Wound Assessment and Documentation

By Girisha Maheshwari, Pavan Mujawdiya, and Shivani Gupta

Chronic wounds and their management pose a serious challenge to clinicians worldwide and are one of the major public health challenges faced by developing countries. Worldwide, over 40 million people develop chronic wounds, which adversely affects their quality of life. However, epidemiological studies concerning chronic wounds and their management are limited, especially in developing countries. According to the largest community-based epidemiological study on wounds in India by Gupta et al., the estimated prevalence of chronic and acute wounds is 4.48/1000 and 10.5/1000 in India. This study is more than a decade old, and there is no recent data available in the public domain. The lack of organized wound data makes it difficult to formulate new therapeutic strategies, create effective health care policies, or offer efficacious treatment options. Complex wounds take time to heal, and if they are not identified at the earliest stage, the treatment process may be complicated.

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.

As health care professionals monitor the wound drainage of a patient, it is critical to be able to recognize the different types of wound drainage. Open wounds and incision wounds may both present varying types of exudate, some of which are perfectly healthy and others that can signal an infection or slow healing. Identifying wounds that need a change in care can speed the healing process. Here are the four main types of wound drainage health care professionals need to know:

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When assessing and documenting a wound, it is important to note the amount and type of wound exudate (drainage). Using our senses is a large part of the initial wound assessment, followed by accurate documentation. Wound exudate or drainage gives us significant information about what is going on with the wound, all the way down to a cellular level, and it is one of the wound components that guide our topical treatments. As mentioned in prior blogs, a dry cell is a dead cell, but a wound with too much moisture will also have delayed healing. Additionally, infection, poor nutrition, impaired mobility, impaired sensory perception, and even malignancy in the wound can impair the healing process.
In acute wounds, drainage typically decreases over several days while the wound heals, whereas in chronic wounds, a large amount of drainage is suggestive of prolonged inflammation with failure to move into the proliferative phase of wound healing. An increase in drainage with malodor can be an indication of infection and should be treated appropriately based on the overall picture and goals of wound care.
There are many different types, consistencies, colors, and characteristics of wound drainage. In this blog, we discuss the most common types and what they could mean.

By Temple University School of Podiatric Medicine Journal Review Club

The treatment of wounds has advanced significantly over the years and has involved a variety of therapy options, but the percentage of wounds that heal after 12 weeks remains at a mere 40%. One idea to improve wound healing is to improve diagnostic imaging of wounds, similar to the technological advances seen in many other specialties. Wound healing is costly, especially given that many wounds are hard to heal or there is difficulty in identifying the best course of treatment for the wound. If the current wound healing treatments show minimal improvement in four weeks and there are still thousands of bacteria-forming units on the wound, the clinician should re-evaluate the therapies being utilized and consider a change in treatment.

By Temple University School of Podiatric Medicine Journal Review Club

A diabetic foot ulcer (DFU) is a wound that has a higher risk of becoming chronic, leading to amputation and, in some cases, even death. Currently, the Wagner and Texas classification are used worldwide to assess the extent of diabetic foot lesion. The authors of this article believe that there is a lack of wound treatment principles based on both classification systems. In the article, they have summarized the STAGE principles of wound treatment for clinical practice based on the Wagner and Texas classification system. The STAGE principle refers to surgical intervention during wound treatment of a DFU. With a focus on the anatomical layers of the wound, the management of blood supply, layer by layer incision to the infected area, maintenance of adequate wound drainage, and step by step treatment of the wound. STAGE is the management of an ulcer through its anatomical layers. Skeleton, Tendon, Angiogenesis, Granulation, and Epithelialization.

By Holly M. Hovan, MSN, GERO-BC, APRN, CWOCN-AP

Wound assessment is one of the initial steps in determining the plan of care, changes in treatment, and the choice of key players in wound management. However, wound assessment needs to be accurately understood and documented by frontline staff to paint a true picture of what is happening with the wound.

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 the wound, as a teaching resource to both patients and new clinicians, and to encourage the use of evidence-based practices. In providing wound care from a distance such as through telewound services, wound photos are taken to help in diagnosis and treatment. The quality of the photo may vary depending on the person taking the photo (clinician, caregiver, patient). However, the emphasis is on using the photo in conjunction with the patient’s clinical wound descriptions and medical history, thereby evaluating the wound, treatment plan, and healing progress. Clinical documentation is a legal, moral, economic, and professional responsibility. Wound photos supplement the written record but should never replace it. Despite the value of wound photography, not all health care settings provide wound photo documentation software or include this as a part of their wound care policies and procedures. The facility or agency should always discuss this issue with the risk manager or legal counsel because each state has its own rules on the use of images.

Benchmarking: Benchmarking is using published wound outcomes reported by others as a framework within which to assess your facility’s outcomes and potential need for improved care.

Chronic wound: A chronic wound is a wound that has failed to progress towards healing in 30 days or more. There are varying factors that can cause a wound to stall, such as infection or a prolonged inflammatory phase. It is important to document the wound’s progress, any stalling factors, and interventions put into place to restart the healing cascade.

Digital wound measuring tool: Digital wound measuring tools include devices that may provide two- or three-dimensional assessment (length, width, depth, surface area) of a wound with electronic medical record software integration and may not require physical contact.