Wound Assessment

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

By Holly M. Hovan, MSN, GERO-BC, 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.

Diane Krasner's picture
wound care documentation

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.

Susan Cleveland's picture

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's picture

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.

WoundSource Practice Accelerator's picture

Aseptic: Aseptic surgical procedures are those that aim at eliminating the risk of transmission of all harmful microorganisms. Aseptic practices can prevent the cross-contamination of pathogens.

Bioburden: The number of microorganisms within a wound is referred to as bioburden. Bioburden management is crucial in post-operative care to prevent infection.

Cellular/tissue-based products: These are products, commonly derived from cadavers or other human and other animal cells, that can aid in closing dehisced surgical wounds by providing a substitute for the skin to act as a barrier while healing.

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WoundCon Faculty's picture

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.

WoundSource Editors's picture

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.

Becky Naughton's picture
Calciphylaxis

By Becky Naughton, RN, MSN, FNP-C, WCC

Picture this: you've been seeing a patient in your wound center for the last several months to treat a slowly healing post-operative abdominal wound. The wound has been gradually responding to an assortment of treatments, including initial wound vacuum therapy after the surgery, followed by alginate and now a collagen dressing. The wound is getting smaller and has new granulation tissue at the base. You're actually a bit surprised that it's healing so nicely because the patient has multiple serious chronic illnesses, including severe chronic kidney disease that requires hemodialysis sessions three times per week, type 2 diabetes, morbid obesity, cardiovascular disease, and peripheral vascular disease.

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The Inflammatory Phase of Wound Healing

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.

WoundSource Editors's picture
Burns

Burns occur when the skin comes into contact with a heat source or caustic substance, commonly fire or flames, boiling liquid, hot objects, electrical current, or chemical agents. Different mechanisms of injury that can cause a burn include scalding, fire, chemical exposure, electrical exposure, and radiation. The extent of injuries that can occur from a burn is highly variable, and morbidity and mortality tend to increase as the surface area of the burn increases. Proper classification of burns is essential in guiding the initial management of the burn wound and achieving optimal outcomes.