Learning Objectives
By the end of this section, you will be able to:
- Identify components of a comprehensive wound assessment
- Examine best practices with wound documentation
- Discuss legal implications of wound care documentation
Comprehensive and concise wound care documentation is as critical as the assessment and care provided to the patient. Wound care documentation fosters interdisciplinary communication and protects the nurse and patient from legal consequences. This module will explore the components of the comprehensive wound assessment and examines best practices and legal implications for ensuring wound care documentation is complete.
Wound Assessment
A comprehensive wound assessment is the written record and picture of the wound’s current status and progress. The wound assessment is the culmination of observation, data collection, and evaluation at each encounter. The initial assessment serves as the baseline for future comparisons; because a wound can change rapidly, it is important to assess for changes in the wound and surrounding skin to signify a need for treatment modifications. Tenderness to touch and the amount of pain the patient reports are essential assessment components. Wound pain is one of the secondary signs of infection, and it is important to differentiate between constant pain and episodic pain, such as that felt only during a dressing change.
Cultural Context
Importance of Skin Color
When caring for a patient, the nurse must be “color aware.” Being color aware acknowledges the relevance of skin color to health. Most skin care guides are based off light skin tones and do not reflect the skins tones of all patients. For example, when assessing an at-risk bony prominence of a darker-skinned individual for a Stage 1 pressure injury, the increased amount of melanin in the skin may mask the blanch response. Instead, after applying light pressure, look for an area that is darker than the surrounding skin or skin that is taut, shiny, or indurated (hardened).
Exudate description and language is important to understand and incorporate. Nurses should use multiple senses when assessing a wound. Visual inspection, palpation, and odor are components of the assessment to guide documentation and intervention. Table 28.7 and Table 28.8 list types of wound exudate and the language to describe the amount of exudate, respectively.
| Exudate Type | Appearance |
|---|---|
| Serous | Clear, amber, thin, watery |
| Serosanguineous | Clear, pink, “blood tinged,” watery |
| Sanguineous | Bloody, reddish, thin, watery |
| Purulent | Opaque, thick, yellow, green |
| Seropurulent | Yellow, tan, cloudy, thick; not to be confused with slough |
| Fibrinous | Cloudy, thin with strands of fibrin |
| Hemorrhagic | Red, thick |
| Term | Quantity |
|---|---|
| None | Wound is dry. |
| Scant | Tissue is moist. |
| Small | Wound bed is wet, with moisture evenly distributed. Drainage encompasses up to 25% of dressing |
| Moderate | Wound bed is saturated. Drainage encompasses 25–75% of dressing |
| Large | Wound bed is bathed in fluid. Drainage is freely expressed and involves more than 75% of dressing |
When assessing the odor of a wound, it is important to wait until after the dressing is discarded and the wound is cleaned. Due to microbes and the wound’s environment under a dressing, odor there is not uncommon; however, the persistence of foul odor after the cleansing of a wound can indicate infection. Descriptors of wound odor may include terms like strong, foul, pungent, fecal, and musty.
Patient History
A comprehensive patient assessment includes both visually inspecting the wound and the whole patient. A wound assessment encompasses not only the wound but the entire patient profile. When assessing wound components, interviewing the patient, and reviewing the patient’s chart, the nurse should assess for wound location, etiology, length of duration, treatments completed or previously attempted, and patient compliance. An assessment includes reviewing accompanying laboratory data. Typical laboratory data to consider and assess for wound care patients include complete blood count (CBC), serum albumin, prealbumin, and blood glucose. A CBC is important to monitor for anemia and infections. Serum albumin and prealbumin are plasma proteins produced by the liver. Low serum albumin counts correlate with increased risk for pressure injury. However, prealbumin is more reliable than albumin in determining the effect of nutritional interventions. Blood glucose is monitored to indicate healing capability. Increased glucose levels are associated with an increased risk of impaired wound healing.
Wound Measurement
Measurement is a critical part of wound care assessment, providing valuable information on the progression or nonprogression of wounds. Consistency and accuracy when measuring a wound are important for meaningful evaluation that can determine the need for treatment modification. All medical institutions should develop and disseminate a protocol for wound measurement, including frequency of assessment, to ensure accuracy. A decrease in wound size is usually an indication of healing.
Wounds should not be compared to objects such as a coin. Rather, wound size should be measured and recorded in centimeters with a measuring device such as a paper or plastic ruler. The most used measurements are length, width, and depth of a wound, as determined and recorded using the linear method, also referred to as the clock method (Figure 28.12). The linear method, with a ruler, is inexpensive, readily available, and causes little to no patient discomfort. Note that this assessment technique does not include the periwound, only the wound base. Imagine the body as the face of an imaginary clock: the head is 12:00 and the feet are 6:00. Length is measured by placing the ruler at the point of maximum length, or from 12:00 to 6:00. Width is measured by placing the ruler at the point of maximum width, or from 3:00 to 9:00. Depth can be assessed by placing a clean cotton tipped applicator into the deepest part of the wound, marking it at the level of the wound edge, and measuring upon removal—similar to the process of assessing a tunnel. Although many wounds are irregularly shaped, the clock method allows for clear communication among assessing clinicians (Figure 28.13).
This method can also be applied to foot wounds. When assessing the plantar surface, the toes would be 12 o’clock and the heel 6 o’clock. The “clock” is also a helpful tool for identifying and recording landmarks or other wound assessment components, such as sinus tracts or undermining. For example, a wound might have undermining at 2 cm from 11 o’clock to 2 o’clock, with one 3 cm tunnel at 12 o’clock. This creates a visual image for all clinicians assessing the wound and can prevent unwarranted trauma to the otherwise friable tissue.
Wound Base
The wound base tissue reveals the phase and progress of wound healing through observation of color, degree of moisture, and amount of epithelialization. As previously discussed, a moist wound bed moves fibroblasts, macrophages, collagenase, and other chemical components across the wound bed, progressing to healing. When assessing the wound base, we refer to the wound bed preparation to guide our visual assessment. Begin by assessing the wound bed, which may appear red, pink, yellow, or black. Clean, granular wounds are typically described as red or pink. If devitalized tissue is present, yellow or black necrotic tissue may also be present. Determine whether the bed is moist or dry and whether granulation is present.
Sometimes a wound can have hypergranulation: excess granulation tissue filling the wound bed beyond the height of the surface of the wound. Hypergranulation must be removed. If more than one tissue component is present, such as both granulation and necrotic burden, document the amount as a percentage. For example, the wound may have 75 percent granulation tissue and 25 percent yellow, adherent fibrin. Assessing the amount of each tissue type at each encounter allows the nurse to more easily track progress or regression of wound healing and determine whether wound treatment needs to be modified.
Periwound Assessment
The periwound is the skin surrounding a wound. It provides valuable information to the assessing clinician. Erythema and warmth at the periwound may indicate inflammation or infection. Interruptions in the periwound skin integrity may indicate reactions to adhesives. The presence of desiccation or maceration may indicate the dressing is ineffective in managing the wound. The presence of excessive dryness in the periwound is known as desiccation. On the other hand, maceration is the presence of excessive moisture.
When assessing and documenting the periwound, it is imperative to note the condition of the skin, hydration, skin abnormalities, color, hair and nail growth if appropriate, temperature, and presence of edema. Table 28.9 provides the detailed rationale of selected periwound assessment components.
| Assessment Finding | Indication |
|---|---|
| Condition and quality of skin |
|
| Color |
|
Wound Documentation
Wound documentation is an essential component of wound assessment and should be undertaken thoroughly, accurately, and consistently. Typically, wounds should be documented upon patient admission and transfer or discharge; between these milestones, documentation should happen weekly, with each dressing change, and with any significant changes to the wound or periwound.
Evidence-Based Practice for Wound Care
Documenting a wound care assessment should include all pieces discussed during the evaluation of a wound: type of wound, measurements, description of the wound base and periwound, drainage, odor, pain, and patient response to treatment. Agencies may have their own charting system or sheet to help with the wound assessment and documentation process, but it is imperative that the bedside provider includes all necessary components in the documentation. Documentation should be thorough, objective, and use simple language. There are many terms involved with wound and skin care, and sometimes it can be difficult to remember them all. The most important component of documenting a wound care assessment is describing precisely what is seen—using the correct terms is helpful but not as important as a precise description. When documenting a wound, you are painting a picture to enable the next clinician or chart reader to visualize what you observed as you assessed and cared for the patient. Using simple terms is acceptable. There are legal implications for incorrectly documenting a term: for example, if a partial-thickness wound on the forearm is documented as a Stage 2 wound, this legally indicates that the wound is a pressure injury. Only pressure injuries should be staged. Timely recording is also a best practice for wound care documentation. If a record is documented after an extended period, note the reason for the delay in the record.
Photography
Wound photography provides a visual record of the wound; when done correctly, it can assist in care decisions and provide litigation support. However, photography should not replace bedside assessments. It is necessary to permanently mark on each photograph the time, date, and patient identification information while maintaining privacy: for example, by using a patient’s initials rather than full name. Each photograph should include a sample measure, such as a 5-cm strip of tape for reference. Clinicians need appropriate training and must consistently follow their institution’s wound photography protocol and policies. Angle of the camera, lighting, and distance can alter the perception of the wound assessment.
Legal Implications
Medico-legal issues in wound management can arise from low quality documentation. To review, the main purpose of wound care documentation is to communicate a wound’s condition and progress to all future providers of the patient. Accurate and clear documentation enables the health-care team to collaborate and share pertinent information about the treatment and care plan. Consistency in documentation is important and prevents gaps in charting. If a patient’s chart is presented during a legal proceeding, gaps in documented care or other omitted information make it more difficult for providers to exonerate themselves; they may even be interpreted as evidence of negligence.
The Centers for Medicare and Medicaid Services (CMS) sets reimbursement rates for medical services rendered and equipment used for the care of patients receiving Medicare. Fees and reimbursement rates vary, including for wound care. In terms of wound care reimbursement, CMS’s documentation standards reflect the previously discussed best practices. Documentation for a wound should include:
- wound dimensions and depth
- presence and extent or absence of necrotic tissue and devitalized or nonviable tissue
- correct description and location of undermining or tunneling
- report of infection by describing wound exudate
It is important to describe the wound in simple, objective terms, without assigning blame or opinionating. When in doubt, describe what you see in clear, concise language as if you are painting a picture for the next clinician to care for the patient.
Another important nursing role with respect to wound care is educating patients on how to care for their wound; nurses should document all education provided. Lawsuits rarely involve wound care itself; rather, they revolve around not following standards of care, improper documentation, or lack of education around the patient’s wound and care.