Wound Assessment Documentation

AR K ANSA S INN OVAT IV E PER F O R M AN C E PR O GR A M (AIPP) Skin Management
TOOLKIT
Wound Assessment Documentation

Ohio KePRO & AMT
Present
The Wound Documentation Series: Session 3
Wound Assessment Documentation: Your Form
Pamela Scarborough
PT, DPT, MS, CDE, CWS, CEEAA
Director of Public Policy & Education
American
Copyright ©Medical Technologies
2012 - AMT Education Division 1
Disclaimer
The information presented herein is provided for educational
and informational purposes only. It is for the attendees’
general knowledge and is not a substitute for legal or medical
advice. Although every effort has been made to provide
accurate information herein, laws change frequently and vary
from state to state. The material provided herein is not
comprehensive for all legal and medical developments and
may contain errors or omissions. If you need advice
regarding a specific medical or legal situation, please consult
a medical or legal professional. Gordian Medical, Inc. dba
American Medical Technologies shall not be liable for any
errors or omissions in this information.
Copyright © 2012 - AMT Education Division 2
Objectives
• Compare facility current wound documentation
practices with recommendations that address current
wound documentation recommendations from F314,
MDS-M-Section and NPUAP guidelines
COPYRIGHT © 2012 AMT EDUCATION DIVISION • USED WITH PERMISSION
THIS MATERIAL WAS PREPARED BY THE ARKANSAS FOUNDATION FOR MEDICAL CARE INC. (AFMC) UNDER CONTRACT WITH THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES.
THE CONTENTS PRESENTED DO NOT NECESSARILY REFLECT ARKANSAS DHS POLICY. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT.
Copyright
ARKANSAS INNOVATIVE PERFORMANCE PROGRAM (AIPP) Skin Management Toolkit © 2012 - AMT Education Division 1•• 1 ••
TOOLKIT
Date Wound Identified
F314 - Assessment & Treatment of

PrU(s)
• Each existing pressure ulcer be identified
• Whether present on admission or developed after
admission
• Factors that influenced the PrU development
• Potential for development of additional ulcers
• Factors causing deterioration of the pressure ulcer(s)
be assessed and addressed (Prevention!!!)
• New pressure ulcer suggests a need to reevaluate
the adequacy of the plan for preventing pressure
ulcers
Copyright © 2011 Gordian Medical, Inc.
dba American Medical Technologies. 5
www.amtwoundcare.com
Location
Describe location anatomically correctly using

current medical terminology
Specific Terms Less Specific Terms

R-ischium R-buttock
R-lateral malleolus R-ankle
L-trochanter L-hip
•• 2 •• ARKANSAS INNOVATIVE PERFORMANCE PROGRAM (AIPP) Skin Management Toolkit

TOOLKIT
Location
• Document in reference to head, front or
back
• Commonly used terms
– Proximal, distal
– Superior, inferior
– Medial, lateral
– Anterior, posterior
– Dorsal, plantar
Etiology
• Plan of care will be specific for etiology identified

• In most instance if etiology incorrect…treatment plan
will not be functional and goals not reached
• Outcomes poor
Most Common Wound Etiologies
Peripheral Venous Diabetic Lymphedema

Pressure Insufficiency
Arterial Neuropathic
Ulcer Foot Ulcer
Disease
(PAD)
ARKANSAS INNOVATIVE PERFORMANCE PROGRAM (AIPP) Skin Management Toolkit •• 3 ••

TOOLKIT
Is it an Atypical Wound?
Basal cell
carcinoma Malignant Melanoma
Lupus
Vasculitis Calciphylaxis
Copyright © 2011 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 10
Depth of Tissue Injury
Classification of Wounds by Tissue

Destruction
– Used to classify wounds whose primary
cause is something other than pressure
• Partial thickness- limited to
epidermis & upper portion of dermis
• Heals by regeneration
• No scar tissue
• No slough
• Healing complete 7-14 days.
• Full-thickness
• Extends through epidermis & dermis
• May involve subcutaneous tissue,
muscle or bone Copyright © 2012 Gordian Medical, Inc.
12 dba American Medical Technologies.

TOOLKIT
NPUAP Staging- Pressure Ulcers

• Classification by Category/Staging
– Identify pressure ulcers by tissue layer involved
– Anatomic description of wound depth
– NPUAP – Revised Feb 2007
• Suspected Deep Tissue Injury
• Category/Stage I
• Category/Stage II
• Category/Stage III
• Category/Stage IV
• Unstageable
– Should only be used on wounds caused by pressure!
– NPUAP.org Copyright © 2012 Gordian Medical, Inc.
Unstageable Pressure Ulcers

• Three types to differentiate
• Number of these unstageable pressure ulcers present upon
admission/ reentry
14
Measurement

TOOLKIT

Wound Measurement:
Depth: Distance from visible surface to deepest point in
wound base not covered with necrotic tissue
Insert moistened
sterile cotton
swab
NOTE: Do not record depth if not able to see TRUE base of

wound. Use unstageable designation. 17
Copyright © 2012 - AMT Education Division
Wound Measurement
Tunneling
A single
pathway that
may extend in
any direction

TOOLKIT
Wound Measurement
Undermining
Tissue destruction that occurs to the underlying intact
skin adjacent to the wound margins.
Formation of a “shelf” of healthy, intact tissue over an
area of dead space and/or necrotic tissue.
Shelf under edge of wound

19
Exudate
Reasons drainage may increase:

• Infected
• After sharp or surgical debridement
• When using collagenase
PS: Drainage drives dressing decisions.
QUANTIFYING WOUND EXUDATE

Status Indicators: Based on a 24-hour observation period
None/Dry Wound bed is dry; there is no visible moisture and the
primary dressing is unmarked; dressing may be adherent to
wound.
Scant/ Small amounts of fluid are visible when the dressing is
Small/ removed; the primary dressing may be marked up to 25%, but
Minimal strikethrough (or saturation through the dressing) is not
occurring; in many cases, this is the goal of exudate
management. Wound bed glistens. Routine dressing changes
fully control the exudate.
Moderate Routine and appropriate dressing changes show that the
drainage has met the dressing’s absorptive ability without
saturating or leakage; may cover 25%-75% of the dressing.
Large/ Dressings are saturated with changes at routine intervals;
Heavy exudate is uncontrolled and freely expressed. More than
Copious/ 75% of the dressing is covered by drainage.
Very Heavy Copyright © 2012 - AMT Education Division 21
Adapted from the Association for the Advancement of Wound Care Quality of Care Wound Glossary

TOOLKIT
Wound Bed
Clinical Presentation of Tissue Types:

Wound Base
Granulation tissue
Full thickness/Stage III PrUs
Slough
Epithelial
tissue
Partial thickness/
Stage II PrUs
Caucasian and
Non-Caucasian skin
23
Clinical Presentation of Tissue Types:

Wound Base
Foreign object/exposed metal implant Hypergranulation tissue (exuberant

visible at base of wound granulation tissue or proud flesh) extends
above the wound edge

TOOLKIT
Ulcer on heel with yellow and red tissue.
Right heel with unstageable pressure ulcer presents with 80% yellow soft
slough at central portion of wound base, with 20% pink granulation tissue
around wound base periphery. Wound edge smooth and well defined;
periwound slightly macerated superiorly.
Pain
CMS and Wound Related Pain

• F314
• Pain, if present: nature and frequency (e.g.,
whether episodic or continuous);

TOOLKIT
Wound Related Pain Experiences

Chronic • Absence of manipulation
Wound Pain • May be continuous/intermittent
• Periodic acute wound pain

Cyclic Wound
• Regular repetitive treatments
Pain (i.e. dressing change)
Noncyclic • Provoked by more sporadic

procedures
Wound Pain (i.e. sharp debridement)
28
Assessment and
Documentation of Pain to Include:
• Location
• Duration
• Character (intensity and radiation)
• Frequency
Wong-Baker FACES™ Pain Rating Scale
©1983 Wong-Baker FACES™ Foundation. Used with permission.

30

TOOLKIT

TOOLKIT
Treatment Plan

TOOLKIT
F314 Interpretative Guidelines

483.25(c)
Based upon the assessment and the resident’s
clinical condition, choices & identified needs, basic
or routine care should include interventions to:
a) Redistribute pressure (such as repositioning,
protecting heels, etc)
b) Minimize exposure to moisture and keep skin clean,
especially of fecal contamination;
c) Provide appropriate pressure redistributing, support
surfaces;
d) Provide non-irritating surfaces;
e) Maintain or improve nutrition and hydration status,
where feasible.
Copyright © 2012 Gordian Medical, Inc. dba American
37 Medical Technologies. www.amtwoundcare.com
Definitions
• Pressure Ulcers (Avoidable/Unavoidable )
• Colonized/Infected Wound
• Cleansing/Irrigation
• Debridement
– Autolytic
– Enzymatic
– Mechanical
– Sharp
– MDT (maggot)
dba American Medical Technologies. 38
M1200 Skin and Ulcer Treatments1

TOOLKIT
Therapeutic Goals Example
Short Term Goal Suggestions

• Decrease wound size by _________ cm
• Increase granulation tissue to_______%
• Decrease necrotic tissue to________%
• Decrease edema ___________ grade (pitting)
• Decrease drainage to ___________(small, moderate)
• Decrease odor ___________ (min, mod)
• Decrease erythema to_____________________
• Decrease undermining or tunneling ______________
• Educate patient/staff/family regarding__________
• Assess efficacy of pressure redistribution devices, off-
loading of heels, positioning, etc
Long Term Goals Suggestions

• Wound closure in 6 wks
• Functional nutrition/hydration status
maintained for wound prevention and healing
• Staff/family/resident safe and competent in
protecting and preventing reoccurrence

TOOLKIT
Dressing Change Protocol Example
F314- DRESSINGS & TREATMENTS

• A facility should be able to show that its document
treatment protocols are based upon current standards of
practice
• Are in accord with the facility’s policies and procedures
• And these policies and procedures are developed with
the medical director’s review and approval (F501)
Do treatments with
these products meet
the “current standards
of practice”?

TOOLKIT
Negative
Pressure Wound
Therapy
Electrical Stimulation
Pulsatile Lavage
Low-frequency Ultrasound w/ Suction
Complicating Factors

TOOLKIT
THIS MATERIAL WAS PREPARED BY THE ARKANSAS FOUNDATION FOR MEDICAL CARE INC. (AFMC) UNDER CONTRACT WITH THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. THE CONTENTS PRESENTED DO NOT NECESSARILY
REFLECT ARKANSAS DHS POLICY. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT. QP2-SJPINT.CCAR,3-8/12

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AR K ANSA S INN OVAT IV E PER F O R M AN C E PR O GR A M (AIPP) Skin Management

Wound Assessment Documentation

Copyright © 2012 - AMT Education Division 3

COPYRIGHT © 2012 AMT EDUCATION DIVISION • USED WITH PERMISSION

Date Wound Identified

Copyright © 2012 - AMT Education Division 4

F314 - Assessment & Treatment of

Describe location anatomically correctly using

Specific Terms Less Specific Terms

•• 2 •• ARKANSAS INNOVATIVE PERFORMANCE PROGRAM (AIPP) Skin Management Toolkit

Copyright © 2012 - AMT Education Division 2

• Plan of care will be specific for etiology identified

Most Common Wound Etiologies

Peripheral Venous Diabetic Lymphedema

Copyright © 2012 - AMT Education Division 9

ARKANSAS INNOVATIVE PERFORMANCE PROGRAM (AIPP) Skin Management Toolkit •• 3 ••

Copyright © 2012 - AMT Education Division 3

Depth of Tissue Injury

Copyright © 2012 - AMT Education Division 11

Classification of Wounds by Tissue

•• 4 •• ARKANSAS INNOVATIVE PERFORMANCE PROGRAM (AIPP) Skin Management Toolkit

Copyright © 2012 - AMT Education Division 4

NPUAP Staging- Pressure Ulcers

Unstageable Pressure Ulcers

Copyright © 2012 - AMT Education Division 15

ARKANSAS INNOVATIVE PERFORMANCE PROGRAM (AIPP) Skin Management Toolkit •• 5 ••

Copyright © 2012 - AMT Education Division 5

Copyright © 2012 - AMT Education Division 16

NOTE: Do not record depth if not able to see TRUE base of

Copyright © 2012 - AMT Education Division 18

•• 6 •• ARKANSAS INNOVATIVE PERFORMANCE PROGRAM (AIPP) Skin Management Toolkit

Copyright © 2012 - AMT Education Division 6

Shelf under edge of wound

Reasons drainage may increase:

QUANTIFYING WOUND EXUDATE

ARKANSAS INNOVATIVE PERFORMANCE PROGRAM (AIPP) Skin Management Toolkit •• 7 ••

Copyright © 2012 - AMT Education Division 7

Copyright © 2012 - AMT Education Division 22

Clinical Presentation of Tissue Types:

Clinical Presentation of Tissue Types:

Foreign object/exposed metal implant Hypergranulation tissue (exuberant

Copyright © 2012 - AMT Education Division 24

•• 8 •• ARKANSAS INNOVATIVE PERFORMANCE PROGRAM (AIPP) Skin Management Toolkit

Copyright © 2012 - AMT Education Division 8

Ulcer on heel with yellow and red tissue.

Copyright © 2012 - AMT Education Division 26

CMS and Wound Related Pain

Copyright © 2012 - AMT Education Division 27

ARKANSAS INNOVATIVE PERFORMANCE PROGRAM (AIPP) Skin Management Toolkit •• 9 ••

Copyright © 2012 - AMT Education Division 9

Wound Related Pain Experiences

• Periodic acute wound pain

Noncyclic • Provoked by more sporadic

Copyright © 2012 - AMT Education Division 29

Wong-Baker FACES™ Pain Rating Scale

©1983 Wong-Baker FACES™ Foundation. Used with permission.

•• 10 •• ARKANSAS INNOVATIVE PERFORMANCE PROGRAM (AIPP) Skin Management Toolkit

Copyright © 2012 - AMT Education Division 10

Copyright © 2012 - AMT Education Division 31

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ARKANSAS INNOVATIVE PERFORMANCE PROGRAM (AIPP) Skin Management Toolkit •• 11 ••

Copyright © 2012 - AMT Education Division 11