wound has a depth less than 0.2 cm, it is scored as 0 at all four points and at general depth. Greater depth and undermining means that the wound has extended into subcutaneous tissues and the wound is now full thickness, which are two indicators of “not good for healing.”
11–15: Wound Depth
Five items on Part II of the SWHT are related to presence of depth of at least 0.2 cm, both in general depth and at the four points of the clock—the 12, 3, 6, and 9 o’clock positions. Depth is measured as described in Chapter 4, and if it is at least 0.2 cm, it is recorded as present. Extent of depth is not reported for this assessment as long as it is at least 0.2 cm. Figure 5.20 has greater than 0.2 cm and is classifi ed as full-thickness depth.
16–19: Undermining/Tunneling
Undermining and tunneling are measured at all four points of the clock, like depth. Likewise, the indication used to report this attribute is present or absent at each point The more points
FIGURE 5.20 Soft, soggy necrosis and bruising often referred to as
“purple” ulcer. Food shows signs of cellulitis and edema. Acute infl am- matory phase. (Copyright © C. Sussman.)
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present. The next column ranks the relationship to healing as not good or good. The last column is where the rating is listed as a score of present or absent. Part II lists measures and extent.
The same scoring system of present or absent for 19 attributes of extent is applied. The attributes are the general depth of greater than 0.2 cm, the depth at the four clock points, and undermining at the four clock points. Date and week of care should be noted on the form. The benefi t of this form is having the defi nitions on the form. This would be helpful to a nurse or PT learning the system or for medical reviewers and surveyors looking for information about the rating system used for documentation.
Form B of the SWHT is the same as Form A, except that in this version the form lacks the explanations printed on the form. Form B lists only the attributes and has columns to record data for multiple weeks as shown in Exhibits 5.1A and 5.1B.
tissue status benchmarks the healing process and becomes a target functional outcome for reporting purposes, such as the wound will be hemorrhage free, undermining free, necrosis free, and so forth. Clinicians can quickly determine a change in wound tissue status during the course of care because, as already described, the wound attributes should change from those that are not good for healing to those that are good for healing.
SWHT Forms
Form A
There are two forms of the SWHT (see Appendix 5A). Form A, Part I contains the 10 tissue attributes, listed in descending order of severity, next to an explanation of each s, followed by a col- umn listing the rating option for the attribute as present or not
Using SWHT Form B
Patient History
Bed and wheelchair bound 90-year-old female with a recur- rent pressure ulcer in the left scapular region as a secondary complication of a signifi cant kyphoscoliosis of the thoracic spine. Scar tissue is present in this area and there is a prior history of pressure ulceration at that location. The SWAT is used to record wound progress with physical therapy wound management over the course of a 4-week period. Since this
wound is a partial-thickness ulcer, there were no scores for depth or undermining and there is adherence from baseline.
Debridement of the necrotic tissue left appearance of a thin layer of granulation tissue. Tables 5.2 and 5.3 show how the SWHT refl ected the wound’s progress.
Case Study Source: Rujita Dhere, MSPT, WCC 2010
CASE STUDY
SWHT Part I: Wound Tissue Attributes
Week 0 1 2 3 4
Date: 2010
1. Hemorrhage 0 0 0 0 0
2. Maceration 0 0 0 0 0
3. Undermining 0 0 0 0 0
4. Erythema 1 1 1 1 0
5. Necrosis 1 1 0 0 0
6. Adherence 1 1 1 1 1
7. Granulation (decreased depth)
0 1 1 1 1
8. Appearance of contraction (reduced size)
0 0 1 1 1
9. Sustained contraction (more reduced size)
0 0 0 1 1
10. Epithelialization 0 0 0 0 1
Total “Not Good” 2 2 1 1 0
Total “Good” 1 2 3 4 5
Key: Present = 1. Absent = 0.
Patient with Upper Back Pressure Ulcer 5.2
TABLE SWHT Part II: Size, Location, Wound Healing Phase
Measures, and Extent
Week 0 1 2 3 4
Date:
11. General depth > 0.2 cm 0 0 0 0 0 12. Depth @ 12:00 > 0.2 cm 0 0 0 0 0
13. Depth @ 3:00 > 0.2 cm 0 0 0 0 0
14. Depth @ 6:00 > 0.2 cm 0 0 0 0 0
15. Depth @ 9:00 > 0.2 cm 0 0 0 0 0
16. Underm @ 12:00 > 0.2 cm 0 0 0 0 0 17. Underm @ 3:00 > 0.2 cm 0 0 0 0 0 18. Underm @ 6:00 > 0.2 cm 0 0 0 0 0 19. Underm @ 9:00 > 0.2 cm 0 0 0 0 0
Location UB UB UB UB UB
Wound healing phase I P P E E
Key: Present = 1. Not present = 0. Location choices: upper body (UB), coccyx (C), trochanter (T), ischial (I), heel (H), and foot (F); add right or left (R or L).
Wound healing phase: infl ammation (I), proliferation (P), epithelialization (E), remodeling (R).
5.3
TABLE
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Case Example 2 Using the SWHT
Exhibits 5.2A and 5.2B show an example of a case where wound healing was monitored over a 5-week course of care, as reported on Form A of the SWHT, Parts I and II. A summary (see Exhibit 5.3) of the case example shows how the SWHT can be used to document a change in wound tissue status from a predominance of not-good-for-healing attributes to a pre- dominance of good attributes. Exhibits 5.2A and 5.2B refl ect the following:
• At baseline, week 0, the patient had the presence of hemor- rhage, necrosis, and erythema, and absence of any attributes good for healing. The presence of these attributes at baseline is an indication that this wound will need aggressive interven- tion to improve.
• At week 2, there were multiple attributes that were indicators that this patient would be in the risk-for-not-healing group, including undermining and depth at all four clock points, further indicating the medical necessity for aggressive inter- vention to put the wound on a course of healing.
• Following aggressive intervention undertaken at week 2, the improvement in the wound tissue status from not good to good is signifi cant by week 4.
SWHT Database
The SWHT can be used to create a wound database on a com- puter. The scoring system of using a 1 or a 0 is computer com- patible for data management and data entry. The SWHT forms are printed on the computer as screens, and data are entered Part I can be printed on one side of a page and Part II on the
other. Printing the forms as a pad punched with a hole pat- tern to match the notebook or chart where a paper form is kept makes it easy and convenient to keep forms on hand.
A set of the explanations and scoring can be printed on the same size paper, and then kept in the notebook for reference.
An additional benefi t of Form B is that it is easy to see a complete history of the change in tissue status over multiple weeks of assessment. Reading the report over time provides a quick and clear evaluation to monitor wound healing progress.
The entire SWHT can become part of the patient’s electronic record by creating a template of the form for completion by the clinician on the computer.
CLINICAL WISDOM
Use of Forms for Wound Measurement Along with the SWHT
Because wound measurement and tissue assessment or reas- sessment are usually done at the same time, it makes sense to record the information at the same time using a companion form. Chapter 4 has examples of a sample wound measure- ment form designed to fi t this model.
EXHIBIT 5.1A
SWHT Short Form Part I: Wound Tissue Attributes Name: __________ Med Rec # _______ Examiner: ______
Week 0 1 2 3 4
1. Hemorrhage 2. Maceration 3. Undermining 4. Erythema 5. Necrosis 6. Adherence
7. Granulation (decreased depth)
8. Appearance of contraction (reduced size)
9. Sustained contraction (more reduced size) 10. Epithelialization
Key: Present = 1. Not present = 0.
Total not good Total good
Source: Copyright © 1997, Sussman Physical Therapy, Inc.
EXHIBIT 5.1B
SWHT Short Form Part II: Size, Location, Wound Healing Phase Measures, and Extent
Date 0 1 2 3 4
11. General depth > 0.2 cm 12. Depth @ 12:00 > 0.2 cm 13. Depth @ 3:00 > 0.2 cm 14. Depth @ 6:00 > 0.2 cm 15. Depth @ 9:00 > 0.2 cm 16. Underm @ 12:00 > 0.2 cm 17. Underm @ 3:00 > 0.2 cm 18. Underm @ 6:00 > 0.2 cm 19. Underm @ 9:00 > 0.2 cm Location
Wound healing phase
Key: Present = 1. Not present = 0. Location choices: upper body (UB), coccyx (C), trochanter (T), ischial (I), heel (H), and foot (F); add right or left (R or L). Wound healing phase: absent (A), chronic (C), infl ammation (I), proliferation (P), epithelialization (E), remodeling (R).
Source: Copyright © 1997, Sussman Physical Therapy, Inc.
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either prospectively or retrospectively. Data reports can be printed, and the captured data can be analyzed for each indi- vidual patient or by group.