Tag: Wound Assessment

Expanding horizons to upskill wound practice and research

With our horizons limited by Covid-related travel restrictions, it is more important than ever to experience and learn about our multicultural world through reading about wound-related research and practice in other jurisdictions and countries. Two such articles provide this important international insight and are included in this issue of the journal. The first by Obilor and colleagues describes the assessment of nurses’ knowledge, attitude and competence in wound assessment in a tertiary healthcare facility in southwest Nigeria. Here they found that many of the nurses surveyed were lacking in wound assessment competence … read more

Periwound Skin Management

Periwound skin management is just as important as wound bed preparation in wound healing. The goal of periwound management is to maintain an optimal moist wound healing environment while preventing skin breakdown and infection. Skin is more vulnerable in patients with certain comorbidities and conditions. Periwound skin breakdown is just one of the culprits that delay wound healing and increase pain … read more

Diabetic Foot Ulcers and Pressure Injuries: How Do You Tell the Difference?

In evaluating a patient with a wound on the foot, a question that often comes to mind is whether that wound is caused by pressure, diabetes mellitus (DM), ischemia, trauma, or a combination. For example, a patient with DM who happens to have an ulcer on the foot may have a diabetic foot ulcer (DFU) or possibly something else. One of the bigger challenges that many clinicians face is trying to determine the etiology of a foot ulcer. There has been a great deal of debate about DFUs and pressure injuries (PIs) on the feet of patients in terms of how to appropriately assess, classify, and treat them. The confusion and lack of evidence in differentiating between these two types of foot ulcers, particularly on the heel, can lead to misdiagnosis, which can increase both financial and patient-related costs … read more

Assessing the Links Between Eschar Removal and Management of Severe Burns

When treating severe burns, surgeons generally consider eschar removal to be the major factor and the top challenge in both initiating and planning for the optimal course of treatment for each patient. Before grafting, all devitalized tissue must be removed, leaving a wound bed of only healthy tissue. Some burn wounds are clearly full-thickness on initial examination, and some are clearly superficial, with relatively straightforward decision making. However, some wounds have an indeterminate depth and are more challenging. Deep partial-thickness, indeterminate-, and … read more

Tele Wound Care Navigation for Wound Care Providers

The digital age is upon us, like it or not, ready or not. For the past few years, payers have incentivized, encouraged, reimbursed, and adopted various digital, remote monitoring systems and devices as a way to encourage providers to adopt more digital, remote methods. Although complete telehealth services were not reimbursed in all care settings in all Zip Codes by all payers throughout the United States at the beginning of 2020, many of the restrictions and barriers to provide nearly complete digital services were suddenly released in response to the needs of a nation in the throes of a pandemic … read more

Wound Assessment: Think Like a Detective

Comprehensive wound assessment is analogous to a detective processing a crime scene. The scene is secured (patient scheduled for an evaluation); the scene is processed (patient history is established); evidence is collected and identified (tests, measures, special tests and/or diagnostics are performed) and a working theory and report is generated to ascertain what transpired and what next steps need to be taken. This is akin to establishing a differential diagnosis, determining contributing factors and creating a plan of care to manage the wound and the patients’ medical needs … read more

Is it a Pressure Injury?

     Factors to Consider When Determining Wound Etiology


As specialists in wound, continence and ostomy care, we are forever in a role of wearing many hats. We are educators to patients, staff, and providers… we are patient advocates and supporters of our bedside nurses… we are liaisons in many aspects of care and help to coordinate care and services for our patient population. We are often referred to as the specialist and are called upon when there is a patient with a wound, skin, ostomy, or continence concern. Our peers trust us, and it is important that we possess the knowledge and skills to share with others when determining etiology and treatment of wounds and skin issues.


Determining Wound Etiology
An issue we are often faced with as skin specialists is determining the etiology of wounds and skin concerns. When determining the etiology of wounds, it is important to look at the entire picture…and, when doing so, understand that many variables can and do make wounds better or worse, but there is usually an isolated variable that caused the wound.


Medical Device-Related Pressure Injuries
Some things to keep in mind: Pressure injuries are usually round, can appear punched out, may be partial- or full-thickness, may have slough or necrotic tissue, and are usually over a bony prominence. In terms of shape, pressure injuries related to devices usually take the shape of that device (think of a linear, fluid-filled blister from Foley catheter tubing on the thigh… a stage 2 medical device-related pressure injury, or a purple or discolored, non-blanchable area on the lip from an endotracheal tube… a mucosal pressure injury). Other devices that may be responsible for pressure injuries are prosthetic devices … read more

How to Assess Wounds for Tunneling and Undermining

by Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS

As part of a thorough wound assessment, in addition to noting location and measuring size, the entire wound bed should be probed for the presence of tunneling and/or undermining. If you are unsure what tunneling and undermining are and how to recognize these phenomena, here’s an explanation of these terms and how to assess wounds for their presence.

Tunneling Wounds

Tunneling is caused by destruction of the fascial planes which results in a narrow passageway. Tunneling results in dead space that has the potential for abscess formation. To measure tunneling, a probe is gently inserted into the passageway until resistance is felt. The distance from the tip of the probe to the point at which the probe is level with the wound edge represents the depth of the tunnel. Clock terms are often used to describe the position of the tunnel within the wound bed. This is helpful in identifying and remeasuring tunnel depth at a later time in order to assess progress of wound healing. Tunneling can occur in any wound, but it occurs most commonly in surgical wounds and wounds occurring from a neuropathic cause … read more

Wound Documentation Standards to Help Avoid Legal Issues

Medical providers, and especially wound care providers, seem to always be under the looming shadow of lawsuits and legal issues. I have written about this before, but it continues to be an issue as I receive requests for legal reviews repeatedly. I have read many charts for legal reviews, and it actually is very straightforward to avoid or mitigate any legal problems.


Important Steps to Take When Documenting a Wound

1. If you have a wound protocol, follow it or document why you didn’t. For example, if your protocol says a bed or chair bound patient on admission is high risk, then treat them as high risk, or document why you didn’t.

2. If you use an assessment tool such as Braden Scale or Norton Scale, be sure you know how to use it properly, and use it per protocol.

3. Document all calls to a physician and the response.

4. If there is a physician order, follow it and document that you adhered to the order.

  • For example, if an order says to notify physician if there is blood in the urine and you see blood in the Foley catheter, notify the physician and document that you did notify them and what the response was.

5. If you notice a change in your patient, report it to the proper person. For example: the patient has stopped eating normally, or the patient is acting differently. In an elderly patient this could be the first sign of infection … read more

Atypical Wounds: Causes and Management

Part 1 in a series discussing the etiology, assessment and management of atypical wounds.

As devoted clinicians to the field of wound management we take a responsibility to educate ourselves and others about wound etiologies and characteristics, as well as management of barriers to achieve positive outcomes. We spend a great deal of our careers learning about the most common offenders, such as pressure injuries, diabetic foot ulcers, venous stasis ulcers, arterial wounds, amputations, and traumatic wounds, to name a few. However, as our careers unfold we are faced with extra challenges, and atypical wounds are among them.

An atypical wound, also known as a wound of unknown etiology, is caused by a disease or condition that doesn’t cause a wound typically …. read more

Wound Documentation Dos & Don’ts

Scope of Practice and Standards of Practice guide nurses1 and other members of the interprofessional wound care team2 in caring for patients with wounds. Documentation in the medical record is a key aspect of the Standard of Practice and serves to record he care delivered to the patient. Your documentation should follow your facility guideline for documentation. This WoundSource Trending Topic blog considers general wound documentation dos and don’ts and presents 10 tips for success … read more