Wound Assessment,

Assessment
Documentation &
Management
HHC Health & Home Care

Susan G
G. Roque RN
RN, CWCN
CWCN, MSCH

Obj ti
Objectives
z
z
z
z
z
z
z

Describe the three phases of healing

List six elements to include when assessing and
documenting wounds
D
Describe
ib th
the ffour titissue ttypes ffound
d iin th
the wound
d
bed
Differentiate pressure ulcer stages as defined by
NPUAP
Define surgical wound and stasis ulcer using the
OASIS definition
Identify wound classification/etiology
List appropriate wound management that provide
moist wound healing

I t d ti
Introduction
z

Wound Assessment is Very Important Key to

Success
z
z
z
z
z

Drives the care plan in motion

R
Response
tto OASIS items
it
Impact on reimbursement
Determines necessary resource utilization
Quality Indicators depend on accurate/consistent
assessment
Emergent Care for Wound Infection, Deteriorating Wound
Status
Increase in Number of Pressure Ulcer
Improvement in Number of Surgical Wounds
Discharge to Community Needing Wound Care

I t d ti
Introductioncont
t
z

Wound Care Management is Goal Oriented

Interventions
z
z

z
z
z

To promote or complete wound healing

To discharge patient with patient or caregiver
demonstrate knowledge and competency
To keep free of infection
To prevent rehospitalization
To prevent skin breakdown

Two Primary Layers of the

Skin
Ski
z

Epidermis outermost layer

z < 1mm thickness, avascular
z Regenerates on average every 28-30 days
z Melanocytes produce and distribute melanin, the
brown pigment of skin
z Langerhans cells first line of defense against
environmental antigens
Dermis innermost layer supports & nourishes epidermis
z Collagen, fibroblast
z Extra cellular matrix formation

Anatomy:
y Human Skin

Ski St
Skin
Structure
t

M j Functions
Major
F
ti
off the
th Skin
Ski
z
z
z
z
z

Protection UV light
light, outside contamination
Thermoregulation & Excretion regulates
body temperature
Sensation pain, touch, temperature and
pressure
Metabolism vitamin D synthesis in
presence of sunlight
p
g
Communication body image

Ski A
Skin
As W
We A
Age

Skin as We Age
z
z
z
z
z

Easily traumatized
Decrease in sebaceous glands
g
Decrease in immune response
Changes
g in thermoregulation
g
Less elasticity

T
Types
off Wound
W
d Healing
H li
1
1.

Primary - Surgical Closed

Edges approximated
L
Lowers
risk
i k off iinfection
f ti
Involves little tissue loss/defect
Heals with minimal scarring

T
Types
off Wound
W
d Healing
H li
2
2.

Secondary
Chronic wounds e.g.: Pressure ulcers,
Surgical wounds that are left open and
allowed to heal by production of scar
tissue
a.
b.
c.
d.

Edges not approximated

Greater tissue loss
Higher risk of infection
Longer healing times

T
Types
off Wound
W
d Healing
H li
3.

Tertiary
T
ti
AKA delayed
d l
dP
Primary
i
IIntention
t ti
(delay between injury and closure)

Surgical wounds left open for 3-5 days

Provides time to decrease edema or infection
Closed with sutures, staples or adhesive skin
closures
Heals with more scar tissue than primary

Three Phases of Wound

Healing
z

Inflammatory Phase reactive phase

z
z

4-6 days of cellular infiltration

Phagocytosis neutrophil remove
necrotic tissue, macrophage ingest
b t i activate
bacteria,
ti t WBC to
t release
l
growth
th
factors
Vasodilation WBC release inflammatory
factors, blood vessels dilate

I fl
Inflammatory
t
Phase
Ph
z

z
z
z

Local
erythema
Edema
Tenderness
Increased
wound
drainage
g
Process time
varies

Three Phases of Healingcont

z

Proliferative Phase regenerative phase

4 - 24 days for normal non-infected wounds
z Fills the wound with connective tissue
(
(granulation)
l ti )
z Contracts the wound edges (contraction)
z Covers the wound with epithelium
Fibroblasts cellular proliferation, synthesize
collagen, release growth factors
Angiogenesis formation of new blood vessels
Granulation major tissue fills wound bed
(connective)
z

Proliferative Phase
z

Regeneration or connective tissue

phase last several weeks
Granulation tissues forms red beefy
buds or granule tissues
G
Granulation
l ti off titissue, fib
fibroblast
bl t
stimulate the production of collagen
Margins pull together, decreasing the
wound size

Proliferative Phase
z

Granulation

Proliferative Phase
z

Contraction

Proliferative Phase
z

Epithelialization - deep pink to pearly pink

pink,
light purple from edges in full thickness wounds
or may form islands of superficial wounds

Th
Three
Phases
Ph
off Healing
H li
cont
z

Maturation Phase remodeling phase

z

z
z

Remodeling collagen fibers rearrange,

contraction and cell migration into the wound
Increase tensile strength
Scar tissue formation

Maturation Phase
z

Remodeling
R
d li phase
h
lasts 21 days to months
or years
Process continues until
the scar tissue has
regained about 80% of
the skin original
strength

W
Wound
d Healing
H li
Cascade
C
d

Defensive - Inflammatory
Maturation
Remodeling

Proliferative/
Fibroblastic
Granulation

Wound Assessment, Documentation

& Management
z

Information Collection
z

z
z
z
z
z

Head to Toe Skin

Assessment
P ti t History
Patient
Hi t

Type/Classification of
Wound
Wound Etiology
Location
Measurement
Appearance, Shape
Pain

Overall Physical Health

z
z

z
z
z
z

Risk Assessment
Identify Causative Factors,
Co-morbidity
Co
morbidity

Nutritional and Hydration

Status
Psychosocial Health
Vascular Status
Environmental and
Caregiver Issues

Whats wrong with this patient?

Wound Location
z

The wound location

should be precisely
identified
Use directional terms
such as left or right,
medial or distal, and
the correct anatomic
location
Buttocks: sacral,,
coccyx, ischium,
trochanteric, etc.
Abdomen: RLQ
RLQ, RUQ
RUQ,
Suprapubic, etc.

Wound Dimensions/Size
z
z

Length head to toe dimension

Width side to side; greatest width
perpendicular to the length
Depth from visible to the deepest area

W
Wound
d Di
Dimensions
i
z

To determine the wounds

wound s depth,
depth insert a
sterile cotton tipped applicator into the
deepest
p
p
part of the wound bed,, g
grasp
p the
applicator at skin level, and then measure the
applicator
pp
from its tip
p to yyour fingers
g

Wound Base
z

Healthy Tissue
z
z
z

Granulation red/pink and beefy appearance

Epithelialization
Epithelial bridging

Necrotic tissue
z
z

Slough yellow, tan

E h black,
Eschar
bl k b
brown

G
Granulation
l ti
& Epithelialization
E ith li li ti
z

Granulation moist,
moist
berry like red or pink

Epithelial tissue dry,

deep pink to pearly
pink,, light
p
g p
purple
p from
edges in full thickness
wounds or may form
islands of superficial
wounds

M
Muscle,
l Tendon
T d
and
d Bone
B
z

Muscle pink to dark

red, firm, highly
vascular

Tendon covering over

muscles shiny white,
thin to thick, contains
muscle or muscle group

Bone

Eschar and Slough

g

Wh t is
What
i Tunneling?
T
li ?
z

Tunneling is a course or pathway that can

extend in any direction from the wound and
results in dead space with potential for
abscess formation
Also called sinus tract

What is Undermining?
g
z

Area of tissue destruction underlying

intact skin along the wound margins
z
z
z
z
z

Space between the surrounding skin and

the wound bed
Usually involves significant portion of
wound edge
May extend entirely around wound
Subcutaneous fat necrosis
Usually indicates aerobic and anaerobic
bacteria are present

How to Measure Tunneling

&U
Undermining
d
i i
z

Apply a cotton-tipped
cotton tipped
applicator gently to
measure depth in
centimeters
Describe the location
using the face of a
clock, with 12 oclock
at the patients head
and 6 oclock at the
patients
patient
s feet

Wound Shape
p & Edges
g
z
z
z
z
z
z
z
z
z

Irregular
Round
Oval
Crater-like
Punched-out
Punched
out
Intact (or not)
Callous
Macerated
Desiccated

W
Wound
d Edgescont
Ed
t
z
z
z

Attached / unattached
Fibrotic / firm
Rolled / curled under /
epibole

Periwound Skin
z

4 cm of the wound edges

z

Edema
Pitting
z Non
N pitting
itti
z

z
z
z
z
z
z

Induration
Erythema
Periwound Pain
Maceration
R h
Rash
Absence of hair

P i
Periwound
d Skincont
Ski
t
z
z

Intact, irritated,
Intact
irritated yeast cellulites
Presence of foreign bodies sutures, drain
tubes staples
tubes,
staples, environmental debris (wood
(wood,
metal, dirt, bone/metal)
Erythema redness irritation, dermatitis,
demarcated borders, red streaking. In dark
skin, may appear purple or a gray hue or
d
deepening
i off th
the ethnic
th i skin
ki color
l
Dry skin

W
Wound
dE
Exudate
d t
z
z

WOUND ODOR
Clean or irrigate wound
with NS
N t th
Note
the presence or
absence of odor

WOUND DRAINAGE
Describe exudate:
z
z
z

Amount
C l
Color
Types
z Serous clear to straw
z Serosanguinous slightly
bloody
z Sanguineous - bloody
z Fibrinous composed of
fibrin and cells
z Purulent thicker,
opaque and colorful

Wound Exudate Characteristics

Exudate Type

Color

Consistency

Significance

Sanguineous/
Bloody

Red

Thin, watery

Indicates low blood vessel

growth
th or di
disruption
ti off
blood vessels

Sero-sanguineous
g

Light
g
red to
pink

Thin, wateryy

Normal during
inflammatory and
proliferative phases of
healing.

Serous

Clear,
light
color

Thin, watery

Normal during
inflammatory and
proliferative phases of
healing.

Seropurulent

Cloudy, Thin, watery

yellow
to tan

May be first signal of

impeding wound infection

Purulent/pus

Yellow,
tan, or

Signals wound infection;

may be associated with

Thick, opaque

M
Measuring
i P
Pain
i
z

Note the presence or absence of pain in the

wound or periwound area
A k the
Ask
th patient
ti t to
t rate
t the
th pain
i on a scale
l off
0-10, with 0 indicating no pain and 10 severe
pain
7 to 10 is mitigating pain

Classification of Wounds by:

y
ACUTE
z
z
z

Usually
U
ll trauma
t
or surgery
Heals quickly through a
well orchestrated process
3 phases of healing with
limited local care
z Hemostasis (0-3
hours)
z Inflammatory (0 to 3
d
days)
)
z Proliferative (321days)
z Maturation (21 days1.5 years)

CHRONIC
z
z

Healing not timely or

orderly
Longer healing time due
to
z Pressure
z Inflammation
z Poor nutrition
z Disease
z Poor circulation
Mayy require
q
active wound
treatment to heal

CHRONIC WOUNDS
z

Most Common Etiology

z Pressure
z Neuropathic - diabetic
z Venous insufficiency
z Arterial
z Infected Surgical Wound
z Dehisced Surgical Wound
z Others: Malignancy,
g
y
Vasculitis, Fistula,
Pyoderma Gangraenosum

W
Wound
d Classification
Cl
ifi ti
by
b Depth
D th
Partial-thickness
Partial
thickness - loss of
epidermis and possible
partial loss of dermis
z Shallow wounds
z No granulation tissue
z Dermal
D
l repair
i with
ith
epithelial tissue
z Healing is rapid in clean
partial-thickness

Full Thickness - tissue

destruction extending
through the dermis to
involve the subcutaneous
layer and possibly muscle
z

Fill with granulation

tissue

Wound contraction

Epithelialization

S
Surgical
i l Wound
W
d Complications
C
li ti
z
z

Post-op
Post
op Infection
Wound Dehiscence acute wound failure,
wound
d di
disruption,
ti
abdominal
bd i l wound
d
separation
z
z
z

Occurs by the 5th and 8th day postoperative

About half are associated with infection
Other risk factors: Obesity,
Obesity Pulmonary disease,
disease
Hypoproteinemia, Hypertension, DM

N
Nursing
i
A
Assessment
t
z
z

OASIS Items for CHHA and Long Term Patient

Assess incision site for any signs and symptoms of
infection
z
z
z
z
z
z
z

Redness
Fever
Heat
Elevated WBC
Purulence
I
Increase
drainage
d i
assess dressing
d
i ffor signs
i
off oozing
i
Odor
Changes in wound appearance and surrounding tissue
M
Measure
wound
d iincision
i i

Wound Care Sheet use to document progress and

non progress of wound status

M1340 Does this patient have

a Surgical Wound?
z
z

No
Yes, patient has at
least on (observable)
surgical wound
Surgical wound known
but not observable due
to non-removable
dressing
z

Cast or dressing per

physician order

What is a Surgical Wounds &

What is Not?
z
z
z
z
z
z

Orthopedic pin sites

Central line sites
Stapled
p
or sutured
incisions
Wound with drains
M di
Medi-port
t sites
it
Implanted infusion
devices or venous
access devices
I & D with excision

8
8
8
8
8
8
8

Cataract surgery
Surgery to the mucosal
membranes,
Gynecological surgical
procedure via vaginal
Ostomies
PICC line
Simple I & D
Debridement or
placement of skin graft

M1342 Status of Most Problematic

(Observable) Surgical Wound
z
z

Most problematic largest, most resistant to

treatment, or an infected surgical wound
Identifies the degree of healing
z
z
z
z

Newly epithelialized incision well approximated, complete

ep e a a o
epithelialization
Fully granulating no s/s of infection, no dead space, no
avascular tissue
Early/partial granulation minimal avascular tissue
tissue, wound
edges open
Not healing - >25% avascular tissue, closed edges,
incisional separation
separation, s/s of infection

Pl and
Plan
d Interventions
I t
ti
z

z
z

Leave dressing undisturbed for 24 to 48 hours after

surgery
Wound may be left uncovered after 48 hours after
surgery
Pain relief as needed
Provide information to patient/caregiver related to
wound healing process and signs and symptoms of
wound
d complications/infection
li ti
/i f ti
Provide emotional support related to reason for
surgical procedure

S
Surgical
i l Wound
W
d Initial
I iti l Visit
Vi it

Surgical Wound Post Removal of

R t ti Sutures
Retention
S t
on VAC
Therapy

Surgical Wound 3 weeks VAC

Therapy
Th

Surgical
g
Wound 4 weeks post
p
VAC

P
Pressure
Ulcers
Ul
z

Compression mechanical injury

z

Circulation capillary vessels collapse

z

Soft
S
ft tissue
ti
compressed
d between
b t
two
t
hard
h d
surfaces
impaired, decreasing the supply of oxygen and
nutrients which results in tissue death

Injury
z

begins in deep tissues

External Factors:
Pressure
Shear
Friction
Maceration

Pressure Points
SITTING POSITION

SUPINE POSITION

Occiput Scapula Sacrum

36 9%
36.9%
1 3%
1.3%
2 4%
2.4%

Heels
30 38%
30.38%

LATERAL PRESSURE
Ischium 8%

Elbow
6 9%
6.9%

Trochanter Knee
6%
5.1%

Malleolus 6.1%

Piper B. Mechanical Forces: Pressure, Shear, and Friction. In Bryant & Nix (Eds.) Acute and Chronic Wounds:
Current management concepts (3rd Ed.) Mosby. 2007

Braden Scale For Predicting Pressure

Ulcer Risk
z

Six Subscales: sensory perception

perception, moisture
moisture,
activity, mobility, nutrition, friction & shear

Four Severity: 1. completely limited, 2. very limited,

3. slightly limited, 4. no impairment

The intensity and duration of pressure

z

Sensory perception, mobility, activity

Tissue intolerance for pressure

z

M i
Moisture,
nutrition,
ii
ffriction/shear
i i / h

Mechanism Of Pressure Ulcer

P
Progression
i
off Pressure
P
Ulcer
Ul

M1300 Pressure Ulcer Assessment: Was

this patient assessed for Risk of
Developing Pressure Ulcers?
z
z

0 - No assessment conducted [ Go to M1306 ]

1 - Yes, based on an evaluation of clinical factors,
e.g., mobility, incontinence, nutrition, etc., without
use of standardized tool
2 - Yes, using a standardized tool, e.g., Braden,
Norton,, other
Always
answer #2

M1302
(M1302) Does this patient have a Risk of
Developing Pressure Ulcers?
z
z

0 - No
1 - Yes
Remember!
A score of 18 & below
requires intervention
to prevent pressure
ulcers

62

If Patient High Risk, Did Intervene

& IImplement?
l
t?
z

Restorative Nursing
z Incontinence Management (skin care, moisture barrier, absorbent
pads or diapers, offer bedpan/urinal, increase water intake)
z Bladder/Bowel Training
z Pressure Ulcer Prevention/Management
/
z
z

Turning & Positioning, Prevent Friction and Shear

Pressure Reduction Support Surface

Rehabilitation Orders
z Improve Mobility
z Transfer/Positioning
Pressure Ulcer Management
z Moist Wound Healing
z Wound Bed Preparation
z Nutrition

M1306 - Does this patient have at least one

unhealed Pressure Ulcer at stage 2 or Higher or
designated as unstageable?
z

Depth must be visible to accurately stage

z Answer No or (Go to M1322)
z Yes (for stage 2,3,4, all unstageable PU)

Select NO if
z
z
z

The patient only has a stage 1

Stage 2 pressure ulcer has healed and
There are no other pressure ulcers

Remember! Stage 3 and 4 can never be considered fully healed.

They may be closed, the wound surface is covered with new
epithelial tissue
tissue.

M1307 - The Oldest Non-epithelialized

Non epithelialized Stage II
Pressure Ulcer that is present at discharge
z

1 - Was present at the most recent SOC/ROC assessment

2 - Developed since the most recent SOC/ROC assessment:

record date pressure ulcer first identified:
__ __ /__ __ /__ __ __ __
month / day / year
NA - No non
non-epithelialized
epithelialized Stage II pressure ulcers are present at
discharge

65

St
Stage
2P
Pressure Ul
Ulcer
z

z
z

Partial thickness loss of

dermis presenting as a
shallow open ulcer with a
red or pink wound bed
Without slough
An intact or open/ruptured
serum- filled blister
Can only heal by the
process of
epithelialization

Epithelialization is the
process of regeneration
of the epidermis across
a wound surface

M1308 Current Number of Unhealed (nonepithelialized)

ith li li d) Pressure
P
Ulcer
Ul
att Each
E h Stage
St
(Enter 0 if none; excludes Stage 1 pressure ulcers)
Column 1
Completed at
SOC/ROC/FU & D/C
Stage Description- Unhealed pressure ulcer
a. Stage II
b. Stage III
c. Stage IV

d. 1 Unstageable: Known or likely but

unstageable due to non-removable dressing or
device

Number Currently
Present

-------------

d. 2 Unstageable: Due to coverage of wound

bed by slough and/or eschar

----

d. 3 Unstageable: Suspected deep tissue

injury in evolution

----

St
Stage
3P
Pressure Ul
Ulcer
z

z
z

Full thickness tissue

loss
Subcutaneous fat may
be visible but bone,
tendon or muscle are
nott exposed
d
Slough may be present
M include
May
i l d ttunneling
li
and undermining

St
Stage
4P
Pressure Ul
Ulcer
z

Full thickness tissue

loss with exposed
bone, tendon, or
muscle
Slough or eschar may
b presentt on some
be
parts of the wound bed
Often include
undermining and
tunneling
g

U t
Unstageable
bl Pressure
P
Ulcer
Ul
z

Full thickness tissue

loss in which the base
of the ulcer is covered
by slough (yellow, tan
gray, green, or brown)
and/or eschar (tan
(tan,
brown, or black) in the
wound bed

S
Suspected
t d Deep
D
Ti
Tissue Injury
I j
z
z

Purple or maroon bruising

Blood-filled blister due
to damage of
underlying soft tissue
from p
pressure and/or
shear
Painful, firm, mushy,
boggy warmer or
boggy,
cooler as compared to
adjacent tissue

Suspected Deep Tissue Injury

Evolution
z

z
z

Pressure related
injury to
subcutaneous tissue
under intact skin
Initially these lesions
Initially,
have the appearance
of a deep bruise
Can deteriorate
quickly
May lead to
development of
St
Stage
III or IV
pressure ulcer, even
under optimal
treatment
Black J. Adv.in Skin & Wound Care 2005;18(8):415-421

M1308 at Recertification and

Di h
Discharge
z
z

Step One Answer Current wounds first

Step Two If there is a wound in column1
z
z
z

Check to see when the ulcer originated

If present at SOC or ROC include that wound in
column 2
If after SOC or ROC do not include in column 2

Step Three If there is a 0 in column 1 then

make sure there is a 0 in column 2

M1308 Current Number of Unhealed (nonepithelialized)

ith li li d) Pressure
P
Ulcer
Ul
att Each
E h Stage
St
(Enter 0 if none; excludes Stage 1 pressure ulcers)

Stage Description- Unhealed pressure ulcer

a. Stage II
b. Stage III
c. Stage IV
d. 1 Unstageable: Known or likely but
unstageable due to non-removable
dressing or device
d. 2 Unstageable:
g
Due to coverage
g of
wound bed by slough and/or eschar
d. 3 Unstageable: Suspected deep tissue
injury in evolution

Column 1
Completed at
SOC/ROC/FU & D/C

Column 2
Complete at FU & D/C

Number Currently Present

Number of those listed in

Column 1 that were present
on admission (most recent
SOC/ROC)

0
0
1
0

0
0
1
0

0
1

0
0

Directions for M1310, M1312 and M1314

If the patient has one or more unhealed (non-epithelialized)
Stage III or IV pressure ulcers, identify the Stage III or IV
pressure ulcer with the largest surface dimension (length x
width) and record in centimeters. If no Stage III or Stage IV
pressure ulcers, go to M1320

Length Head to Toe

Width Side to Side

75

M1320 - Status of Most Problematic

(Observable) Pressure Ulcer:
z
z
z
z
z

0 Newly epithelialized
1 Fully granulating
3 Early/partial granulation
4 Not healing
NA No observable ulcer
Identifies the degree of closure visible in the
most problematic observable pressure ulcer,
stage
t
2 or hi
higher
h

P
Pressure
Ulcer
Ul
Initial
I iti l visit
i it

Pressure Ulcer Post Surgical

D b id
Debridement
t

Pressure Ulcer Post

H d
Hydrogel
l Dressing
D
i
3x
3 a Week
W k

M1322 Current Number of

St
Stage
1P
Pressure Ul
Ulcers
z

Intact skin with nonblanchable redness

over a bony
prominences
i
Difficult to detect in
individuals with dark
skin tones
May not have visible
blanching; color may
differ from surrounding
area

On OASIS
OASIS, a stage 1 &
2 pressure ulcer status
of healing is nonh li
healing

S
Scenarios
i
1
1.

You are completing a Recertification OASIS

OASIS. Mrs
Mrs.
Negron still has one stage 2 PU that was present
at SOC. A fully epithelialized stage 3 at SOC is
now a stage
t
4 PU.
PU Answer
A
M1308 C
Currentt
Number of Unhealed Pressure Ulcers.

2.

How would you complete M1308 Current Number

of Unhealed Pressure Ulcers if Mrs. Negron now
has a new DTI on her right heel? What
implications does this have for our patient? Our
agency quality measure?

M1308 Current Number of Unhealed (nonepithelialized)

ith li li d) Pressure
P
Ulcer
Ul
att Each
E h Stage
St
(Enter 0 if none; excludes Stage 1 pressure ulcers)

Stage Description- Unhealed pressure ulcer

a. Stage II
b. Stage III
c. Stage IV
d. 1 Unstageable: Known or likely but
unstageable due to non-removable
dressing or device
d. 2 Unstageable: Due to coverage of
wound bed by slough and/or eschar
d. 3 Unstageable: Suspected deep tissue
injury in evolution

Column 1
Completed at
SOC/ROC/FU & D/C

Column 2
Complete at FU & D/C

Number Currently Present

Number of those listed in

Column 1 that were present
on admission (most recent
SOC/ROC)

1
0

1
0

1
0

1
0

0
0

0
0

M1308 Current Number of Unhealed (nonepithelialized)

ith li li d) Pressure
P
Ulcer
Ul
att Each
E h Stage
St
(Enter 0 if none; excludes Stage 1 pressure ulcers)

Stage Description- Unhealed pressure ulcer

a. Stage II
b. Stage III
c. Stage IV
d. 1 Unstageable: Known or likely but
unstageable due to non-removable
dressing or device
d. 2 Unstageable:
g
Due to coverage
g of
wound bed by slough and/or eschar
d. 3 Unstageable: Suspected deep tissue
injury in evolution

Column 1
Completed at
SOC/ROC/FU & D/C

Column 2
Complete at FU & D/C

Number Currently Present

Number of those listed in

Column 1 that were present
on admission (most recent
SOC/ROC)

1
0
1
0

1
0
1
0

0
1

0
0

Pressure Ulcer Process Measures

M1300 SOC/ROC Was the patient assessed for
Risk of Developing Pressure Ulcer?
M2250 SOC/ROC Does
D
th
the physician
h i i ordered
d d
plan of care including interventions to prevent
Pressure Ulcer
M2400 Transfer/Discharge Were the following
interventions BOTH included in the physicianphysician
ordered POC and implemented?

P
Processes
Measured
M
d in
i OASIS C

Care Plan
I l
Implementation
t ti
Education
Prevention

Timely
Ti l Care
C
Assessment

Care Planning
Care Coordination

MD Communication
C
i ti
z
z

Referral
Report of Assessment Findings
z
z
z

z
z

60 Day Summary - summary of all care and

outcomes during past 60 days
Verbal Orders
z

Parameters
Change in Condition/Status
Lab work test results

Change of treatment, medications, additional discipline

including visit frequency, duration and interventions

Coordination Notes and Interim Order if needed

P
Pressure
Ulcer
Ul
Management
M
t
z

Address causative factors relieve pressure,

pressure avoid
friction and shear
z
z
z

Skin care
z
z

z
z

Support surface
Lift sheet, overhead trapeze
Turning and positioning, maximize mobility
Incontinent care, bladder/bowel training
Moisture barrier

Nutrition
N
t iti Protein,
P t i iincrease calorie,
l i supplement
l
t
with multivitamin (Vit A, C & E), zinc
Wound care Moist wound healing

W
Wound
d Management
M
t Principles
Pi i l
z

Control or Eliminate Causative Factors

z
z
z

Pressure, Shear, Friction Moisture

Circulatoryy Impairment
p
Neuropathy

Provide Systemic Support to Reduce Existing

and Potential Cofactors
z
z
z

Nutritional and Fluid Support

Edema
Control of Systemic Condition Affecting Wound Healing
z i.e., blood glucose

Wound Management
Pi i l
Principles
cont.
z

Maintain Physiologic Wound Environment

z
z
z
z
z
z
z
z

Prevent and Manage Infection

Clean Wound
Remove Nonviable Tissue (debridement)
Maintain Appropriate Level of Moisture
Eliminate dead space
Control Odor
Eliminate or Minimize Pain
Protect Periwound Skin

TIME Principles
p
of Wound Bed
Preparation
T Tissue nonviable or deficient
I Infection or inflammation
M Moisture imbalance
E Edge of wound
o nd non
non-advancing
ad ancing

Treatment Options: Moist

Wound Environment
z
z
z
z
z
z
z

Wet to Dry NS vs Moist NS Dressing fill

loosely
Debridement,,
Transparent Film
Hyperbaric, Topical
Hydrocolloid
Antimicrobial Agents,
Growth Factors
Factors,
Hydrogel
Dermal Graft
Foam
Calcium Alginate
Negative Pressure Wound Therapy

Management of Lower
Extremity Ulcers
Challenges Impacting Lower Extremities
z
z
z

Venous Insufficiency 85% of lower limb ulcer

Arterial Insufficiency
Diabetic/Neuropathy

Vascular Anatomy of the

L
Lower
Extremity
E t
it
z

Main Role of Blood Vessels to provide O2

rich blood to the foot, then return the O2
p
blood back to the heart
depleted
z
z
z

z
z

Superficial veins
Deep veins
Communicating veins

Arterial and/or venous system can

malfunction
lf
ti
Recognizing and evaluating pathology
leading to ulcer formation is crucial

V
Venous
Stasis
St i Ulcers
Ul
z

Faulty valves in leg

veins leads to venous
hypertension
z

z
z

venous blood does not

completely leave the
veins
Fl id lleaks
Fluids
k ffrom the
h
vessels and forms
edema in the tissue
S lli
Swelling
Development of ulcers in
ankle or calf

Signs and Symptoms of

V
Venous
Insufficiency
I
ffi i
z
z
z

Palpable peripheral pulses

pulses, may be difficult to
palpate due to edema
Temperature normal warm
Capillary refill normal
z

Skin changes
z

z
z

<3 seconds
varicose, or spider

Edema
Pain
z

Dull ache, heaviness, fatigue, relief by elevation

Characteristics of Venous
Ulcers
Ul
z
z
z
z
z
z
z
z

Pigmented skin surrounding

Above malleolus
Edema
Weeping lesions
Irregular wound edges
Shallow depth
p
Pain relief with elevation
Small to large

V
Venous
Ulcer
Ul
Management
M
t
z
z
z
z

Elevation to improve venous return

Ambulation
Ulcer care to maintain moist wound environment
Compression to reduce pressure differential and
maintain capillary function
z
z
z
z

JJobst,
b t Sigvaris
Si
i light
li ht supportt tto moderate
d t compression
i
UNNA boot non-elastic compression
2 layer wrap 20-25 mm Hg
4 layer wrap 40 mm Hg (profore)

No compression for arterial insufficiency, CHF,

septic phlebitis/infection/cellulites

A t i l Ulcers
Arterial
Ul
z

z
z
z

HARDENING OR
OCCLUSION OF
ARTERIES
(arteriosclerosis
or atherosclerosis)
Known as PAD
Intermittent claudication
Delayed capillary refill

Characteristics of Arterial
Ulcers
Ul
z
z
z
z
z
z
z
z

Appear as punched out (tips of toes

toes, foot)
Small, Round, Shallow Depth
Minimal drainage
Pain with leg elevation
Decreased temperature to the extremity
Absent or diminished pulse
Ul
Ulceration
ti or gangrene off th
the llower extremity
t
it
ABI <.5 indicates multilevel arterial
obstruction

ABI Determine Presence of

and
dS
Severity
it off PAD
z

z
z

Helps determine if compression can be safely

applied
A kl /B hi l Index
Ankle/Brachial
I d
Using Doppler:
Ankle Arterial BP
Brachial Arterial BP

= ABI

Signs and Symptoms of

A t i l Insufficiency
Arterial
I
ffi i
z
z
z
z
z
z
z

Intermittent Claudication
Cramping or Aching Sensation in Calf
Associated with Walking
Relieved with Rest
Femoral and Pedal Pulse Present
Delayed
y Capillary
p
y Refill,, >3 seconds
Skin Pallor when Leg Elevated >1 minute

Signs and Symptoms of

A t i l Insufficiency
Arterial
I
ffi i
z
z
z
z

z
z

Nocturnal Pain
Pain with Elevation
Decreased Temperature to the Extremity
Wound/Ulcers on Tips of Toes, Toes, Foot, Rarely
Above Calf
Ulceration or Gangrene
ABI <.5 Indicates
Multilevel Arterial
Obstruction

A t i l Ulcer
Arterial
Ul
Management
M
t
z
z
z
z
z
z

Vascular consult to evaluate potential for

revascularization
No smoking or smoking cessation
Moisturize dry skin, Do not apply between
toes
Avoid trauma
Appropriate foot wear
Wound care moist wound healing if
q
blood flow
adequate

DFU - Neuropathic
N
thi Ulcer
Ul
z

z
z
z
z
z
z

Diabetic neuropathy loss of sensation

sensation,
autonomic changes, motor changes
P i h l vascular
Peripheral
l di
disease
Plantar
Usually granular
Minimal drainage
Callous wound edges
Bounding pulses

Signs and Symptoms of

Di b ti Neuropathy
Diabetic
N
th
z

Perfusion
z
z
z

Sensory Changes loss of sensation

z

Semmes-Weinstein
Semmes
Weinstein Filament Test

Autonomic Changes absence of sweat/oil

production
z
z

pale color, delayed capillary refill or may be normal

Diminished hair distribution
Warm or cold to touch

Ingrown or thickened toenails

Dry cracked areas, fissures

Motor Changes clawed toes

toes, foot drop
drop, bunions
bunions,
flat foot, Charcot degeneration

Ch
Charcot
tA
Arthropathy
th
th
z
z
z
z
z
z

Bones Weakened and Fractured

No Pain on Ambulation
Edematous and Warm
X-ray with Abnormality
Rocker Bottom Foot
R/O Osteomyelitis
y
z
z

Bone biopsy
MRI is more accurate but expensive
p

Very Important to Listen to

P ti t Thorough
Patient
Th
h History
Hi t

Lower extremity pain?

Where is the pain?
When did it start?
Do you have swelling in your legs?
What relieves the swelling?
What factors aggravate or relieve pain?
What time of day is pain experienced?
Describe the pain:

Aching?
g Burning?
g Constant? Intermittent?

Neuropathic Ulcer
Management
z
z
z
z
z

Debridement of callous
Off-loading
Wound care moist
Patient education
Adjunctive treatment
z
z
z
z

Total contact casting

Electric stimulation
Hyperbaric oxygen
Growth factors

P ti t Education
Patient
Ed
ti
z
z
z
z
z
z
z
z

Daily inspection of feet with mirror if necessary

Avoid chemical, mechanical and thermal trauma
No smoking
Wash, dry well, especially between toes
Moisturize but not between toes
Moisturize,
Avoid temperature extremes
Do not walk barefoot
Avoid walking on hot surfaces (beach, sidewalk)

P ti t Education
Patient
Ed
ti
z
z
z
z
z
z
z
z

No hot water soaks

soaks, no heating pads
Avoid chemical agents (corn, callus remover
pads)
Avoid adhesive tape
Check shoes for objects
Do not cut own calluses/corns
No garters
garters, no thong shoes/sandals
Wear stockings or socks with shoes
Wear well
well-fitting
fitting shoes

P ti t Education
Patient
Ed
ti
z
z
z
z
z
z
z

File or have nails cut straight across

NO bathroom surgery
See podiatrist or nurse for nail care
Notify MD ASAP if blister or ulcer develops
Pressure relief measures: heels off bed
bed,
sheepskin, heel protectors
Use orthotics
Keep tetanus current

S
Summary:
Key
K P
Points
i t
z
z
z
z
z
z
z
z
z

Early and proper diagnosis assess vascular status

Aggressive treatment of infection
Deep
p debridement
Pressure relief
Patient education
Glucose control
Collaboration Nutritionist, MD, Podiatrist, PT
C
Consider
id alternative
lt
ti th
therapies
i
Topical avoid harmful agent

REMEMBER:
Assessment is the foundation
for successful management of
patients with lower extremity
wounds
wounds

What is Topical
p
O2
Therapy?
z

Treatment used to help heal open wounds by

providing pure oxygen directly to the wound
site
Oxygen is delivered directly to the surface of
th wound
the
d
Topical Oxygen Therapy provides a natural,
safe
f and
d non invasive
i
i alternative
lt
ti ffor wound
d
healing that can be administered in any
setting

Topical Oxygen Wound

Therapy
Th

FDA Approved
One-time Use, Portable
Disposable Devices

Protocol:

z
z

z
z
z
z

90 Minutes Per Treatment

4 Consecutive Days
3 Days Rest
Repeat
p
Cycle
y
Until Wound Is Healed