or fibrin slough.When tr,ving todocument the elfect of treatuents on wound debridement,investigators have used rating scales (eg, no necrotic tissue,some necrotic tissue, some fibrin slough, etc) or have quan-tified the amollnt of necrotic tissue by estinaring the per-centage of tissue involved. Specifica1ly, they will facilitatethe assessment and documentation of changes in ther,vound bed related to debriclenrent.

Estinrating a lanlle (eg, less thtn 25(% necrotic tissue or25"/,-50%o necrotic tissue) has been studied as part of thePressure Sore Status Tool."' See Chaptcrs 513 arrd 59 of this

sourcc book. A studyinvolving

44registercd nurse rvoutrd

care experts suggested that percentage descrrptions ofnecrotic tissr-re/fibrin slough are valid concepts for dete'r-mining which rype of dressing to use, and these descriptorsare now- commonly requircd to be used r'vhen document-ing the statlls of a wound.'" In another study, drarvingp ofvenous ulcers rvere used to compare the results of visually

euantifyipg '"vound-bed appearance to using a digital-image-analysis system for this purpose."' In this small study,considerable inter-observer and iutra-observer valiationswere found, but the averages bet',veen visual and equiprnc-ntobtained assesslrcnts dicl not differ significantl,v. Based onthe limited research available, visr.ral estirnations may be

considered too unrcliable for research purposes. Horvever,fi'om a clinical pcrspcctive, the1, are rnore precise lvhen try-ing to ascertain outcomes than present or absent ratiugs.

Assessing the wound edges and surrounding skin.In addition to assessing the extent and depth of urrdcmrin-ing, the conclition of the wound edges should be noted.Assessment of the rvound edges includes distinctness,degree of attachment to rhe rvound base, color, and thick-ness.rtttt'' For example, if it is difficult to see where thewound ends and the surrounding skrn starts, re-epitheliza-tion may be taking place. ancl this obscrvation shor-rld becharted. Chronic wounds may also prcsent r'vith thick("ro11ed") wound margins. This condition has also been

defined as epibole or "closed rvound edges."" Closedwound edges are usually an indication that the wound hasbeen present for some time and that tlre newly formedepithelial cells hav-e migrated dorvn and around the rvoundedge because they did not find moist, healthy; granulationtissue to lesurface in the 'tvound bed.

CHRONIC WOUND CARE, 4th Ed]tiON 121


12/86

5). Redness of the surrounding skin can be icative of

van Riiswiik and Catanzaro

The conditlon ofthe surrounding skintant information about the status of the woueffects of treatment. Surrounding skin assessevaluating co1or, induration, edema, and su

less-than-optimal patient and wound care, ie,pressure or prolonged inflammation." Irritationrounding skin, which may aiso impair woundresult from contact with feces or urine, from athe dressing or tape used, or from a reaction toinappropriate dressing,/tape removal. In patientsly pigmented skin, skin color changes (eg, abetween the patienti usual skin color and theskin surrounding the wound) shouldFurthermore, inflammation/vasodilation willincrease in skin temperature. A temperaturebetween the skin immediately surrounding andlance from the wound can be assessed using thehand or finger."'Also, redness, tenderness,swelling of the surrounding skin are the classlc

of inGction.''"''When

the surrounding skinexposed to moisture for a prolonged period of

it signs of capillary leakage (hemosiderin plipodermatosclerosis) or ischenria (absence of

extent (in centimeters) of induration andpitting or nonpitting characterisric..Assessing exudate and odor. The type and

wound exudate should be assessed. because these

not possible when using non-gauze dressings, adressings is time consuming and requires special

Another commonly used method involvesamount of moisture in the wound bed and the


the surrounding skin."'o In the clinic, rating the amount ofwound exudate will be useful only if a description of eachrating is provided. For example, when the wound is dry,there is no exudate; whereas, a moist r.vound is indicative ofscant or small amounts of exudate. When the tissucs arew'et/saturated and there is exudate in the wound bed. theamount of exudate could be rated as moderate. and whenthe tissues are saturated (sometimes including maceration ofthe surrounding skin) and the wound is bathing in fluid, theamount ofexudate could be considered large.The contentvalidiry ofthese descriptors, but not their prospective valid-iry or reliabiliry has been established.' In addition toanlount, the type of exudate should be described. Mostcommonly, exudate type is recorded as serous (clear fluidwithout b1ood, pus, or debris); serosanguineous (thin,watery, pale red to pink fluid); sanguineous or bloody(b1oody, bright red); and seropurulent or purulent (thick,cloudy, yel1ow, or tan).2e,sd72\Irhile the validity and reliabili-ry ofthese descriptors have not been rested, their use in theclinical setting has not been disputed.

Traditionally, the presence of wound odor (and pus) wasused to diagnose inGction. Hence, when moisture-retentivedressings were first used, the odor that inevitably accompa-nied their removal was sometimes mistaken for infection.A11 wounds, particularly after they have been occlr-rded, willenrit an odor, and as with all wound-assessment variables,cleansing is important prior to assessing odor. Necroticwounds tend to have an otlensive odor, and wounds inGct-ed with anaerobic bacteria tend to produce a distinct acridor putrid snee11.'5 Odor is a subjective assessment and can-not be quantified. However, a descriptive odor assessmentcan provide important information, because a change in thetype or amount of odor may be indicative of a change in

wound status.As with all assessment parameters, standardiz-ing what to assess, how to assess, and how to document itwill increase their usefulness. Odor assessments can includea description ofthe odor (eg, sweet, iike fresh blood, putrid)as well as a description of the amount of odor (eg, fi11ed theroom, could only sme11 it imrnediately following dressingremoval, disappeared when dressing was discarded).

'When caring for patients with fungating wounds, thegoal of odor assessment may be to evaluate the ellectivenessof odor-control measures. To assess odor witl-r the dressingin p1ace, the following scale can be used: no odor at closerange, faint odor at close range, moderate odor in room, orstrong odor in room."'

Clinical assessment of infection. The classic clinicalsigns of infection, defined as the invasion and multipJicationof microorganisms in body tissues that result in loca1 ce11u1ar injury, include redness, tenderness, warmth, swelling ofthe surrounding skin, the presence ofpus, and skin anesthe-sia or sloughing."i" One or more of these signs of inGction

impor-and theincludes(Figure

unrelieved

the sur-aling, can

'eact1on toquent orth dark-

difference

of maceration (pale, white, or grey tissue) may observedIn patients with 1eg ulcers, the surrounding skin y exhib-

mth, endslgns

has been, slgns

ation,

to lnJury.edema

as well as

nount ofharacter-

and

noted.r'8

cause andiflerenceshort dis-

r of the

k of the

result inamounts

weighingipment.73

thenof

growth,coo1, clammy skin)."' Assessing and documenting lenessof the sr.rrrounding skin is important, because y molstas well as over\ dry skin (commonly seen in paimpaired peripheral perfusion) is more proneInduration (an abnormal firmness of the tissues)

with

are assessed by gently pressing the skin within a mate-ly 4 cm of the wound. Document the locati and the

istics provide important information about wouthe most appropriate treatment. However, al t1me, no

xists. Oneeliable and valid wound exudate assessment toolproposed definition includes a conbination ofdescriptions and quanti$ring the amount of ate whenusing gauze." In this definition, minima1 exudate 5 cc/24

changeours) equates to no more than one (gauze)per day, moderate exudate (5-10 ccl24 hour$2-3 dressing changes per day, and wounds with hi

of exudate (> 10 cc,zday) require 3 or more g changesper day. Unfortunarely. quanu6/ing exudate in thi

122 CHRONIC WOUND CARE, 4th Edition


13/86


are usually readily recognizable in acute wounds. In chron-ic wounds, however, unrelieved pressure, chronic inflamma-tion, and allergic reactions to dressings can also cause red-ness, tenderness, warmth, and swelling of the surroundingskin. As a result, inGctions in chronic wounds, particularlypressure ulcers, can easily be overdiagnosed or underdiag-nosed, even when wound cultures are obtained.T' Forexample, when wound-care specialists were asked to diag-nose infection by looking at the photographs of 120 non-healing wounds, the percentage of correctly diagnosedinfections ranged from 37 o/r9 0%, indicating great variabil-ity and low reliability-"

It has been suggested that traditional definitions ofwound infection are too narrow for all granuiatingwounds.'5 Evidence suggesting that chronic wounds maypresent with bacterial colonization levels that delay healingis increasing, and suggestions that wound infection is a con-rinuum that includes critical colonization have been made."Future research to determine the clinical validity and relia-biliry of these terrns hopefully will help reduce current

ambiguiry of diag'nosing infection and making appropriateEeatment decisions.'When looking for signs of inGction,other assessment criteria that should be considered aredelayed healing, discoloration, friable granulation tissue thatbleeds easily, unexpected painltenderness, pocketing at thebase of the wound, bridging (with epithelium) at the baseof the wound, abnormal smell, and wound breakdown. Forexample, when assessing the wound, clinicians should rou-tinely evaluate changes in the size and appearance of thewound and look for the green or blue hue of Pseudomonas,the du1l appearance ofwounds infected with anaerobes, andgranulation tissue that bleeds easily and has a gelatinoustexture. Also, it has been found that if a diabetic foot ulcer

extends down to bone, osteomyelitis andlor joint infectionmay be present.80 If a wound infection or osteomyelitis issuspected based on the clinical assessment findings, a quan-titative or semiquantitative culture, roentgenogram (x-ray),bone scan, magnetic resonance imaging, or indium 111 scanmay be ordered to confirm the diagnosis.'r''du' Additionalassessments of s,rrstemic toxicity (temperature, blood pres-sure) and results ofblood culture, complete blood cell countwith differential, and creatinine, bicarbonate, creatine, phos-phokinase, and C-reactive protein 1evels may have to beobtained to guide treatment.Tl Finally, when baseline patientand wound-assessment findings (Figure 2) indicate that thepatient has an increased risk ofinfection, consider increas-

ing the wound-assessment frequency and obtaining a swabculture or biopsy if the wound fails to improve 1-2 weeksafter appropriate therapy has been instiruted. In addition toinfection, delayed wound healing may be the only indica-tor of cutaneous candidiasis or carcinoma.t' There is nostandard or consensus on when a wound biopsy is indicat-

ed. Indications range from all wounds, including the arypi-cal wound, to the recalcitrant, unresponsive wound.82 Inaddition to a patient history that may suggest an increasedrisk of maiignancy, wound-assessment findings that maywarrant a biopsy include increasing wound size, malodor,pain, irregular wound base or margins, exophytic wounds,excess granulation tissue, bleeding, or drainage.

Documentation and interpretation. In addition todocumenting all findings in a standardized manner, inter-pretation and evaluation of changes in wound assessmentvariables, including area, should be evaluated to ascerrainprogress toward the goal of care.While research to deter-mine which mathematical formula most accurately reflectswound-healing rates continues, clinicians may decide tosimply calculate the change in absolute area by subtractingthe initial wound area from the most recent area (initial -current). Methods that facilitate comparisons between dif-ferent wounds include calculating percent change as a func-tion ofbaseline area (baseline area - current area = baselinearea x 100) or linear advancement of the wound edge.e'The

latter also involves measuring the wound perimeter.As longas changes in wound size are measured and calculated con-sistendy, their inherent imperfections will not affect theoverall goal of clinica.l wound assessment. Color photo-graphs and digital images can also serve as a perrunentrecord ofthe status ofthe wound at baseiine and at regularintervals thereafter. Photographs may also facilitate reim-bursement and patient/caregiver teaching and can serve asmotivarional tools.sa Most facilities have developed proto-cols for photographic documentation, including informedconsent procedures, that should be followed."

Regardless of the rype of camera used, it is helpful toremember the definition of a medical photograph is a pho-

tograph that accurately maximizes clinical informationwhile minimizing irrelevant data.o'' Focus on the woundand try to eliminate clutter around the area to be pho-tographed. Always include a measuring tape next to thewound to increase perspective and facilitate comparisons.To maximize clinical information, taking a picture of thelocation of the wound (eg, the entire back or leg) may alsobe he1pful. Last, but not least, for all images, do not forgetto develop an easy-to-use labeling and indexing system aswell as a secure storage system.

ConclusionWound assessments provide the foundation of the plan of

care and are the only means of determining the effective-ness of interventions. Regular reassessments may also mod-vate patients and caregivers, and they will help cliniciansdevelop a much-needed treatment outcome database.Knowledge about the appropriateness, validiry and reliabil-iry of commoniy used assessment terms and methods

CHRONIC WOUND CARE,4th Edition 123


14/86

Take Home Messages for. A thorough wound assessment lncludes a omplete

patient evaluation.. Treatrrent is preoicaLec on rhe res.Llis regular

assessments,. In clinical practice, consistency of asses

r rcar] ic - a',

Self-Assessment Questions1. Comrlonly assessed r,vound char:rcterrstics i

A. Wound depth, wound size, tissue type, etissue perfuslon

B. Wound depth, tissue perfusion, surroundindition. and rvound odor

, and

C. Tissue tule, alnount of exudate, r,vounding skin condition, r,vound eriologi and c

D. Tissue q/pe, anount of exudate, r,vonnd and size,edgesdor, surrounding skin condition, and rvou

van Rijswilk and Catanzaro

remain to describe wounds, develop plansJ)r ertain oLrt( onrc) i. increl'ing. yet nrunknorvn.' However, application of existingthe clinic rvill help chnicians provide evidencand optinize or-rtcomes.

2.Wound size is an inportant characteristic toregular basis because:

A. It helps clinicians select the right dressingB. Docurncntation of wound size alTects rein

rates

C. Change in rvound size is a predictor of hea

D. A change in rvound size correlates rvith apatient statLls

3.The process of r,vound assessment can best beA. Collecting, verifying, and organizing i

about the wound for the purpose of evaeffectiveness of the plan of care


1999;26(5):238 2,{9.Cooper DM. Wound assessnrent irnd evaluarion. Irr: J3ryant R, ed.Aattc ard Chronic Wltutds: Nursirg Managenuir. St Louis, Mo:Mosby Year 13ook; 1992 69-90.MaklebustJ, Margolis l). L)ressure ulcers: deilnition ald assessmentpararrrcters.,4 dr I7b u n d C ate. 1 9 L) 5 ;8 (1) : suppl (r-7.van Rijswijk L. Frequency ofreassessnrcnt ofpressure rrlcers. ldirWouul Carc. 1995;8(4):suppi 19-2.t.l,'lerriant Webstet's Collegiate Di rtionary. 1 Oth ed. Springfi eld, Mass:Mcrriam Websrcr, Inc: 199.1.van Rijsrvijk L. The languagc of l,ouods. In: Krasoer DL,Rodehcaver G'f, Sibbald RC, eds. Clrorir Wountl Care: A ClinicalSource Book -fbr Heabbatc ProJess.iorLals. ,lth ecl. Malvern, Pa: HMPComrnunications: 2007:25 28.Karirn I\B, Brito BL, l)ntrieux RP L:rssance Fl HrgelJ MMl, 2assesslnelt lls an indicator ofrvound lrealing: a feasibilit,v study,idlSkin Wound Carc. 2006:1 9 (6) :321 327.Ennis WJ, Me ncses P \Vound healing at the loc:rl level: the sturnedrvoutrd. Osrony Wo u ru] 1,1 an.age. 2000 ;,16 ( 1A Suppl) : 3 c)S-.lt3S.Bolton L, McNccs P, 1:n11 [\i-i511:jjk L, et al; Vround OutcomesStudy Croup. Wound hcaling ourcomes using standardizecl assess-Inent arrd care in clirrical practtce.J ll1tnd OstLttty Oontincncc Nurt.2004;3 1 (2):65-7 1.Polansky M, van llijsrvijk L. Utilizing survival analvsis techniquesin chronic l,ound healing studies. I,I/OL,i\D,S.199:t;6(5):150 158.Bergstronr N, Bennett MA, Carlson CE, et a1. Clinical PrdtticcGuideline Ntnber I .5:1it:anrLenr of Pres,.rrt (/1ren. Rockillic. Md: USt)eparnnent of Hcalth and Hunran Serviccs. Agenc,v for HealthCare Irolicv and Ilesearch; 1994.AHCPR Publication 95-0652.

Ccnters lor Mcdicare aDd Medicaicl Services. Srare C)pcratirusllalral. Ilaltiruore, Md: Centcrs for Medicare and MedicaiclServices; 200,tr. Publication #100 07.Brem H, Sheehan 1l Rosenbers HJ, Schneider JS, Boulton AJ.Evidence-based protocol lbr draberic foot ulcers. PldJf R(.o/i-!trSurg. 2OO6;1 17 (7 Suppl): I 93S 2095.Lazarus GS, Cooper L)M, Knighton DR. ct al. Delinitiors andguidelines 1br assessrncnr of rvounds aud evaluarion of healing.Arch Dermatol. 1 99'1; 130(,1)::t89,193.Clark RA Cutaneous tjssue reprir: basic biological considerations.I. J An Aud Dernatol. 1985;13(5 Pt 1):70-5-725.Arurstrorrs DC, Laverv LA, Harkless LB. Valiclarion of a diabcticrvonncl classification systcn. Diabetu Care. 1998;21(5):855-859.Classification and grading of chronic venous disease in thc lorverlirtrbs. A consensus statenrcnt: Fcbrrrlrv 22 26, 199,1, Maui.Hawaii. l)ernatol Stry. 191)5;21(7):642 646.Lavery LA. Armstrong 1)G, Harkless Lll. Classification of diabetjcioot wounds. O s t o rr y llit u nrl lla n agt. 19 L)7 ; 1 3 (2) : I 1-5 3.Frvkbctg R(i, Arrrrstrong DCi,

Giurini J,et al;

Arrrerican Collegeof Foot and Arikle Surgcons. Diaberic foot disordcrs: a clinicalpractice guideliile.American College of Foot anclAnkle Surl;eons.J Foot Anklc Sarg. 2000;39(5 Suppl):S1 60.Association for the Advancenent of Wound Care (AAWC).Sutlrlary alsorithrl for venous ulcer care rvirh annotations ofavailable evidencc. Malvern, Pa: AAWC; 2005.Worrnd, Ostomn:rnd Continence Nurses Sociery (WOCN).Guicleline for prevention ancl managenient of pressure ulcers.Glenvre*', ll1: Wound, Ostorrr,l', rnd Continencc Nurses Society(wOCN);2003.'Wound OstorDy and Continence Nurses Society WOC]NGuiciance Docunrert on Orsis Skin urd Wound Stetus (revised07,u 06). Available at: hrtp://*,rvwu-ocn.org/educatior/pdt7\Xrt)CNOASIS guidancel\ev072-106.pd| Accessed October 30, 2006.llolton L, r,an Rr.1sw5k L. Wound dressings: ineeting cliiical arldbiological needs. Dcmatol Nrr-.. 1991;3(3):1,tr6 1(r1.SheaJD. l)ressure sores: classification and nunagcrredt. CLin OrthopRelar Res. 1975;(1 12):89 100.l)tessure ulcers prev:rience, cost, and risk assessment: consensusrlevelopntent conlireuce statemcnt The National l)ressure (JlcerAdvisorv P atc1. D e r ub i tus. 19 8I) :2 (2:) :2 1 -28.L)et'loor T. Schoonhoven L, \,hndemec K, Westrate J, M,vn,v l).Rchabiiity of the European Pressure Ulcer Advisory Panel classification system. J.,1rlr Nirr. 2006;5.1(2): 1fl9-1913.Y:rrkorry GM, Kirk PM. Carlson C, et al. Classification of pressu-eulcers.,lnl D e r na ttl. 1 990i126 (9) : 1 2 1 I 12 19.

care, and

remains1n

based care

methods

skin con-

surroulld-

rselnent

hange in

elined as

for the

rd so as

12

t3

11

,.

10

11

2-O

7l

18

19

16.

21

ting the

B. Watching end tracking changes in the rvoupurpose of documenting its s131Ll.

C. Keeping track of information aboutro [:ci]it.rte contr nrrnicJtion

D. Collecting wound status information lbr t purposeof selecting the most appropriatc treatlnent alitres

Answers: I-D, 2-C, 3-A

References1 . ISeitz JM, r,rn ll-ijsrvijk L

validation srucly. JUsing rvound carc algorithrlltound Ostorty ConLL

CHRONIC \A/OUND CARE, 4th Editlon


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Wound Assessment and Documentation van Rijswiik and Catanzaro

33.

35.

29

3l

3+

37

i9

+2

51.

I']cdlcv GE. Comparison ofprcssure ulcer gracling scales: a stud,v ofclirrical ucilitv ancl intcr-rater r.-lirbilitv. ftt J Nrln Stl,/.2{t0-l:-11(2);129 i 1{).Brtes-Jensen BM, Vredevoe DL, llrecht ML. Vali,lin and relirbiliryof rlre Prcssru'e Sore Status Tool. Derrliri-r. 1 992;5(6):20-28.W;rg;ner FW Jr- Thc d1'suscular foot: a s-ysteul for diagnosis aldtr.afnletrt. Foot Auklt. 1981;2(2):6'{-1 22.C)dland ClF, Short JM. Structrrre of the skin. Tn: Thotttas B, ArndtKA, Fitzparrick WH. eds. l)crmatololX' in Ge neral Medicine. Nc*.York. NY: McGrm -Hill Book Co; I 971.Arnold N. Watter\1arth B. Wound staging: ciru rrursci ;rpp11' chss-roonr education to the clirrical scttin!l? OJro,r/ llbnnd.\lntage.1995t-11(5):4(t 4:1.Buntinr E. Beckcrs H,l)e Kcvscr G, et a1. Intcr-observcr rariationin thc assessment of skin ulccration. J \l\und Care.1t)96;5('1):166 17{).Woodburl, MG, Houghtorr PE. Carrpbell KE, Keast I)H. Pressureulcer assessurent instruneuts: a i:ritical apprrisal. OstautJ, lVotndrUaruge. 1 999:.15(5) :-12-55.Berlos.irz l)R, l{etliffO. Crrddigarr J. Rodeheavcr G: NatiorralPresiure Lllcer Advisor,v Pancl. The PUSH tool: a surveJ, to cletcr-nrirre ics perceivccl usefulness. AdL Sktn |Vpuutl Odrc.2ttt)5; I 8(9) :-l8t)--ltt3.Krasncr l). Wound measu-erue1lts: sorl1e tools of thc trade. ,4lr -1rNtr:t. 1 992:92(5):li9-90.Mrkkbut JA. Sieggrccn M. Pn:-rat Lilcer:: Orit,telinL's .li,r Prttrnrionard Nllrlrlg llan.rytnuLt. 2nd ecl. Springhouse, Pa: SpringhousePublications: 1 995:-13-66.llouranelli M. Maqliaro A. Objective asscssnlcnt in rvound hcaling.In: Kirsner RS, Falabella AF, eds. lllorild Hrollrp. Boca Ratou, I-la:

Trvlor & Fmncis Crcup: 2005:671-679.L)vson M, Mootllcv S, Vericc L. Verling W, Weimuirn J, Wilson PWound healirrg assess[lent using 2[t MHz u]trasouncl and photographl'. SAirr Rcs

-l ednol. 20{ t.3;9(2): 1 I (r- I2 t.Mrrks J, Hughes t-E. Hardinc K(i, (-au1:bc11 H, Ribcirr CD.l)rcdiction of healing time as an ,ricl to the ruanagerncnt of openltranulatms rvourcls. II,brldJ Srrrg 19133:7(3):6.11-6-15.Skeue AI, Snrith JM. Dore CJ, Chrrlett A, Lcl.is Jl).Venous legulcers: a prognostic indcx to prcdict tiure to healmg. Blf.1 992:31)5 (6U62):1 1 1 9-1 121.vau Rijsrrijk L. Full-thickncss 1eg ulcers: patie:rt clertographics andprcclictors of lrealirtg. Multi-Center Lcg Ulccr Studv Ciroup. -/ FiaarPrat t, 199 3 :36(6):625-632.tl-obson MC.]']hillips L(i. Larvrencc WT, ct rl.The safbtv ,rnd etlectof topical]y rppliecl rcconrbinrnt brsic fibrotrlast grorvth lactor onthe hcaling of chronic prcssure sores. Antt Sa,!.1 992r216(-l) :-l{t1--1{)6.Arnold TE. Stanley JC, Fcllorv EP et al. Prospccrive, rnufticenterstuc{y of rrranaeing lorver cxtreruit\ verlolrs ulcers. Aun Vasc Srug.199-t;tt(+):356 362.-lalluran P, Muscare E, Crrson 1l Eaglstcin WH. I-elrngaV Lritillratcof healirrq prerlicts coruplete hr'a1ing of venous ulcers. .4nlrDcutatol. 1997 ;133(1 0): 123 I -1231.Kancor J, Mrrgolis DJ. Efficacv rnd prognosric value of sinrplcrvourrd nrersurrnrents. Ar& [)e r nntol, 1 998; 1 3.1(1 2) : I 57 1 1 57-1.Shcchan P,Joncs Il CiiuriniJM, Caselli A,Vevcs A. Percc'nt change inuouncl arca of diabccic foot ulcers ovcr r 4-rvc'ek pcriocl rs a robustpretlictor of completc healing in r I 2 rvcck prospective trial. ,P/a-rrRero,r.rtr -SrLg. 2t)t)6; I 17 (7 Suppl):239S-2+.1S.1)rince S,1)odds SR. Usc'ofrrlccr size end iniriel responses ro trert-rrrcnt to predict the healing time of 1eg Lrlccrs. J l1:ound Oare.2t){)6; 1 5(7):299-3().3.vau llijsrvijk L. Polarrksv M. Preclictors of time to healing cleepprcssure ulccrs. rl'Ot.'.\D-S. 1991:6(5):l 59-l(r5.Ma,vnrvitz HN. Shape and ilrcl rneastrrerlent consiclcrations in theassessDent of diabetic plantar ulcers. IT,'Ot,'\DS. 1 997:9(1 ) :2 1-28.Cethin G, Cos.mrn S. Wound measurnlent cornparing the usc ofacctrte tracirgs antl Visittak cligital p)animetr,v J Cllrr t\irn.201)6:15(1):422127 .tsr,rrnt JL. ltrooks TL, Schuridt li, Mostorv EN. Ilcliabi)ir,v ofrvound rlelsuring techniques in rn outpatierrr rvouncl centcr.() t o ny lliw n cl -lIarargc. 200 1 ;"{7 ( 1) :{1-5 1.Roc'lcheaver GT, Srotts NA. Methods ior asscssing ch:rnge irr prcssure ulcer status. l./r/ |1,'ound Cue. 1995:E(-t):rrppl 34-36.Liskav AM, Mion LC. Davis BR. Comparison of ts,o devices for

\1.ound nreasurerlrcnt. [)crnntol Nin-. 1993;5(6):-137 ++1,.+3+.Keast f)H, I3on'ering CI{, Evans AWi Mackeau GL, Burrorvs C,D'Souza L. MEASURE: a proposed asscssnlent lran.-rvork fi>rde'veloping besi practice rccorlrucndations lbr rvound assessmerlt.|l,ittutd Rcpau' Rqgcr. 2l)04:12(3 Suppl):S1 S17.W'cingartet MS. Papazoglou E. Zubkor. L, Zhu L, Vorona (1,'Walchack A. Mcasureurcnt of optical prcpertics to cluand$ healincof chrorlic cliabetic rvouncls. llhutd Rtptir Rr3ett.20tt6; l-l(3):361370.Tharvcr HA, Houghton PE. Woodbur,v MG, Kerst D. Caurpbell K.A conrparisorr of conrputer assisted ard rlarrual rr.ound size nlers-llrcnrent. Ork)rr), I'l:ouild f,Idnaq( 2(X)2;-ltt(l 0):-16-53.

Harcliue KG. Mcthocls 1br assessing charrge i:r ulcer status.,4rlrLlo u n i Care. 1 995:8(1) :rupp1 37--12,Rrorqr-Etris M, Pribblc J. Lal-)rci:que J. Eralultion of tso toundrneasurerllent u)ethods in a rrulti-ccntcr. controlled stucl,v. O-rlorrrlI li'rr/,/.\ldl/,t{r. l.)r)+:-+r)(7):+-l-+8.Langemo I)K, Mell:urcl H, Hansori L), Olson ts, Hurter S, Henlv S.f.Tivo-clinrensionirl wouncl nreasurernL'ut: corrparison of ,+ tech-niques. .-ldr [i irrrrrl C,rre. I 998; 1 I (7):3-]7-3+3.Houglrton PE, Kincricl CB, Cumpbcll KE, Wootlbury MC, KcastL)H. I)hotographic assesr)e1lt of the appcarancc of clrronic pressureand leg ulcers. C)von),lliwild \linr.(r. 2(x)();l(r(l):20 3(t.Phssuran ll Mclhuish JM, Harcliug KCl. Methods of rneasurir[luouucl size: l comparrti\re smdy tlOLII\iDS. 199.1:6(2):5.1 61.Melhuish JM. Plassrran P, Harcling KO. Circunrferencc, rrea andvolurrre of thc healinu rvound. J lllt t md Ct re. 1 99.1:3(8) :.j80-396.Hasvard PG. Hilhnau CR. Quat MJ, Robsou MC. Sur{ace arcanreisurernent ofpressrrrc sores usinq rvc:und nrolcls and corrputcr-ized iutaging.J,4rr Ceriatr Sor. I 993;,11 (3):238-2.+0.

Krasncr I). Wourd carc: hou to use thc red vc'llot black svsteur..4m J Nars. 199.5;95(5) :4-l-.17.Mekkes JR. Westchof W Inrase processing in the stud_v of woLuldhcalinq. Cli,r Dcmatol. 1995;13(1):401--107.Stotts NA. Itnpairecl wouncl he:rling. Irr: Carricri Kohhrran VK.LindsayAM,Wcst CM. c'ds. 1']allrtrplrltitlo.qiaL PlttnLtnenoti /',/ t\i/aili(.Philadelphia, Pr:V.B Srunders Oo; 1993:3.13 3(16.Bennctr MA. l\cport ofthc task forcc ou the irrlplicatjons ibr dark-lv pignrentcd intact skin in thc prediction arrd prcrcntiorr of prts-sure trlcers. ,ldul.fbund C,in. 1995;8(6):3.1 35.Lorvthian P l)rcssure sores: a scf,rch ior deiiuition. Nili Srorrd.1991;9(l 1):30-32.Altentcier W, Burkerts F. Pruitt L). Sanclrrsky ltrl lltnual ou Contrttl o-l'Inltctiou irr Sutgical Patiutrs.2nd cd. Philadelphir, Pa:JB Lippincotr;19{J-l:19 -30.Stevens DL, Uisno AL, Charrrbers l[E er al; lnl-ectious l)iseirscsSocietv ofAnrerica. Practice guidclines fbr the cliagnosis aud Drrn-.s.rDent of skin :rnd sofr-rissue irrfectiorrs. Clit lnltct Dis.2l)i:)5;.{ 1 (11)): 1 373 1.10{r.Mulder GD. Quantihing rvowrd lluicls for the cliuician ardrrsearchcr. Ostrtny L|;owrd ,llarr,iqc. I 9t)1;-l{ )(ti):(r6-69.Dcalc'y C, Cuneror J, Arro*'uuich M. A stuclv conrprring trvoobjc-ccive rrrcthods of quantitr.ing thc production of sound esudates.rl [/orrid Can. 2{}06; I 5(1): 1.19 153.Baranoski S. lMoturcl assessnrent ancl dressing selectiou. OJrdrr),ll'ot n d ) Ia n a.qc. 1 995;1 I (7 Suppl):7S 1 25.(iutrinu KII Harcling I(C. Critcria 1br idcntif irg louuil intiction.J l.;Vowtd Care. 199-1:-1(1):198 2l)1.Faller NA. Llvrcnce KG. (Modi6cd Baker-Haig) oclor scrle. e;1992Faller & Larvrcuce.Tirorrson Pt). Irnrnuttololl', uicrcbiologl,, ucl the recalcitrorcnorrncl. Orara), Ilirund tr[magc. 2{){)0;1(r(1 A Suppl):77S-ll2S.Lorctttzen HE Cottrup E Clinical assesslrrcrlt ofinfcction in nouhealing ulcers analvzetl bv latcrrc class anal-rsis. ll'ilrarl RcTuir Rcqrrr.20t)6; l.l(3):350-351.Wirrte I!, Cutting K, Kirrslev A.Topical antinricrobuls in thr: con-trol of rround biobuden. Osroly ll.irir n d ) la n qt'. 2l)06 :52(8) :26-58.Nervrran LCi, Waller J, P:rle srxr CJ. et ll. Uususpccted oslcr>myc.lirisin cliabetic lbot ulcers. l)iaqnosis ancl monitr>ring bv leukocytescanninq *ith ndium in 1 11 oxl'quinoJine. J-.{.\1.{.1

()t)1 ;266 (9) : 1 216- 125 1 .

Cliandoni MB, Grebski WJ. Cutaneous candidiasis as I cause ofclclayed srrrqicrl rvound healing. J An Atai Dtrrtrnol.I 99.1;30(6) :9U 1-98,1.Trent JII Kirsrrer RS. Malignanc.v arrd rvoulds. In: Kirsner RS,

57

60

61

58.

71

73

74

79

6+

65

38.

,+3

+l

.+5

17

5(l

5-+

81

125lrY. *ouND CARE, 4th Edition


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Falabella AE eds. Wourul Healing. Boca Raton, Fla: Tr & FrancisGrotp;2005:321 333.


Wound Ostomy and Continence Nurses Sociery Photography inwound documentation. Available at: http://ww.wocn. org,/publi-cations/posstate/pdTphotoposition.pdf. Accessed October 30,2006.Gilbert G. The Complete Photogruphl Careers Handboot. 2nd ed. NewYork, NY: The Photographic Arts Cente4 L992.

-lessup RL. What is the best method for assessing thehealing? A comparison of 3 mathematical formulas. ,4C are. 2006;L9 (3) :138-L 47 .

o{ woundSkin Wound

84 Faller NA, Lawrence KG. Frank S, Barnard A.an alternate !se. Ostomy Wound Mandge. 7994;40(4)

CHRONIC WOUND CARE. 4th Edition


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Nutnitional Assessment and lntervention inthe Adult with a Chronic WoundAllen ).Zagoren, DO, MPA, FACOS, FACN; Deborah R.Johnson, MS, RN,CWOCN; Nancy Amick, MPA, RN, CWOCN

ObjectivesTê reader wl, be câ lenged Lo:. Analyze (e/ co'npone^Ls ol a n,rt"it on sc'een ro idenrrfy ad, rs w,t" malnrr.iL on o' at - sk fo- .nalnurriL on. nrplerrenr a nurnton aclon plan Lo address Lê nuri-ior celecr.Artcuaterl'e

noactwrolebocyn-t"itonnasonrherne[aboliceavronn'enrofr.echroncwo-r.d' lrrpie-nent a^d suooo't ruL'ition nLe've^Lior s oased o. scientiflc pri:c oles a.d, when ava abe, select evice^ce-based rutrrrron nte've^Lrons Lo iac .rare c^ronrc wou^c êaling.

lntroductionrFhe Lrcets of the clrronic r.vound are rnanv and var-

I ,.0 Consenru'('\isr: an)ong healrhcare protb.sion-

I a-1s to explain rvhy some wounds do not heal: con-stant focal pressurer poor vascular inflow, inGction, con-coilitant diseases, and poor venous return. How-ever,healthcare professionals often neglect to identift the con-conitant and subtle nutritional defects that rnight prolong

the healing process or contribute to nonhealing.This chapter rvil1 assist the reader to understand nutri-

tion screening, nutritionai assessment, and the irnpact ofpoor nutritron on the wound healing environment.

Current evidence addressing the impact of nutrition onthe healing rvound and potential nlltrition therapies toenhance wound healing will also be discr-rssed. Attentionwill be focused on the evidence current\ available regard-ing the impact of nufirion upon the healing wound, uti-lizing the follou.ing generally accepted strength of evi-dence criteria:. Level A: randomized. controlled" blinded data exist and

support best practice

. Level B: controlled, randornized data or u,e1l designednonrandornized data exist and support best practice

. Level C: expert opinion, editorial conscnsus! or descrip

tive research data exist; data may be anecdotal and donot conforrn to higher evidence lel,els

. Level D: no evidence current\ found in the literarure.The intracellular environrnent ultimately controls tissue

status; if ceilular metabolisrn is inpaired, a cascade ofevents occurs, often leading to Foor trssue integriry ce1ldesrruction, or ti'sue dcath.

Whole body nutrition is reflected in this microenviron-

ment. A well nourishe d person will not experience a delayin wound closure because of a s)rstenic nutrient deGct.However, if ce11u1ar nretabolism is irnpaired or altered (secondary to poor or under nutrition), wound healing (ofanvand all tissues) will be significantly impacted. There is adelicate balance between the rnacro- and nricronutrientintake and resultant rvound heahng and tensile strength.

Total body nutrition is a complex physiologic and bio-chernical illtegratiol] (a rhorough discussion and descrip-tion are be,vond the scope and purpose of this chapter).This compler integration is influenced by many patientfactors. Examples include but are not lirdted to:[. Nutrition factors: access to food, food intake, and pro-

cessing of nutrients2. Psychological factors: depression, dementia, or cognitive

changes

Zagoren Af, [ohnson l)R, Amick N. Nutritional asscssment and intervention in the adu]t rvith a chronic rvound- In: Krasuer L)L. Rocleheaver GTSibbaldRG,eds.ChronicWoundCare:AClinicol SourceBookforHeolthcoreProfessionols.4thed.Malvern,Pa: HMPClonrnrunications,2(l(17:127 136

127HRONIC \II/OUND CARE, 4th Edition


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Zagoren, Johnson, and Amick

(% IBW) = {BW (actual) x 100}IBW

(% UBW) = {actual BW x 100}UBW

Men =106 lb/5

ft+

6 lbladditional inch (tl0%)

Women = I00 lb/5 ft + 5 lb/additional inch (+ |

Anthropometrics: ldeal body weight (lBW) islimited in the real world. Usual body weighta more realistic and useful assessmen[ tool.

3. Socioeconomic factors: finarrces and support,1. Environment:r1 factors: secure housing and ac

and refrigerator5. Disease process factors: h,vperglycenria,

nrenria.

The microcellular environment is directlv

by these factors. The final metabolic endpoirhealed rvound) is the result ofa rvel1 coordired, balanced event. Each step in this complexing sequence requires a stable biochcmicalrvhich ultimately is the result of adequate foodnutrient processing.

'Whi1e hurnan physiolog,v is resiliert, any athe provision, availability, or processing of tmali and often r.vi11, alter the stabiliry ofprocess. It is a tribute to the beauf,v of the intmilier.r that most rvounds heal, despite alterationphysioiogic balance.

Nutritional Screening andThe nricrocellular environment reflects the

environrncnt in rvhich it is found. Hence, ifalteration of balance. or an actual loss of availa

1eve1s reduce rvound protein content and,decrease wound tensile strength. Thereforescreening is important to identify patients at ror alteled nurrition.All individuais presenting

metabolites and elements, a resultant tissue Fect nravoccur. Impaired protein and calorie intake crotal body protein depletion. Decreascd total

Nutritional Assessment and lntervention

of the elderly is essential due to the prevalence of chron-ic illness and socioeconomic factors that are 1ike1v to placethem at additional risk.

Nutrition screening tools identifi, patient characterlsticsknown to be associated with nutrition problelns. Thesepatient characteristics can be objective, subjective, physical,psychological, socioeconomic, medical, cu1tura1, and/orfunctional. There are a number of screening tools avariableto guide the wound crre practitioner. The Nutritior-rScreer.ring Initiative Project' and the Mini Nr-rtritionalAsscssment (MNA)] are 2 examples.

The Nutrition Screening Initiative Project tool wasdesigned for and validated in the outpatient, geriatric pop-ulation and is nor'v being validated in other populations.r

The MNA rvas also designed for the elderly popr-rhtron;it is easy to adrninister, patient friendly, inexpensive, highlysensitive (96%) and specific (98%), and reproducible.':

Once iclentified, the person with rnalnutrition or at riskcan receive appropriate nutrition intervention. The nutri-tion care plan is guided by a fbrnral rrutrition assessnlent;

consultation with a registered dictitian is recommended.Traditionall,v, in clinical practice, the cornplex riutrition

assessment is only pedormed when a severe defect or nutri-tional alteration is identilied through nutrition screening. Itis important to note, despite thc iogic, thcrc is no A or B:rtrength of evidence-based resealch to support that nutri-tion intelventron will rcduce the overall healing course.There is, however, 1eve1 C strength of evidence to supportthat nutrition intervenrion r,vi11 prevent or reduce the incr-dence of negative healing outcornes.'

Ultimately, r.vound healing is the result of protein pro-cessing.This physiologic event (healing) recluires the assrrn-ilation of protein (eg, anrino acids, peptides, polypeptide$

to fonn a healing matrix. Ener6X, is requircd for healing tooccur. Nutritional assessment helps the observer identifi adeficiency in either of these rni.cro ol mrcrocnvironrncnts.

Lean body mass is reflcctive of total body protein com-partnlent (ie, in evaluation, the size and relative densiry ofbody protein to body fat).t Lean bodv rnass may be assessedthrough direct or indirect lneasurenlents. Direct nteasure-ments (eg, isotope dilution tecl'rniques, nelrtron activation,bioelectric irlpedance analysis), rvhile extremely accurateand useful lor research purposes, are not practical, clinical,cost-effective tools. Indirect measurenlents (anthrcpomet-rics) are rnore practical and less costly. Antlrropometricmeasurements are measurements of bodv ce11 mass, anclexamples include height, rveight, and body mass index(BMI). Body rnass index is a measure of r.veight for height(BUt = ll'eight expressecl in kilogranx divided by heightsquared in meters). The persor-r rvho screens as havingweight loss (or massive rveight gain) should have anthropo-metric components assessed. A medical proGssional (eg,

111S

ss to stove

, aDd

nfluenced

(a stable,, integrat-und heal-ironment,

ke and

atlon 1nnutflents

e healingIhurnrn

ln lnacro-

hysiologicis an

cellular

lead toprotein

timatel,v,

nutrluonfor poor

chron-as part ofc rvounds should receive nutritiori screening

their initial evair-ration.Nutrition screening identifies individr-rals are ma1-

nourished or rvho are at risk for malnutriti The pur-pose of the screening is to determine if a rnnutrition assessment is necess:rr1.. Screeningshould be simple, efiicient, and able to be admi byany member of the healthcare tean1. Nutriti

detailed

neters

CHRONIC WOUND CARE, 4th Edition2fJ

screeilng


19/86

Nutritional Assessment and lntervention Zagoren, Johnson, and Amick

A. Historyl. Weight change

Overall loss in past 6 months: amount =

-

kg; % loss =Change in past 2 weeks:

-

increase; no change; _ decrease

Dietary intake change (relative to normal):- No change

-

Change

-

duration (weeks)type:

-

suboptimal solid diet; full liquid dieq _hypocaloric liquids;

-starvation. Gastrointestinal symptoms (that persisted for> 2 weeks)

none; nausea;- vomiting;

-

diarrhea;

-

anorexia

4. Functional capacityNo dysfunction (eg, full capacity)Dysfunction

-

duration (weeks)type:

-

working suboptimally;

-

ambulatory;

-

bedridden

5. Disease and its relation to nutritional requirements:Primary diagnosis (specifY)Metabolic demand (stress):_ no stress;

-

low stress;

-

moderate stress;

-

high stress

B. Physical (for eochtroitspecify:0 = normal, I = mild,2 = moderate,3 = severe):loss of subcutaneous fat (triceps, chest)muscle wasting (quadriceps, deltoids)ankle edemasacral edemaascites

SGA rating (select one):A = well-nourishedB = moderately (or suspected of being) malnourishedC = severely malnourished

7.

c.

dietitian, nr-rrse, physiologist, physician, pharmacist) can per-

form the assessnlent. lJsuai body lveigl.rt tilrmula is shou'n

m Table 1. By calculating the ratio of the ditlerencebetrveen the lean bod1, cornparmrent and bodv fat, the per-

son lnay be cornpared to a standard.Tl-ris can be donc rvithtotal bod1, u.eight and its rclat:iorrship to a stalldard:

9/n Deficit - 100 actual r.veight x 100ideal rveight

Actnal u.eight and ideal rvetght are sr-rbjcct to variousinconsistencies ancl can be influenced b1' non-nutritionalfactors, eg, certain medications, bod.v rvater fluid changes,lirnb :rn'rputation, and/or chronic disease states.Total bodvnrass nreasurement is an observation and tnitst bc utillzed zrs

a conlponent or tool in further nutrlttonal evaluation.Thc wor.rnd care practitioner can better understand the

person! ultimatc total body protern status bccause totalbody protein is also rcflcctecl in ]mtnoral proteirrs (eg. crr-culating proteins that include albumrn, globulin, and hor-

nrones). These humoral protcins sliould be evaluated asu,c11.The assessment of hurnoral or visccral proteins rcqtrires

sonre invasion ofthe bodv collrpartlnent by clrarving blood

li.i . l. ,rt .l.r :. .rr,. l,',.'r,

r: .p;g6 ,,,1 ,' .,1 , .p6k.r', ,.,.:l i '.: r ::,,r,,,rr ,,Riik t:t.,.r, .,'

, ,.'...:l.l

Albumin < 2.5 < 3.0 to 2.5 < 3.5 to 3.0

Total Protein < 5.0 < 6.0 to 5.0 < 6.0 to 6.5TLC < 900 < 1500 to 900 < l800to 1500

to obtain r:henrical nleasLlrement. The decision to obtairlthis biochen'rica1 data should be balanced with the commonscnse evaluation ol the person's st:ltLls. Most rvounds healdespite nutrition status; hcnce, the decision to obtain bro-chemical data should be founded on the observer's keysense of need. This patient ma,v have a brochemical nutri-tion defect. Iftl'rere is sr:spicion or a question that there is Ibiochemical defect, the person's total protein, serum albu-min, and total lymphocyte count (TLC) may give furtherclues reg:rrding the overall nutritional stallrs. More sophisti-cated bioc}rernical markcrs may be asscssed (eg, transferrin,

CHRONIC WOUND CARE, 4th Edtion 129


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Zagoren, Johnson, and Amick

% ideal body wt.

% weight loss

Albumin (gm/dl )

Transferrin (mgldL )

Total lymphocytecount (mm3)

prealbumin, retinoi binding protein) s,henassessnlent has identified increased risk (Tab1e3). Horvever, the healthcare prolessionai iscertain non-nlltrition factors adr''ersely affect these bio-chemical data. Specific non-nutrition f affecting

limited to,hese biochemical data can include, but are not

trauma, sepsis, or concornitant medications.stress reaction rnay suddenly deplete these

Nutritional Assessment and lntervention

70-80

I 5*25

2.1-2.7

t00-t50

800-t,t99

25

r grcatel thau I vc'ar in dula-tiorr. The human skin equivalent \\ias ulore effcctiv'e thancourplession therapy in median timc to u.'ound closure (61c'lays r,'crsus 181 da,v) and in the percentase of patients hcaledby 6 months (63% r,ersus 49'/o). A retlospective cost-eflfbc-tiveness analysis was condr-rcted using a Markovdecisi


52/86

Phillips

Bed type Cost per 100Patients

Standard ICU bed 125,177.12Air-suspension bed 51,019.52* Cost per pressure ulcer prevented

Adapted from lnman KJ et al. Clinical utility and1993;269:|139-1 143.

turc-reterrtive dressings, while initi:1l1y morethe long run more cost effective than saline-soa$ed gauze.tl

lnman et a1'' assessed the clinical utility and cost effec-tiveness ofan air-suspension bed in the preven$on ofpres-sure ulcers. In this study,100 consecutive Nritically illpatients at risk for the development of pressurclulcers wererandomly assigned to receive treatment on ei{her an arr-suspensior.r bed or a standard intensive care unflt bed u,ithlrequent nurse-assisted turning. The air-stspens]on bed r'vasassociated r.vith fewer patients developingor severe pressure ulcers (Table 2).

, multiple

In patients at risk, the use ofan air-suspensror| bed in theprevention of pressure ulcers was a cost-effective therapy.Detskl. and Naglie" proposed that neurintroduced when any ofthese 3 conditions are et:

Cost Effectiveness in \Mound Care

ulcers Cost saved per Pressure ulcers Cost effectiveness100 patiena prevented per ratio*

I 00 patientsPer

80

t6

00 patient

74.157.60 64


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Cost Effectiveness in Wound Care Phillips

Using a Markov simulation model, Ghatnekar et a1'"'determined that the ulcer-free interval rvas increased bt1 24%and the amputation risk reduced by 9% with becaplermrnplus good rvould care compared to good nound care a1one.

ConclusionIn view of the paucity of studies comparing rhe cost

effectiveness of wound care modalities. the lack of standard-

ized methods of calculating costs of wound care, and thedifferences in outcomes that are measured, it is impossibleto clarify the cost effectiveness of healing, debridement, orpain reliefrvith regard to existing resealch studies.

Measurement scales should be developed to produ,ce a um-versally acceptable method that includes only objective, meas-urable data." Such scales should be patient centered and showwound type plus numbel of scores before and after treatment.Until universal objective scales to measure cost effectivenessare available, the clinician nrust read published studies critical-ly and take cost-per-unit outcome into accoullt to deterDrineif treatment measures are indeed cost effective.

Take Home Messages for Practice i. Costs are not the same as cost effectiveness.Tl\e cost-

per-unit outcome must be assessed to determine costerecl iveness.

. Until universal objeAive scales to measure cofl effec-tiveness are available, the clinician must read publishedstudies critically and take cost-per-unit outcorne intoaccount to determine whether treatment mteasuresare indeed cosr effecrive.

Self-Assessment Questions1. Direct cost, indirect cost, and outcome are important inassessing cos! effectiveness of treatment.

A.TiueB. False

2.The cheapest treatment is ahvays the most cost effecrive.A. TrueB. False

3. Studies ofcost effectiveness should mcasure cosr per-unitoutcome.

A.TrueB. False

4. The words "cost" and "cost effectiveness" of trcatmentmay be used interchangeably.

A.True

B. False

5. There is a standardized methodologv for calculatingwound care costs-

A.TrueB. False

6. Direct costs include the following except:A. Costs of dressingsB. Caregiver tir:reC. Days lost from work

Answers: 1-A, 2-B, 3-A, 4-8, 5-8, 6-C

Consensus StatementsT1. Diagnosis and prevention (of primary disease and

recurrence) should be the first aim ofall those organ-izing and providing wound care.

2, Patients, carers, health professionals, and those rvho payfor care all need scientifically valid data on the eco-nonric value ofwound care therapies.

3. Economic modeis should take direcr and indirect costand outcomes into account.

4. The direct costs ofrvound care can be identified andcalculated.

5. Direct costs of care constitute a substantial andincreasing proportion of total healthcare costs.

6. Indirect costs should always be taken into account andtheir influence on total treatment costs evaluated.Thisinflucnce cJn var)/ From serring to sctring.

7. Indirect costs irrclude costs of opportunities lost fcrrpatients, carers, and health proGssionals to performother valuable activities.

8. In wound care, cost effectiveness can be expressed bythe equation: Cost efectiueness :'direct +'?indirect costs (fachieuing 'parametcrs o;f success prcdetennined in a specifcperiod of time.

1. Direct cosrs include costs of primary and secondarydressings used on the wound, ancillary supplies tocleanse and dress the wound, surgical and radiologi-cal interventions, treatment to manale wound com-piications, rnedications to manage wound pain, inpa-tient care directll, related to the wound, caregivertirne, travel by caregivcr or patients, and disposal ofr,vound care n.raterial or products.

2. Indireu rosrs include costs relared ro quality of life,

assistance in complering activities of daily iiving, costof days lost from work, and cosrs of litigation.3. Pdrdmeters of suress rlay vary rvith patient and setting.

Examples could include any of the following: com-pletc healing, reduction in rvound care, and reductionin wound surface area.

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lledkal Outc


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-he reade'wi I be cha lenged to:. Distinguish lederal reimbursement as it rel:[tes to wound care provded n a specific clinical setting.

Utilize the documentationelements that ccf nstitute medical necessity to suPPort rermbursement for wound

care services, producrs, and Lechnotog es. Analyze Medicare coverage requ rements ii:r I adjunctive wound care theraPy.

Regulatory lssues andReimbursement C hallengesGlenda J. Motta, RN, MPH, ET

Objectives

lntroductionR. ecul.rron irsucr and rcintbttrsetrretrt tncchanistttP ;. .r..r.rou impact otr the quaLiry o[ care, theI \,,,.oJr.tion of neu ccclrnolog.icr. the uriUzrriorr of

products and services, patiellt access to care, payment forploviders, and the actual outcomes of carc delivered.Program budgets, such as those for Medicare and Medicaid,

arc fixed in advance, and the rcimbr-rrsement or payment

rnechanisnr often deternrine how funds are distributed andrvhich services, products, and technologies are corzeted.

Healthcare pr-ofessionals are often uncomforr;ab1e withthe busiiress aspects ofpatient carc. Horvever, like it or not,hea-lthcare is big business, resources are tight, atld patientsare being identified by hor.v much revenue 1[sr1 generateor lose for healthcare providers. Smart wound ,care clini-cians are expanding their advocacl, role b,v consideringthese factors r'vhen caring for their patients.To ensure ade-quate coverage and pal,ment for services, dressings, sup-pIies, devices, biologics, drugs, and other techno.logies, c1i-

nicians must learn how to document assessments, inter-ventions, patient adherence to treatment plans, and clinical

as rvell as financial outcomes of care.Clinicians often ask manufacturers, sale representatives,

ol distributors rvhether thc nerv dressing, technology, or

service is leimbursed. To ansr'ver this question, severalpieces of information are required, including:. Clinical setting ofnse (eg, acute care hospital, rehabili-

tation center, subacute care or skilled nursing laciliryhome health agency, p\siclrn oltrce, outpatient clinic,ambulatory surgerlr center, a paiient'.s home)

' Payer qPe (eg, Medicare, Medicaid, managed careorganization, health maintenance orqanization IHMO],

supplemental insurer, private insurer, Veterans'Administration, rvorkers' cornpensation). Coverage policy for the individual payer. Medical necessiry lecluirements for coverage of the serv-

ice, dressing, supply, devrce, biologic, drug, or technology. Patient diagnosis rhat supports the medical necessity for

the service, dressing, supply, device, biologic, drug, ortechnology

. Codes assigned/verified by various insurers for billing:rnd reporting costs

. Fee schednle, assignecl paynrent amount, payrnentlnethodology, or procedure for determining the anlotlntto be rcimbursed for covercd ffeatment.

Key Elements of ReimbursementReimbursernent conrprises thesc key elements: 1)

Motta CiJ. Regulatory issues ancl reimbursement challenges. In: Krasner DL, ll.odehear.er GT, Sibbald 11G, eds. ChronicWound Core:A Clinicol SourceBook for Heolthcore Professionols. 4th ed. Mah'ern, Pa: HMP Communicrtions,200T:165 175.

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each individual insurer assume that responsibiliryFor Medicare coverage policy decisions, the rnment

(NCD)tilizes a National Coverage Determinatioprocess.A formal request for a NCD can be initia eitherby an outside party or internally by Medicare ff. A keypart of the NCD pr-ocess is an evaluation of witem or service rs reasonable and necessary. Med(ylnakers . aU ltor the be.t .r'icntifit

Documents

Chronic Wound Care Ch13 22