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Medical Diagnosis: Acute or Chronic Wound

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Re-evaluate plan of care or address underlying etiology if ulcer has not reduced in size during 2 to 4 weeks of care Wound is not infected and is healing as evidenced by a reduction in size

after 2 to 4 weeks of care. No evidence of new skin breakdown.

Secondary Dressing

Reduce risk factors for developing chronic ulcers and delayed healing, e.g.:

Expected Outcomes Delayed Healing

Wound Assessments Observed Goals of

Patient Care

Wound bed/exudate Wound bed/tissue

Depth

Surrounding skin

Wound edges

Goals of Wound Care

Primary Dressing

Patient Care Plan

Re-evaluate plan of care or address underlying etiology if ulcer has not reduced in size during 2 to 4 weeks of care Wound is not infected and is healing as evidenced by a reduction in size

after 2 to 4 weeks of care. No evidence of new skin breakdown.

Secondary Dressing

Reduce risk factors for developing chronic ulcers and delayed healing, e.g.:

Expected Outcomes Delayed Healing

Wound Assessments Observed Goals of

Patient Care

Wound bed/exudate Wound bed/tissue

Depth

Primary Dressing

Patient Care Plan

Medical Diagnosis: Acute or Chronic Wound

Nursing Diagnosis: Skin Integrity Impaired or Tissue Integrity Impaired

> 25% necrotic tissue/fibrin slough Wet-heavily exuding

Cleanse and Debride* Wound Superficial or partial thickness Full-thickness

Wound Care Plan Cleanse/Debride

Exudate Management

Moisture Retentive Dressing

Surrounding skin

Wound edges

Goals of Wound Care

Healthy/

reddened

Healthy Healthy Undermined

White/gray/

macerated

Healthy/

reddened

White/gray/

macerated

Absorb excess exudate/

maintain moist environment

Prevent premature wound closure Absorb excess exudate/

maintain moist environment

*Wound Debridement Options:

- Autolytic

- Enzymatic - Apply enzymatic debridement agent according to package insert instructions, avoiding exposure to intact skin.

- Surgical - Qualified provider removes devitalized tissue with scalpel or other sharp instrument.

Obtain hemostasis before dressing wound.

Reduce risk factors for ulcer development and delayed healing. Prevent wound complications and promote wound healing.

Assess for Clinical Signs and Symptoms of Infection (Purulent exudate and/or elevated temperature and/or peripheral induration or edema)

RISK FACTORS

Arterial ulcers: Smoking, hypertension, hyperlipidemia and inactivity. Review surgical/medical management options to improve arterial circulation.

Diabetic ulcers: Smoking, hypertension, obesity, hyperlipidemia and high blood glucose. Review surgical/medical management options and use appropriate off-loading techniques.

Pressure ulcers: Pressure, shear, friction, nutritional deficiencies, dehydration and dry skin conditions, skin exposure to moisture or wound contamination secondary to incontinence, perspiration or other fluids, e.g. skin protection.

Venous ulcers: Edema with leg elevation, ambulation and compression. If patient is not ambulatory, assure frequent ankle flexes. Review surgical/medical management options to improve arterial circulation and compression bandages if appropriate.

Mixed arterial-venous ulcers: Smoking, hypertension, inactivity, hyperlipidemia. Review surgical/medical management options to improve arterial circulation and compression bandages if appropriate.

All patients: Provide patient and/or caregiver teaching and support. Confirm and treat infection if needed. Assess and manage wound pain and odor if present.

Obtain clean wound bed

FIGURE 5.26 General full-thickness wound with critical BWAT severity score treatment algorithm. (Reprinted from ConvaTec, with permission.)

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Re-evaluate plan of care or address underlying etiology if ulcer has not reduced in size during 2 to 4 weeks of care Wound is not infected and is healing as evidenced by a reduction in size

after 2 to 4 weeks of care. No evidence of new skin breakdown.

Secondary Dressing

Reduce risk factors for developing chronic ulcers and delayed healing, e.g.:

Expected Outcomes Delayed Healing

Wound Assessments Observed Goals of

Patient Care

Wound bed/exudate Wound bed/tissue

Depth

Surrounding skin

Wound edges

Goals of Wound Care

Primary Dressing

Patient Care Plan

Medical Diagnosis: Acute or Chronic Wound

Nursing Diagnosis: Skin Integrity Impaired or Tissue Integrity Impaired

< 25% necrotic tissue/fibrin slough Moist-moderately exuding

Cleanse Wound

Superficial or partial thickness Full-thickness

Healthy/

reddened

Healthy

Maintain moist environment

Healthy Undermined

Wound Care Plan Cleanse

White/gray/

macerated

Healthy/

reddened

White/gray/

macerated

Absorb excess exudate/

maintain moist environment

Maintain moist environment

Absorb excess exudate/

maintain moist environment

Prevent premature wound closure

Moisture Retentive Dressing

Exudate Management

Moisture Retentive Dressing

Exudate Management

N/A

Moisture Retentive Dressing

N/A

Moisture Retentive Dressing

Reduce risk factors for ulcer development and delayed healing. Prevent wound complications and promote wound healing.

Assess for Clinical Signs and Symptoms of Infection (Purulent exudate and/or elevated temperature and/or peripheral induration or edema)

RISK FACTORS

Arterial ulcers: Smoking, hypertension, hyperlipidemia and inactivity. Review surgical/medical management options to improve arterial circulation.

Diabetic ulcers: Smoking, hypertension, obesity, hyperlipidemia and high blood glucose. Review surgical/medical management options and use appropriate off-loading techniques.

Pressure ulcers: Pressure, shear, friction, nutritional deficiencies, dehydration and dry skin conditions, skin exposure to moisture or wound contamination secondary to incontinence, perspiration or other fluids, e.g. skin protection.

Venous ulcers: Edema with leg elevation, ambulation and compression. If patient is not ambulatory, assure frequent ankle flexes. Review surgical/medical management options to improve arterial circulation and compression bandages if appropriate.

Mixed arterial-venous ulcers: Smoking, hypertension, inactivity, hyperlipidemia. Review surgical/medical management options to improve arterial circulation and compression bandages if appropriate.

All patients: Provide patient and/or caregiver teaching and support. Confirm and treat infection if needed. Assess and manage wound pain and odor if present.

Obtain clean wound bed

FIGURE 5.27 General full-thickness wound with undermining or pocketing with moderate BWAT severity score treat- ment algorithm. (Reprinted from ConvaTec, with permission.)

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Re-evaluate plan of care or address underlying etiology if ulcer has not reduced in size during 2 to 4 weeks of care Wound is not infected and is healing as evidenced by a reduction in size

after 2 to 4 weeks of care. No evidence of new skin breakdown.

Secondary Dressing

Reduce risk factors for developing chronic ulcers and delayed healing, e.g.:

Expected Outcomes Delayed Healing

Wound Assessments Observed Goals of

Patient Care

Wound bed/exudate Wound bed/tissue

Depth

Surrounding skin

Wound edges

Goals of Wound Care

Primary Dressing

Patient Care Plan

Medical Diagnosis: Acute or Chronic Wound

Nursing Diagnosis: Skin Integrity Impaired or Tissue Integrity Impaired

> 25% necrotic tissue/fibrin slough Dry-minimal moisture

Cleanse and Debride* Wound Superficial or partial thickness Full-thickness

Healthy/reddened

Healthy

Provide moist environment

Healthy Undermined

Healthy/reddened

Provide moist environment/

prevent premature wound closure

Wound Care Plan Cleanse/Debride

Wound Hydration

Moisture Retentive Dressing Obtain clean wound bed

*Wound Debridement Options:

- Autolytic

- Enzymatic - Apply enzymatic debridement agent according to package insert instructions, avoiding exposure to intact skin.

- Surgical - Qualified provider removes devitalized tissue with scalpel or other sharp instrument.

Obtain hemostasis before dressing wound.

Reduce risk factors for ulcer development and delayed healing. Prevent wound complications and promote wound healing.

Assess for Clinical Signs and Symptoms of Infection (Purulent exudate and/or elevated temperature and/or peripheral induration or edema)

RISK FACTORS

Arterial ulcers:Smoking, hypertension, hyperlipidemia and inactivity. Review surgical/medical management options to improve arterial circulation.

Diabetic ulcers:Smoking, hypertension, obesity, hyperlipidemia and high blood glucose. Review surgical/medical management options and use appropriate off-loading techniques.

Pressure ulcers:Pressure, shear, friction, nutritional deficiencies, dehydration and dry skin conditions, skin exposure to moisture or wound contamination secondary to incontinence, perspiration or other fluids, e.g. skin protection.

Venous ulcers:Edema with leg elevation, ambulation and compression. If patient is not ambulatory, assure frequent ankle flexes. Review surgical/medical management options to improve arterial circulation and compression bandages if appropriate.

Mixed arterial-venous ulcers: Smoking, hypertension, inactivity, hyperlipidemia. Review surgical/medical management options to improve arterial circulation and compression bandages if appropriate.

All patients:Provide patient and/or caregiver teaching and support. Confirm and treat infection if needed. Assess and manage wound pain and odor if present.

FIGURE 5.28 Critical BWAT severity score with dry eschar treatment algorithm. (Reprinted from ConvaTec, with permission.)

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an adequate support surface, determining need for more advanced wound care, and consideration of the status of the whole patient is also part of the care plan.

Outcomes with Standardized Wound Assessment Using the BWAT

The BWAT was evaluated as part of a standardized assessment and treatment program in a prospective multicenter study of wound healing outcomes.30 Wound healing outcomes from March 26 to October 31, 2001 were recorded on patients in three long-term care facilities, one long-term acute care hos- pital, and 12 home care agencies for wounds selected by staff to receive care based on computer-generated validated wound care algorithms, which were based on BWAT scores. Most of the 767 wounds selected to receive the standardized protocols of care based on BWAT scores were stage III to IV pressure ulcers (n = 373; mean healing time 62 days) or full-thickness venous ulcers (n = 124; mean healing time 57 days). The study provides data on use of BWAT scores to identify treatments and measure healing. In addition to being used to identify spe- cifi c wound treatments, the BWAT has been used to describe characteristics of recurrent pressure ulcers in persons with spi- nal cord injury as these ulcers have not been well described.

Because the BWAT evaluates multiple wound characteristics it is particularly well suited for describing specifi c wound char- acteristics in special populations or wounds. For example, recurrent pressure ulcers in persons with spinal cord injury tend to occur at the same anatomic location as the original ulcer, present as full-thickness ulcers with a mean BWAT score of 33.63, minimal exudate, and with nearly half presenting with undermining (48%) and necrotic slough (50%).31 The BWAT has also been used as an outcome measure examining use of negative pressure wound therapy for pressure ulcers in a long-term acute care setting.32 The BWAT is incorporated into several health-care organizational electronic medical records (EMR) and lends itself well to EMR in terms of data entry and data access for reports.

WOUND HEALING ASSESSMENT TOOLS

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