Wound Assessment and Documentation

By Holly Hovan MSN, APRN, CWOCN-AP

As wound care professionals, the Braden Scale for Predicting Pressure Sore Risk® is near and dear to our hearts. With that in mind, our evidence-based tool needs to be used correctly to yield accurate results. Working with long-term care and geriatric populations opens up a world of multiple pre-existing comorbidities and risk factors that aren’t always explicitly written into the Braden Scale categories. Additionally, the frequency of Braden Scale use may contribute to a multitude of different scores. The resident behaves differently on different shifts, for example, being asleep on the night shift but up and about on days. What is the correct way to score these patients? I believe that a less frequent Braden Scale assessment yields more accurate results. However, we should still complete a Braden Scale on admission, during transfer, when receiving, and most importantly, with any change in condition.

By Diane L. Krasner, PhD, RN, FAAN

Scope of Practice and Standards of Practice guide nurses and other members of the interprofessional wound care team in caring for patients with wounds. Documentation in the medical record is a key aspect of the standard of practice and serves to record the care delivered to the patient or resident. Your documentation should follow your facility guideline for documentation. Accurate documentation helps to improve patient safety, outcomes, and quality of care.

This WoundSource Trending Topic blog considers general wound documentation dos and don'ts and presents 10 tips for success. Good, better, and best documentation examples are included for each tip.

By Susan Cleveland, BSN, RN, WCC, CDP

The subject of my previous blog on skin assessment was interview; here in part 2, we will look at the elements of observation. Interviewing clients and significant others can provide the clinician with valuable information related to the client’s knowledge of their situation and a historic review of skin issues or potential events. However, observation is also necessary in a comprehensive skin assessment.

Holly Hovan MSN, APRN, RN-BC, CWOCN-AP

Identifying wound etiology before initiating topical treatment is important. Additionally, correctly documenting wound etiology is significant in health care settings for many reasons. Accurate documentation and appropriate topical treatment are two critical components of a strong wound treatment plan and program. Bedside staff members should be comfortable with describing wounds, tissue types, and differentiating wound etiologies. Training should be provided by the certified wound care clinician, along with follow-up (chart reviews and documentation checks, one-on-one education as needed, and routine competency or education days). Additionally, the wound care clinician should be able to develop an appropriate treatment plan based on wound etiology, by involving additional disciplines as needed to best treat the whole patient.

By Samantha Kuplicki, MSN, APRN-CNS, AGCNS-BC, CWCN-AP, CWS, RNFA

Should pain management interventions be put in place before debriding a venous ulcer?

Without question, yes. Any comprehensive wound treatment plan must include a thorough pain assessment, accounting for cyclical and non-cyclical pain sources. This will best guide interventions based on patient’s unique history, which can potentially include complicating factors such as complex personal pain management secondary to chronic pain, inability to tolerate specific interventions because of existing comorbid conditions, limited financial or social resources, etc. Multimodal pain management is standard of care, using the least invasive options and beginning pharmacologic therapy with the lowest necessary dosage possible.

By the WoundSource Editors

Health care providers are currently faced with an all-time high of challenges and strain related to the crisis of COVID-19. They are confronted with short staffing, limited personal protective equipment supplies, delegated duties outside their role, and the worry of being infected with the virus. There are health care workers who are not living at home because of the high risk of infecting their family members and others who are quarantining themselves within their homes away from their families. As health care workers focus on working hard on the frontlines for their patients, they must also remember to take care of themselves. Learning and applying self-care practices are just as important to ensure that health care workers remain safe and healthy to optimize delivery of care for their patients.

By Holly Hovan MSN, RN-BC, APRN, ACNS-BC, CWOCN-AP

The novel coronavirus, responsible for the COVID-19 disease, has certainly impacted us all somehow. Whether you work in a hospital setting, an outpatient clinic, a doctor's office, or a specialty setting, this pandemic has altered the lives and careers of all of us in health care.

By the WoundSource Editors

Before the mid-1990s, venous disorders and disease were classified almost solely on clinical appearance, which failed to achieve diagnostic precision or reproducible treatment results. In response to this, the American Venous Forum developed a classification system in 1994, which was revised in 2004. This classification system has gained widespread acceptance across the clinical and medical research communities, and most published papers now use all or part of the CEAP system (defined in the next section). This system was once again updated in 2020.

By the WoundSource Editors

Wound healing is a complex biological process that involves a sequence of molecular and cellular events to restore damaged tissue. These events occur within the extracellular matrix, a complex three-dimensional acellular environment that is present within all tissue and essential for life. Remodeling within this extracellular matrix is necessary for tissue repair throughout the wound healing process, including during the inflammatory phase.

By the WoundSource Editors

Necrotic wounds are characterized by devitalized, or dead, tissue. Necrosis may be caused by malignancy, infection, trauma, ischemia, inflammation, or exposure to toxins. It may also be caused by improper care of an existing wound site. Devitalized tissue has no blood supply, and its presence prevents wound healing. It is necessary for necrotic tissue to be removed to allow wound healing to occur.