For the home carepatient, accurate, thorough, and consistent wound assessment provides information about wound status and is critical for developing a treatment plan that supports healing. However, this patient's plan of care also requires knowledge of the total person, including the patient's other medical conditions and lifestyle. This article presents the comprehensive assessment for the home care patient who requires wound care, including baseline history and physical examination, wound assessment, treatment plan, impact on OASIS documentation, wound care orders, and follow-up visits.
Initial Evaluation: History and Physical Examination
Patients are referred to home care for wound management and care because of wound drainage or pain, the patient's inability to change dressings, or delayed healing. The documentation that accompanies this patient's referral can include information on wound status, etiology, and treatment plan.
The referral information may be incomplete, especially wound etiology and treatment over time. Patient records may contain a history and physical examination from the referral source. If not present in the records, obtaining these data from the referral source is the first step in planning the patient's care (Maklebust, 1997;van Rijswijk, 1996).
Wound History
Information about the wound's history is particularly helpful, including:
* when it occurred,
* its initial size and location,
* how it occurred,
* what happened to the wound over time,
* approaches used to enhance healing,
* how well these approaches have worked,
* factors thought to delay healing, and
* associated manifestations such as itching, and/or disruption of surrounding tissue with drainage.
If this information is not included with the documentation, the nurse elicits it as part of the intake history. The nurse also explores other circumstances that affect the wound, such as whether the wound is part of a continuing illness (e.g., delayed stump healing after limb amputation due to peripheral vascular disease), or due to acute illness (e.g., sternal dehiscence after coronary artery bypass grafting). Table 1 summarizes the dimensions of a wound history (Siedel et al., 1999).
Factors Affecting Healing
While taking the patient's health history, the nurse gathers information about diseases and conditions frequently associated with delayed or disrupted healing. Significant common contributors to impaired healing are cardiovascular disease, diabetes, renal failure, immunosuppression, gastrointestinal disease, collagen disease, malignancy, septic shock, trauma, infection, liver disease, pulmonary disease, depression and psychosis, and musculoskeletal disease. Other conditions that affect healing include:
* impaired oxygenation, impaired perfusion, immunocompromise, malnutrition, bacterial contamination, increased sympathetic nervous system outflow pain, noise, stress, and treatment-related factors (such as use of long-term antibiotics, antiinflammatory drugs, chemotherapy, and steroids);
* therapies received as part of prior care, such as radiation at the wound site (Lazarus et al., 1994;Stotts, 2003);
* allergies to drugs such as antibiotics or topical agents.
Family History
The family history focuses on diseases that may affect healing such as diabetes, peripheral vascular disease, or a coagulopathy. This history notes the presence of these conditions in the first degree biologic family including the patient's parents, siblings, grandparents, children, and grandchildren.
Functional Abilities
Evaluating functional abilities is key to assessing the level of nursing care the patient needs as well as the patient's ability to assume responsibility for self-care, including changing his or her own dressing, applying compression stockings, or adhering to an antibiotic regimen. To assume proper self-care, patients must demonstrate the ability to move and turn themselves as well as show adequate hand strength and flexibility. Patients whose function is compromised may experience delayed healing due to impaired mobility and circulation.
Personal and Social History
Personal and social history needs to address the person's place of residence, with whom he or she lives, social support, usual dietary pattern, daily activities, and source and amount of income, as well as information about:
* who cooks and does the grocery shopping,
* education level and willingness and/or ability to learn,
* religion, including cultural practices as they relate to wound care (such as use of hot or cold in healing);
* risk assessment, including:
[black small square] alcohol and drug use, sedentary lifestyle, and smoking (Siedel et al., 1999);
[black small square] pressure ulcer risk assessment for bed-or chairbound wound patients, using a valid and reliable instrument such as the Braden scale. A Braden score of "very limited mobility" is a key predictor of pressure ulcer development in home care patients age 60 or older (Berquist & Frantz, 1999).
Review of Systems
This final major portion of the history asks the patient if he or she has any other information that the provider needs to know. Table 2 summarizes patient history components relevant to wound care (Seidel et al., 1999). After completing the entire history the nurse can identify which areas require special attention during the physical examination.
Physician Exam
The physical examination consists of taking vital signs, evaluating the physical effects of any concurrent conditions, and performing a physical assessment focused on wound-related pathology.
Physical assessment of vascular ulcers includes evaluating the affected extremity's color, capillary refill, temperature, pulses, and edema, noting the limb's skin, nails, and hair.
Venous ulcers, the most frequently occurring lower extremity ulcers, usually involve lower extremity edema and aching that is worse at the end of the day or with dependency. Venous ulcers also are associated with skin discoloration due to red blood cells leaking into the periulcer area. These patients often have a history of deep vein thrombosis, leg injury, obesity, phlebitis, prior vein surgery, and lifestyles that require prolonged standing (de Araujo et al., 2003).
In contrast, arterial ulcers are associated with systemic arteriosclerosis. Signs and symptoms include intermittent claudication that is aggravated with walking or leg elevation, and alleviated with standing (Schainfeld, 2001). Pulses usually are weak or absent. Impaired blood flow is indicated by thin skin, pale, or dusky tissue indicating poor perfusion, and the lack of hair, especially distally on the affected extremity.
It is essential to differentiate between stasis (venous) ulcers and arterial ulcers because venous ulcers require compression. Compressing an arterial ulcer and decreasing blood flow could endanger a limb, a terrible consequence of incomplete or incorrect assessment.
Diabetic ulcers, the third most common type of lower extremity ulcer, usually occur on the foot's plantar surface (sole) in the presence of sensorimotor and autonomic neuropathy. The patient does not perceive foot trauma because of the neuropathy and so continues to place weight on the injured tissue, exacerbating tissue damage (Krasner, 1998;Mekkes, Loots, Van Der Wal, & Bos, 2003).
Pressure ulcers (PU), resulting from pressure that causes ischemia and tissue necrosis over bony prominences, occur most frequently at the sacrum and heels. PUs are categorized by stage (Table 3) which reflects wound depth. More severe PUs (stage III and IV) often involve tissue undermining where the surface opening is not as large as the tissue damage under the skin. Tunneling also frequently occurs with stage III and IV PUs (Stotts, 2003).
Home care for surgical wounds usually occurs with surgical complications such as delayed healing or dehiscence. A patient's wound may still have drains and sutures when the patient is referred to home care.
Wound Classification and Assessment
OASIS documents stasis ulcers, pressure ulcers, and surgical wounds; however, home care nurses provide integrated assessment and documentation of all wounds (Baranoski & Thimsen, 2003). There are several different approaches to wound assessment (Bates-Jensen, 1996;Lazarus et al., 1994;Stotts, 2003;van Rijswijk, 1996), but no single approach is superior to the others in evaluating wounds. One approach is to use a partial-thickness versus a full-thickness model (Stotts, 2003), a paradigm that incorporates knowledge of the skin's anatomic structures and related tissues.
Wound Type
In partial-thickness injuries (e.g., abrasions, skin tears, skin graft sites), there is damage to the epidermis and part of the dermis. Epithelial resurfacing occurs from the base of hair follicles and skin glands. Because these structures are widely distributed, healing is relatively rapid in clean partial-thickness wounds as compared with full-thickness wounds (Stotts, 2003).
New epithelial tissue looks like small tufts or patches of pale pink tissue in the wound, regardless of the skin's intact color. There may be pink to beefy-red granulation tissue when the partial-thickness wound occurs deep in the dermis (Brown-Etris, 1995).
Tissue damage in full-thickness wounds extends into the subcutaneous tissue and muscle (Stotts, 2003). Healing requires that new vessels form, granulation tissue develops, contraction occurs, and epithelial tissue migrates and covers the open wound surface. A complex series of cellular interactions mediated by cytokines and growth factors orchestrate these processes.
Full-thickness wounds are closed by primary intention or left open to heal by secondary intention (Stotts, 1998). With primary intention closure, the wound edges are approximated using sutures, staples, or steri-strips. This approach is used when the wound is clean and there is little tissue loss (surgical incisions and lacerations). Secondary intention closure allows irregular or contaminated wound edges to close by developing granulation tissue, epithelialization, and contraction. Pressure ulcers and traumatic wounds often heal by secondary intention. Tables 4 and 5 list signs of normal and abnormal healing for primary intention and secondary intention wounds.
Measuring Wound Size
Measuring wound size is a critical component of wound assessment:
* length: at the wound's longest point;
* width: side to side at the wound's widest point;
* depth: at the wound's deepest point to 0.1 cm.
This multidimensional approach is recommended because wounds do not heal at an equal rate in all directions (Stotts, 1998;van Rijswijk, 1996).
Documenting Wound Size
Nurses can use several methods to document wound size, including:
* tracing the wound on a clear plastic template or "baggie" (in some settings, this becomes a part of the permanent record);
* taking photographs to document location, size, and nature of tissue;
* noting wound location on a human figure drawn on a sheet of paper. If patients have more than one wound, each wound is numbered and the description of each wound listed accordingly. This provides for continuity in successive assessments (van Rijkswijk, 1996).
When wound size is slow to change, the trajectory of healing can be followed by evaluating alterations in the nature of the tissue (e.g., granulation bed, disrupted edge), the exudate (e.g., changes in color, consistency, amount), and odor. When the wound is deteriorating or just not healing over several visits, the effectiveness of the total plan of care must be carefully evaluated.
Wound Staging
Wound staging classifies wound depth (see Table 3). Ninety percent of home care agencies use this staging system recommended by the National Pressure Ulcer Advisory Panel (NPUAP, 1998) and adapted by the AHCPR (Eager, 1997). In a Survey and Certification letter dated August 6, 2001, CMS stated, "HHA clinicians are encouraged to use the new guidance to assist with clinical assessments of wound patients." The link to the S&C letter and guidance can be found at:
http://www.cms.hhs.gov/medicaid/survey-cert/080601.pdf
Periwound skin assessment provides key information about the risk that the wound will increase in size. During assessment the nurse evaluates erythema, edema, induration, capillary refill, lymphangitis, callus, hair distribution, exposed tissue, and surrounding tissue function and status (Lazarus et al., 1994). However, periwound skin evaluation is not to be confused with wound assessment.
UCSF Home Health Care developed and uses an approach to accurately, thoroughly, and consistently assess wounds, by adapting and expanding the guidelines for wound classification published by the Wound, Ostomy and Continence Nurses Society (WOCN, 2001) (see Figure 1). Our approach clearly defines wound categories so all nurses use a common definition. Thus, healing is operationally defined by signs and symptoms for each category of healing (e.g., fully granulating, early/partial granulating).
Treatment Plan and Documentation
The treatment plan should include the following components:
* a diagram of the wound (size and shape), its location, its nature, supplies needed, and step-by-step instructions for care including cleaning, packing, and periwound skin protection. Ideally, specific dates need to be established indicating expected progress.
* written evaluation with data on the effectiveness of the local and systemic treatments as well as progress or lack of progress in healing documented with critical but concise observations.
* prescribed wound care, including specific wound care products that are:
* clinically appropriate for the wound type,
* reliable,
* within the patient's financial reach,
* readily available, and easily used by the patient or caregiver.
The care plan must consider the patient's or caregiver's ability to participate in care, including their ability to change dressings and provide basic care, including nutrition, and mobility or ability to help the person move. When a patient or caregiver is able to participate in care, the nurse provides written instructions, demonstrates the dressing change, and supervises the patient and caregiver until they are able to perform the procedure independently. The nurse also revises the care plan as needed based on ongoing evaluation.
UCSF Home Health Care adapted a wound assessment and management diagram from Bryant's text (2001) to enhance the fit between clinical findings, treatment regimen, and the product formulary (see Figure 2). The algorithm guides the nurse through a logical procedure of care, based on assessment findings. This algorithm helps reduce unwarranted changes in wound care, as it provides shared understanding of the care rationale. It also recognizes that wound care changes as a wound heals, and provides appropriate evaluation and response.
Wound Care Orders
The patient referral usually includes wound care orders. The nurse needs to evaluate these orders for appropriateness, based on wound assessment and available caregiver support. For example, an order to dress a homebound patient's sacral ulcer using a moist-to-moist gauze dressing that must be changed twice daily is not a practical treatment option if the nurse is authorized to visit only once per day and there is limited or no caregiver support.
Communication with physicians may be difficult because many are unaware of the newer products that are more appropriate for care at home, do not accept the concept of moist healing (Ovington, 2001), and are unaware of barriers to wound care in the home setting. These issues must be addressed with the physician and a plan developed in the assessment phase so the patient, caregiver, and all team members understand how care will proceed. For wounds requiring frequent dressing changes, the care plan must indicate a finite and predictable end for wound care.
Follow-Up Visits
At subsequent visits, the nurse performs the following:
* evaluates change in overall health status;
* provides follow-up for any area noted earlier as a potential problem, including but not limited to nutritional intake, ability to apply compression stockings, fluid intake, pain management, and functional ability;
* notes disease processes that affect wound healing, thus considering a change in treatment regimen for heart failure, chronic obstructive pulmonary disease, or diabetes control;
* performs vital sign assessment;
* incorporates PU risk assessment using an instrument such as the Braden scale (AHCPR, 1992) and takes steps to reduce risk of skin breakdown;
* assesses wounds, documenting status and comparing wound with previous visit;
* revises instructions to patient and/or care-giver as needed.
Once the patient and caregiver demonstrate satisfactory performance of wound care, the home care clinician reduces the frequency of visits but continues to assess the wound and measure its healing at specific intervals. The clinician maintains regular communication with the physician or nurse practitioner to provide information about the progress of wound healing.
Summary
The home care nurse is a crucial and influential collaborator when a patient is referred for wound care. Accurate and consistent identification of wounds, and differentiation of wound type, is critical to care and healing. Obtaining adequate data from referral documents or through a comprehensive history and physical assessment on the initial visit(s) provides a starting point for care planning.
Based on the assistive and financial resources available to the patient, the home care nurse validates the proposed plan of care and adapts and modifies it as needed, based on knowledge of wound types and care products, and in collaboration with the healthcare team. However, the plan's success depends most on educating the patient and caregiver to facilitate independent care.
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