Today's Wound Clinic - Spring 2008 - (Page 42)

instruction system as a criteria for hyperbaric oxygen therapy and so it continues to be used in wound center documentation. In general, whenever there is a validated grading or classification system, it is advisable to use it, but only as intended (eg, the NPUAP system can only be used for pressure sores, not for other wound types).The C.E.A.P. classification system can be used for venous ulcers. Other wounds can be simply documented as partial-or full-thickness. Tissue Type. Documentation of the tissue type helps to define the treatment protocol. Necrotic wounds usually need debridement (depending on the vascular status), while clean wounds call for management of the environment. Commonly, clinicians will document the tissue type as an estimated percentage of the total wound space. Some facilities may have access to more sophisticated software, which can map out the percentage of tissue types from a photograph. However, most clinicians use the guesstimate method. Tissue types are generally described in terms of types of devitalized tissue, eschar, slough and fibrin, and then the remaining viable tissue. It is difficult to quantify the amount of tissue, which is viable. In many documentation systems, the common descriptor for this is granulation tissue. However, granulation ought to refer to vascular tissue, that is, regenerating capillaries.What if the tissue is pale, flat and non-granulating? The wound care industry lacks a universally agreed upon vocabulary for tissue descriptors. Even material such as slough can be described in a myriad of ways. While each clinic can establish a vocabulary they find appropriately descriptive (eg, pale, dusky, clean but non-granulating, etc.), it would benefit the field to establish a universally accepted set of terms, which would mean the same thing from one facility to another. It is critically important to document any exposed structure present in the wound such as muscle, bone, tendon or fascia. These have implications when billing debridement procedures, and grading or staging a wound. Wound Edge. Different than the periwound skin, the evaluation and documentation of the condition of the wound edge places focus on an area of the 42 Spring 2008 Today’s Wound Clinic wound that is often overlooked. Being tuned into rolled edges or epibole can demonstrate the need for specific treatments such as debridement of the edge to enhance wound healing by stimulating an edge effect or migration of epithelial cells. Periwound Skin. The condition of the skin surrounding the wound can signal the need for a change in exudate management. Intact undamaged periwound skin indicates adequate exudate management. Macerated or denuded skin tells a different story, leading the clinician to make a choice in dressing management that can better absorb the wound exudate. Additional cues to management issues include callous along the periphery of a plantar diabetic foot ulcer, indicating additional continued trauma and probably the need for improved offloading or compliance with the offloading prescribed. Exudate. The exudate or drainage from a wound needs to be described not only in regards to quantity, but quality or character and color also. Often the only options include serous, sanguineous, or the combination sero-sanguineous, or purulent or green.The latter two options conjure up a mental picture of the byproduct of bacterial growth when in actuality it may be an expected appearance of the treatment in use. Consider the wound that has been treated with a hydrocolloid or some other topical which leaves a liquefied residue behind. Similarly, wounds that are post application of a bioengineered tissue or after treatment with a papain-urea-chlorophyllin copper preparation such as Panafil® (HealthPoint, Dallas, Tex) which has a deep green color. Adding the choice treatment residue can alleviate that ambiguity. Providing the ability to type or write in specific descriptors related to the color or character (clear, cloudy or opaque) can further define the exudate. Odor. This is very simple. There is either odor or there is not, and the odor can be mild, moderate or strong. Either way, the very presence or absence of odor needs to be documented for comparison at subsequent evaluations. Pain. The patient’s perception of their pain. Use of the commonly accepted visual analog scale to determine a patient’s pain level should be employed. Pain spe- cific to the wound should be assessed. In addition, generalized pain may be considered the fifth vital sign, so pain may need to be collected in more than one area of the chart. There are standardized pain assessments which assist in determining the effect of pain on activities of daily living, as well as worst, best, and ideal or goal pain levels which can be used to structure pain interventions. STANDARDIZED ASSESSMENTS There are validated tools, which can be of assistance in assessing wounds. Barbara Bates-Jensen’s BWAT is one of those. Whatever method is chosen, staff should be trained to use methods consistently, and this can be a considerable challenge. There are two important therapeutic considerations when it comes to wound documentation. Certain wound characteristics drive clinical decision-making. For example, maceration, foul odor, a large volume of exudate or necrotic material ought to drive certain clinical decisions with regard to dressing product choices. Getting these descriptors right will assist with making the right clinical decisions. The second therapeutic consideration has to do with assessing wound progress. During assessing of the wound progress, professionals generally rely on wound measurements. However, one could argue that before a wound begins to decrease in size, other parameters improve. A wound originally full of slough with a large amount of purulent exudate which has now become well granulated with a minimal amount of serous exudate, could be seen as improved, even before measurements have decreased. A standardized method of wound assessment would allow one to identify these improvements prior to the change in wound size. The specialty of wound care would be benefited if there was agreement to a universal assessment tool.This would be a substantial challenge as an industry since many organizations have historical data which would be affected by changes in collection methods. However, standardizing the wound assessment process would have the considerable benefit of making data comparable from one facility to another, and would likely facility clinical research.

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Today's Wound Clinic - Spring 2008 Contents InTroduction InBusiness Documentation: The 30,000-Foot View Documentation: Clearing Up the Role of Compliance InTech InPhotography InFluence InStruction InNews InCentive Ad Index

Today's Wound Clinic - Spring 2008

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