1. Hess, Cathy Thomas BSN, RN, CWOCN

Article Content

A chronic wound is, simply stated, an insult or injury to the skin that has failed to heal. The patient with a chronic wound generally presents with a host of factors that impede the healing process. Chronic diseases, such as diabetes, vascular insufficiency, and various autoimmune diseases, can inhibit the wound from healing properly. In addition, chronic diseases affect the overall condition of the patient's skin, including its moisture level and texture. These factors can ultimately lead to generalized patient discomfort.


To achieve successful skin and wound healing, clinicians must meticulously follow every step of skin and wound management, including assessment, planning, implementation, evaluation, and documentation. Clinicians are responsible for assessing the patient's skin, wounds, and dressings/drugs/devices; implementing wound care orders; selecting and changing wound care orders; and preventing infection during procedures. Identifying and addressing systemic factors in wound healing are also essential for successful outcomes. Clinical interventions vary according to the assessment.


A thorough wound assessment includes the following:


* the condition of the patient's skin


* the condition of the skin around the wound


* the status of the wound (whether acute or chronic)


* the amount of wound exudate, if any


* the presence or absence of necrosis


* the appearance of the wound, such as whether the wound is red, yellow, or black


* evidence of possible infection or lack thereof


* the degree of cleaning and packing required


* the nature of the dressings needed


* management of the drainage


* management of the patient's pain.



A thorough review of the patient's medical history, laboratory tests, medications, and diet can assist the clinician in determining the cause of the skin condition or wound. Chronic wounds, for example, can be caused by a multitude of different diseases. Primary causes include pressure, chronic venous insufficiency, lower-extremity arterial disease, and diabetic neuropathy. Differential assessment of the skin condition or wound, before implementation of management strategies, is essential for understanding its cause and development.


Understanding the patient's family, social, and medical history may provide important insight into why the wound is not healing. Clinicians should follow these guidelines when conducting a comprehensive patient assessment:


* review the patient's medical history, which details allergies, laboratory studies, radiological studies, vascular studies, medications, past illnesses, surgical procedures, and other pertinent facts related to the patient's illnesses and problems


* review the patient's family history, focusing on parents, siblings, grandparents, and natural children and detailing the age and general health information of living relatives, the death and cause of death of all deceased family members, and any chronic diseases that occur in the immediate family (this information may alert the clinician to any inherited or congenital conditions or diseases)


* review the patient's social history, which describes age-appropriate information regarding past and current activities, such as marital status; living arrangements; current employment; occupational history; use of drugs, alcohol, or tobacco; sexual history; level of education; and other social factors that may influence the patient's activities of daily living


* obtain a list of past and current medications and dressings, including which have been effective and which have failed


* review previous treatments, dressings, drugs, adjunctive modalities (such as physical therapy, skin replacements, and growth factors) and determine their effectiveness


* review all laboratory, radiology, and vascular studies that have been performed


* review the patient's nutritional status and supportive therapies


* review (if indicated) all support surfaces and positioning devices used to manage the patient's tissue load


* review (if indicated) any use of devices, such as compression stockings, custom shoes or braces, and assistive devices


* review all clinician consultations related to specialty management programs for skin and wound care


* assess the patient's knowledge of the disease, and document all factors that affect learning needs


* address and correct (if possible) all underlying pathologies compromising the wound- or skin-healing process, such as neuropathic, pressure, vascular, or venous hypertension.



Remember, initiation and coordination of a successful skin and wound care plan cannot begin without a comprehensive patient assessment.


Source: Hess CT. Clinical Guide: Skin & Wound Care; 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.