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Comprehensive Patient and Wound Assessments

Hess, Cathy Thomas, BSN, RN, CWCN

Advances in Skin & Wound Care: June 2019 - Volume 32 - Issue 6 - p 287–288
doi: 10.1097/01.ASW.0000558514.64758.7f
DEPARTMENTS: PRACTICE POINTS
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This installment of Practice Points is excerpted from Hess CT. Assessing documenting chronic wounds. Clinical Guide to Skin and Wound Care. 7th ed. Philadelphia, PA: Wolters Kluwer; 2012. Cathy Thomas Hess, BSN, RN, CWCN, is Vice President and Chief Clinical Officer for Wound Care, Net Health. Ms Hess presides over Net Health 360 WoundExpert Professional Services, which offers products and solutions to optimize process and workflows. Address correspondence to Ms Hess via email: chess@nethealth.com.

Performing a comprehensive patient assessment is an essential first step toward healing a chronic skin condition or wound. After the clinician has assessed the patient, identified any underlying conditions affecting healing, performed a complete assessment of the patient’s nutrition status, performed the proper tests to provide an accurate diagnosis of the underlying problem, assessed the patient’s knowledge of the disease, and documented all factors that affect the learning needs of the patient, a complete skin and wound assessment can be completed.

The assessment is set in motion with a one-on-one discussion between the patient or caregiver and clinicians who have cared for the patient’s skin and wound. Understanding the patient’s past and current family, social, and medical history may provide important insight into why the wound isn’t healing. Clinical interventions will vary according to the assessment.

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Checklist: Obtaining a History

A thorough review of the patient’s medical history, laboratory tests, medications, and diet can help the clinician determine the cause of the skin condition or wound. Chronic wounds, for example, can be caused by a multitude of different diseases. To obtain a patient’s history, follow these steps:

✓ Review the patient’s medical history, including allergies, laboratory studies, radiologic studies, vascular studies, medications, past illnesses, surgical procedures, and other pertinent facts related to the patient’s illnesses and problems. Ask the patient if his/her skin’s appearance changes with the seasons.

✓ Review the patient’s family history, paying particular attention to 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 will alert you to the presence of inherited or congenital conditions or diseases.

✓ Review the patient’s social history, including age-appropriate information regarding past and current activities, such as marital status, living arrangements, current employment and occupational history, sexual history, level of education, and use of drugs, alcohol, or tobacco.

✓ Ask about the patient’s bathing routines and about the different soaps, shampoos, conditioners, lotions, oils, and other topical products he/she uses routinely. Any such products may lead to changes in skin, appearing as xerosis, pruritus, wounds, rashes, or a change in skin color.

✓ Obtain a list of past and current medications and dressings, including all medications and dressings that have been used, have been effective, or have failed.

✓ Review previous treatments, dressings, drugs, and 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 nutrition status and supportive therapies.

For the patient who has a wound:

✓ Review all clinician consultations related to specialty management programs for skin and wound care.

✓ 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.

✓ Assess the patient’s knowledge of the disease and document all factors that affect learning needs.

These findings will provide the clinician with a strong foundation upon which to manage the patient’s skin and wound. An incomplete assessment may delay the skin- or wound-healing process.

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Performing a Physical Assessment

Differential assessment of the skin condition or wound is essential to understanding its cause and development. First, assess the patient’s skin temperature, dryness, itching, bruising, and changes in texture of skin and nail composition. Also, assess the skin for color and uniform appearance, thickness, symmetry, and primary or secondary lesions.

Examine the patient’s nails for changes in thickness, splitting, discoloration, breaking, and separation from the nail bed. Question the patient about changes in his/her nails, which may be a sign of a systemic condition.

Document all the findings of the skin assessment. Note, too, any presence of a skin condition: erythema, itching, scratching, skin weeping, skin blistering, bruising, primary lesions, secondary lesions, and open wounds.

A comprehensive wound assessment is the next important step. The wound assessment helps define the status of the wound and helps identify impediments to the healing process. A clear understanding of the anatomy of the skin is essential for assessing and classifying the wound and defining the level of tissue destruction. A detailed assessment of the patient’s wound status includes, but is not limited to, the following parameters:

Location. Anatomic location describes the lesion and the nearest bony prominence or another anatomic landmark. Detailing each wound’s location is imperative for accurate documentation and consistent care by each provider working with the patient.

Size (length, width, depth, undermining). Accurate wound measurements can assist the clinician in designing an appropriate care plan. Consistent vocabulary and units of measure are essential when documenting or describing the wound.

Color and type of wound tissue. Wound bed description and wound color provide a consistent approach in defining the tissue in the base of the wound. Descriptors such as granulation tissue, slough, and eschar are generally used to define tissue type. Color of the tissue also has been used to distinguish viable tissue from nonviable tissue.

Exudate or drainage amount and type. The amount of wound exudate or drainage is assessed and described with each dressing change. The number of dressing changes needed per week can help with estimating the amount of exudate present. Large amounts of exudate may indicate an infection and a barrier to healing.

Odor. Odor helps define the presence and type of bacteria in the wound and is assessed only after the clinician has cleaned the wound.

Periwound skin condition. Periwound skin is assessed for color and temperature. Inflammation or erythema may indicate wound infection or dermatitis; assessing for maceration or denuded tissue is also important. Macerated periwound skin should prompt the clinician to assess the topical wound dressing for its ability to manage exudate. Macerated or denuded periwound skin is also a concern when the clinician needs to anchor a dressing.

Wound margins. The condition of the wound margins can provide the clinician with information about the wound’s chronicity or healing ability. Newly formed epithelium along the wound edge, commonly flat and pale pink to lavender in color (termed the edge effect), indicates stimulated healing.

Pain. The presence, absence, or type of pain may indicate infection, underlying tissue destruction, neuropathy, or vascular insufficiency.

Adjunctive therapies. Adjunctive therapies and support, such as negative-pressure wound therapy, support surfaces for bed and chair, and rehabilitation services, play a vital role. The patient’s wound should determine the level of therapy needed.

Patient knowledge. The educational needs of the patient must be evaluated on an individual basis, beginning with a nonjudgmental assessment of the patient’s knowledge relevant to the care plan. An experienced clinician should direct the educational activities.

Dressing management. A moist wound healing environment requires a proper dressing. Considerations for choosing proper primary and secondary dressings are based on wound characteristics, including size, undermining or tunneling, and amount of exudate.

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