Wound photo documentation captures a visual reference and helps provide a timeline for healing status for the patient’s medical record. Pictures in wound care can be used to ensure accuracy of measurements, to encourage objective assessments, to reduce the risk of misinterpreting the cause of...
By Holly Hovan MSN, APRN, GERO-BC, CWOCN-AP
Wound care and healing require an evidenced-based, interprofessional approach, following standards of care, and treating the whole patient, not just the hole in the patient. Often, wound care clinicians are consulted for recommendations on the treatment of chronic or non-healing wounds, as well as other wound, ostomy, and continence issues. Treating a wound and successfully healing a wound require a holistic approach for the best outcomes.
The first step in wound care is identifying wound etiology. We cannot successfully treat or heal something when we do not understand the cause. For example, with a wound caused by pressure, we need to remove the cause (pressure), be sure the patient is offloading from the area, and ensure that appropriate sleeping and seating surfaces are in place and that not too much time is spent in one position. With a wound caused by edema—again, we need to treat the cause—medical management (as appropriate for the patient’s condition), elevation, and compression (if appropriate) are indicated. In a wound caused by a systemic or autoimmune issue, this may require some investigation and biopsy—but again, the cause must first be identified and treated systemically.
Once we identify wound etiology and focus our treatment plan on the cause, the remainder of the treatment plan can be addressed interprofessionally:
1. Identify the cause: Determine whether a biopsy is needed depending on wound presentation and duration. Involve other disciplines as appropriate (dermatology, general surgery, plastic surgery, orthopedics, podiatry, etc.).
2. Break down the Braden Scale for Predicting Pressure Sore Risk©.
- Sensory perception: What risk factors does the patient have (diabetes, neuropathy, vascular disease, spinal cord injury)? Do they have feeling in their legs or feet? A monofilament test may be helpful here. Open-ended questions and interviewing are important. Also, it is important to go beyond just asking the patient, “Do you have feeling in your feet and legs?” Thorough assessment and documentation are key.
- Moisture: Is moisture present (from incontinence—bowel or bladder, diaphoresis, leaking tubes, drains, or other wounds; tracheostomy sites and ostomies are important to consider here, along with fistulas)?
- Activity: Does the patient stay in bed all day? Is the patient up to the chair? How does the patient ambulate (walking, wheelchair, motorized scooter, use of an assistive device—these variables are important to consider because they all impact overall mobility). Additionally, how often is the patient mobile throughout the day?
- Mobility: Does the patient need help to turn in bed or reposition? Can the patient weight shift independently in a chair?
- Nutrition: Assess nutritional status, and follow-up with a dietitian, diabetic educator, and other disciplines as needed or appropriate. Consider the patient’s mode of nutrition (oral, tube feeding, total parenteral nutrition, NPO for a test or procedure) and the how well the mode of nutrition is received. For example, if a patient receives tube feeding but it is not well tolerated, their nutritional status may not be adequate if the prescribed amount is not received. Is the patient experiencing nausea or vomiting or gastrointestinal distress? Do they have diarrhea or gastrointestinal upset from certain foods? Protein intake is important. Consulting with a dietitian to come up with a comprehensive plan for nutrition intake and dietary management of diabetes is important here. Diabetic educators are also great resources.
- Friction and shear: Is the patient able to lift themselves off the bed completely when they scoot up? Do they slide down in the bed or the chair? These patients are definitely at high risk for friction and shear. Be sure interventions are in place.
Now that we have looked at the Braden Scale and addressed each category, it is important to put appropriate interventions in place for each category to addresses the deficiencies to heal our wound successfully. Reading the definitions within the Braden Scale and addressing each appropriately are key.
After a comprehensive physical assessment, along with history, patient interview, and wound assessment, etiology should be identified and/or a plan should be put in place to identify wound etiology (e.g., biopsy). Then, a topical treatment should be selected, along with addressing the patient with a holistic approach, using the Braden Scale as a guide. Keep in mind that a patient’s Braden score can change depending on their condition and/or a change in condition. It is important to assess wounds and changes in the Braden score routinely and adjust the plan of care as needed when changes occur.
Taking an evidence-based approach with an interprofessional team, addressing the whole patient, adhering to close follow-up and adjusting the plan of care, and following standards of care are all key components in successfully healing a wound. Step number one should involve identifying and treating the etiology of the wound, and then building the rest of the treatment plan based on those findings. There are many critical components in healing, and understanding these will certainly help to provide the best outcomes and healing for our patients!
About the Author
Holly is a board certified gerontological nurse and advanced practice wound, ostomy, and continence nurse coordinator at The Department of Veterans Affairs Medical Center in Cleveland, Ohio. She has a passion for education, teaching, and our veterans. Holly has been practicing in WOC nursing for approximately six years. She has much experience with the long-term care population and chronic wounds as well as pressure injuries, diabetic ulcers, venous and arterial wounds, surgical wounds, radiation dermatitis, and wounds requiring advanced wound therapy for healing. Holly enjoys teaching new nurses about wound care and, most importantly, pressure injury prevention. She enjoys working with each patient to come up with an individualized plan of care based on their needs and overall medical situation. She values the importance of taking an interprofessional approach with wound care and prevention overall, and involves each member of the health care team as much as possible. She also values the significance of the support of leadership within her facility and the overall impact of great teamwork for positive outcomes.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.