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.