Wound Assessment and Documentation

WoundSource Practice Accelerator's picture
pressure injury risk assessment

By the WoundSource Editors

Pressure ulcers/injuries pose a major risk to patients by increasing morbidity and mortality and causing significant discomfort.1 They are also prevalent, particularly in long-term care facilities, where patient populations may be at higher risk of developing pressure injuries as a result of factors of age, immobility, and comorbidities.2 To reduce the incidence of pressure injuries effectively, nurses and other health care professionals should be aware of the risk factors and the means to evaluate patients. This will allow caregivers to take steps to prevent problems before they develop and treat them more effectively if they do.

Holly Hovan's picture
Moisture on Skin

By Holly Hovan MSN, APRN, CWOCN-AP

When nurses hear the term moisture, they usually almost always think of urinary or fecal incontinence, or both. There are actually several other reasons why a patient could be moist. Continued moisture breaks down the skin, especially when the pH of the aggravating agent is lower (urine, stomach contents—think fistula, stool). When there is too much moisture in contact with our skin for too long, we become vulnerable to this moisture, and our skin breaks down. Increased moisture places a patient at risk for a pressure injury as the skin is already in a fragile state.

WoundSource Editors's picture
Surgical wound drainage

By the WoundSource Editors

In normal wound healing, exudate plays an important role in allowing the migration of cells across the wound bed, facilitating the distribution of growth and immune factors vital to healing. Managing wound drainage involves making sure that exudate production is not too much or too little, and making sure the exudate does not have pus which would indicate an infection. Proper wound drainage management improves the patient's quality of life, promotes healing, and enhances health care effectiveness.

WoundSource Editors's picture
wound healing

By the WoundSource Editors

Promoting the wound healing process is a primary responsibility for most health care practitioners. It can take 1-3 days for a closed wound to actually establish a seal. Infections usually occur in 3-6 days but may not appear for up to 30 days, according to the CDC guidelines for preventing surgical infections. The wound healing process can be seen as an overlapping healing continuum, which can be divided into four primary phases:

Holly Hovan's picture
neuropathy testing for sensory perception (Braden Scale)

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 in order 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 the Braden Scale may also contribute to a multitude of different scores; the resident behaves differently on different shifts, for example, asleep on night shift but up and about on days. What is the correct way to score them? I believe that a less frequent Braden Scale assessment yields more accurate results. However, we should still complete a Braden Scale on admission, transfer, receiving, and most importantly, with any change in condition.

Holly Hovan's picture
comparison

By Holly Hovan MSN, APRN, CWOCN-AP

As wound care clinicians, we are aware that part of the process of consulting requires a comprehensive wound assessment, looking at wound characteristics, causative factors, and drainage. As I've previously mentioned, we've all heard the term, "a dry cell is a dead cell." However, not all wounds are dry.

Janet Wolfson's picture
compression therapy for lymphedema

By Janet Wolfson PT, CLWT, CWS, CLT-LANA

The intersection of wounds and lymphedema has been on my mind this week as challenging patients and a new reduction garment cross my dual specialty life. One patient with chronic swelling with weeping for more than a decade, another referred a few days before discharge who will need a few weeks Complex Lymphatic Therapy and a reduction garment that he and his spouse can manage for showering. Still another experiencing light weeping, chronic edema and is post-heart failure. They are all inpatient rehab clients attempting to improve their mobility and self care enough to go home. So, the wish list for reduction compression and absorbent wound care products needs to fit some special needs.

Cheryl Carver's picture
pressure-injuries

By Cheryl Carver LPN, WCC, CWCA, CWCP, FACCWS, DAPWCA, CLTC

Incorrect staging of pressure injuries can cause many types of repercussions. Incorrect documentation can also be worse than no documentation. Pressure injuries and staging mistakes are avoidable, so educating clinicians how to stage with confidence is the goal.

Janet Wolfson's picture
patient interview questions

By Janet Wolfson PT, CLWT, CWS, CLT-LANA

I was recently listening to one of my favorite news sources, NPR, enjoying an interview with James E. Ryan, the author of "Wait, What? - and Life's Other Essential Questions". The premise was that asking the right questions can lead to a happier and more successful life. A physician called in to relate that this was something he had been doing in his medical practice. I couldn't have agreed more – the questions I ask my patients (and then listening to their answers) can go a long way toward making an intervention in their health care more successful.

Janet Wolfson's picture
delayed wound healing

By Janet Wolfson PT, CLWT, CWS, CLT-LANA

Delayed wound healing: how did it start, what are we doing to prevent delay, and what could we be doing differently when delay is noted?