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Discuss the inclusion and exclusion criteria of a wound assessment chart.

The importance of wound assessment in wound management

Skin is the largest organ of the body. It makes up to 16% of the body’s weight. It serves several vital functions: immune function, temperature regulation sensation, synthesis of vitamin D. The skin is a dynamic organ that is constantly changing. It constantly sheds off and gets replaced by the inner layer. A wound develops when the skin tissue gets damaged by trauma. This compromises its functioning (Menna, 2017). Wound assessment plays an important role in wound management as it facilitates in identifying factors that may be preventing wounds from healing. However, wound assessments are often subjective and is practitioner reliant, the information collected can vary dependent on skill and education of the individual. In wound assessment consistency can be difficult as assessments such as pain, size of the wound, exudate and odor can vary between clinicians (Fletcher, 2007). A structured wound measurement tool can remove imprecise terms and measurement techniques.

This assignment will focus on developing a wound assessment chart. This charts’ appropriateness will be described in terms of the workplace, the patient group and the size of the work setting. Secondly, a description of the professional group working at the setting and its consideration in developing the chart. Thirdly, a justification of developing the wound assessment chart. Fourthly, consideration of the documentation, can it stand by its own or is it part of the hospital. Fifthly, ensure that the chart is user friendly. Sixthly, come up with a rationale of the inclusion and the exclusion of each characteristic when developing the chart. That is a discuss on the inclusion and exclusion criteria of a wound assessment chart used in a private podiatry practice (Krasner, 1992). Lastly, a summary of the assignment.

The professional team.

Podiatrist treat foot and lower limb conditions including diabetic and foot ulcers (QUT website). Podiatrists in a multidisciplinary team are involved in primary prevention and management of diabetes related foot complications including foot ulcers (Lazzarini, 2014). Evidence has shown that early prevention, education for patient and staff, treatment from a multidisciplinary team can reduce amputation rates by 49-85% (Andrews, Houdek, & Kiemele, 2015). Management strategies that are often implemented by podiatrist include sharps debridement, dressing changes and offloading the pressures on the wounded foot (Gibson et al, 2013). A variation of disciplines makes up a multidisciplinary team, those involved typically are vascular surgeons, endocrinologist, orthopaedic surgeons, nurse specialist, podiatrist and orthotists (Buggy & Moore, 2017). It is therefore important to have a reliable assessment tool with consistent language to assist in the share care and collaboration of health professionals.

The need for a structured measurement tool

The Queensland High Risk Foot Form (QHRFF) was a tool developed to capture risk factors, assess foot wounds, and analyse patient outcomes in a hospital setting. The QHRFF assessment tool showed majority of the criteria to be moderate in validity and reliability, however, the authors states that a systematic literature review was not performed and was limited to podiatrists only to test the inter-reliability of the tool.

For podiatrist in private clinics, often working on their own and can be limited with time and funding an assessment tool was improved to suit their needs. The assessment tool needed to be time efficient and had instruction on how to assess high risk foot, improve so as to suit private practice, stand on its on in documentation and have instructions on how to use the chart (Greatrix-White & Moxey 2015).

The wound healing assessment chart.

Greatrix-White & Moxey (2015) study reported that nurses are not confident in developing a wound management plan and executing it out. The study suggested that for best practice in wound management, nurses required a structured assessment tool and educational guidelines with a clear guideline.

The primary/basic level in contact with the patient, the patient’s details are important in identification purpose. They match the patient and the wound assessment to be done. Secondly, the wound assessment is a holistic assessment and in order to ensure that its holistic the patients detail and condition are important. The patient’s comorbidities that could affect the wound healing should be recorded. This will allow the healthcare to put them into consideration when planning their wound management (Menna, 2017).

The site and the size of the wound.

Grey et al., (2006) identification and recording the wound site is important, especially if there is more than one area of skin breakdown. In addition to this, the site of wound is important in the diagnosis of an underlying ailment that could be associated with the wound development. In the case of diabetic foot ulcer, they arise in the areas of abnormal distribution of pressure while the venous ulcers develop in the gaiter area of the leg.

Every wound needs to be reassessed and measured each time it gets dressed. Since it is a nursing procedure documentation of the findings should be recorded. To assess the depth of the wound, the measurements starts from the epidermis to the part that is deepest. Grey et al., (2006) suggested that to get the margins of the wounds a transparent acetate sheets and estimate the surface area.  This should be done every time the wound is dressed. It forms the baseline to be referred for wound healing progresses.

Factors that affect wound healing

Factors affecting wound healing.

The following factors influences wound healing: nutrition status of the patient, present medication of the patient and the aetiology of the wound. Good nutritional support promotes the healing of the wound. When the patient is malnourished there is delays, complicates and inhibits the healing process (Williams & Leaper 2010). It is therefore important to assess the nutritional status of the patient with a wound and it should be recorded. In case of inadequacy, health promotion should be offered and also the patient should be referred to a dietitian. The tools to assess nutritional status includes the malnutrition universal screening tool (MUST), body mass index (BMI).

The anti-coagulants and anti-platelets drugs interferes with the clotting process which negatively affects the wound healing process. medications such as non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and disease modifying anti-rheumatic drugs (DMARDs) they lowers the immunity levels which increases the infection rates affecting the healing process (Fletcher, 2010).

Etiology of the wound is important in planning the care of the wound and in assessing its healing progress. In case the wound is as a result of diabetes mellitus the healing progress is expected to increase slowly and gradually and its management includes controlling the blood sugars. In case it’s as a result of sickle cell/sickle ulcers, the management revolves around managing sickle cell disease (Fletcher, 2010).

An infected wound produces purulent discharge. For effective wound healing, this discharge has to be controlled. The wound environment has to be kept warm and moist so as to ensure effective healing (Winter 2012) and also prevent skin maceration. A healthy exudate is normally clear and amber colored and has no odor. It becomes malodorous as the wound bacterial infection increases.

The changes in the characteristics of the exudate should be reported. Increase in protein content is associated with infection and also it is associated with the exudate being sticky and thick. When the exudate is thin and runny, it may be as a result of low protein content which is associated with venous congestion, cardiac disease or malnutrition (White & Cutting, 2016).

It is therefore important for the health practitioner assessing the wound healing to assess the exudate; colour, consistency, odor and the amount. Measuring and recording the amount of the exudate of a wound at times is difficult. To make it easy, the dressing used should be assessed in terms of being soiled. The observations made can be indicative of exudate levels increasing, remaining static or decreasing (White & Cutting, 2016).

The role of podiatrists in wound management

For effective wound treatment, the nursing management should focus on finding out the etiology of the wound. Secondly, identify the comorbidities or/and complications that would contribute to the wound development or delayed wound healing. Thirdly, assessing the status of the wound. Lastly, develop a wound management plan (White & Cutting, 2016).

To assess this the international advisory board on wound bed assessment formulated the TIME acronym to aid the health care providers with a tool that enables the systematic approach to the wound management. The acronym is important as it optimizes the wound bed by reducing the exudate and moisture which reduces the bacterial burden and corrects any abnormalities that may be present (Williams & Leaper 2010). The acronym TIME:

The wound bed tissue should be assessed and identified, where the tissue is deficient and non-viable there is delayed in healing. The removal of this tissue is vital in facilitating wound healing. In addition to this, devitalized tissue not only does it prevent the wound healing but it also increases the wound infection. In case of necrotic tissues, (eschars) they should be removed so as to facilitate healing. Lastly, slough a yellow fibrinous tissues which contains fibrin, pus and dead cells lengthens the process of inflammation and it prevents the proliferative phase of wound healing (Stephen-Hayes & Thompson, 2017). To promote healing the slough should be removed.

If the wound is infected the wound requires treatment and also the wound healing process is delayed. It causes pain and discomfort to the patient. Through critical colonization all wounds contain bacterial infection. Cooper (2015) reported that the diagnosis of bacterial wound infection is a task for a clinical skill. The microbiology data obtained should be used to aid in formulating the clinical diagnosis. The wound swabs should be taken and appropriate antibiotics administered.

Moisture is important in wound healing as it enhances the autolytic process. It also acts as a medium for the transport of the growth factors that are essential during the epithelization phase of wound healing (Cutting & Tong 2014). When the wound dries, a scab forms which causes wound contraction that delays the wound healing. When the wound gets so wet, the exudate damages the peri-wound skin that causes maceration. The choice of the wound dressing material so as to have the correct amount of moisture retained is important so as to enhance wound dressing.

The failure of the wound to heal can be deduced through the lack of improvement on the wound dimensions. Secondly, the failure of the edges of epidermal improve as times goes by. An undermined margin of the wound is indicative of wound infection or as a result of critical colonization. If this is the case the wound requires reassessment and the current treatment should have reassessed too. In addition, the patient can be referred to a tissue viable specialist for appropriate advice on the wound management (White & Cutting 2016).

Involvement in multidisciplinary teams

Patients with wounds suffers with pain. Solowiej et al., (2010) they experience different type of pain that occurs resulting from the chronic wound, this includes neuropathic pain, the pain as a result of the treatment of the wound and the anticipatory pain. It is important to assess the patient’s pain as it is essential in planning the patient’s care as it provides the health care provider with the baseline information important in selecting the management strategies that are appropriate and the appropriate dressing products.

Unresolved pain causes stress to the patient that results in delays in wound healing (Reddy et al., 2013). Psychological stress has been found to have negative impacts on healing in different settings and wound types.  The studies have shown psychological stress impair wound healing by decreasing local pro-inflammatory cytokines. The health care provider should explain all procedures to the patients so as to alleviate the patients stress/anxiety. During dressing procedure, the patient should only feel some sensation. The aim of this is to limit both the pain and the discomfort to its minimum and also to ensure that the patient is involved in their care plan. The assessment includes; initial assessment, background pain and review assessment. The pain levels of the patient should be recorded so as to be able to identify the pain patterns.

Posnett & Franks, (2017) the wound care is a costly area of treatment, it costs the National Health Services (NHS) between 2 and 3 billion a year. It is important to understand the wound assessment and management as it is important in ensuring that the care is cost-effective and evidence based interventions. The nurses need to develop accurate wound assessment and be able to identify the related areas of care that requires attention (Harding et al., 2008). The wound assessment should be holistic. Accurate wound assessment is an essential skill that should be acquired by the health care providers so as to effectively plan, implement and evaluate care for patients.

In addition, Greatrix-White & Moxey (2015) study reported that nurses are not confident in developing a wound management plan and executing it out. The study suggested that for best practice in wound management, nurses required a structured assessment tool and educational guidelines with a clear guideline.

As started above the wound healing assessment chart ensures that the assessment ensures that there is holistic care. This is obtained by not only focusing on the wound but by focusing on the patient as an individual (Cooper, 2015). The chart inclusion includes; the patient history, the size and site of wound, the factors affecting wound healing, the patients pain, and the wound bed appearance. The patient history is important in patient identification. It is also important in the holistic care. The size and the site of the patient’s wound is important in assessing the wound healing. The factors affecting wound healing are important to assess as they help in understanding the wound healing progress and in planning the wound management as they can be eliminated. In addition, the wound bed appearance is important in assessing the patient’s wound healing. Lastly, the former is important as it helps in identifying the dressing materials and regime. All the above are important as they trace the wound healing progress and the outcome (Menna Lloyd, 2017).

Conclusion.

In conclusion the wound healing assessment chart includes a lot of documentation, therefore it can stand alone. The chart is also detailed and it ensures that the patient care is holistic. The wound healing assessment chart includes; the patient history, the size and site of wound, the factors affecting wound healing, the patients pain, and the wound bed appearance. The patient history is important in patient identification. The size and the site of the patient’s wound is important in assessing the wound healing. The factors affecting wound healing are important to assess as they help in understanding the wound healing progress and in planning the wound management as they can be eliminated. The chart can also be interpreted by different health care providers therefore it friendly. Lastly, it entails a detailed documentation which makes it qualify as a document that can stand by itself.

References

Cooper R., (2015). Identifying Criteria for Wound Infection. Medical Education Partnership Ltd, London.

Cutting K, Tong A (2013). Wound Physiology and Moist Wound Healing. Medical Communications Ltd, Holsworthy.

European Wound Management Association (2008.) Hard-to-Heal Wounds: A Holistic Approach. https://tiny.cc/pjvcc (accessed 28 April 2011)

Fletcher J (2010). Development of a new wound assessment form. Wounds UK 6(1): 92–9

Grey JE, Enoch S, Harding K (2006). Wound assessment. BMJ, 332(7536): 285–8

Harding KG et al (2018) Best Practice Statement. Optimising Wound Care. https://tiny.cc/7jwgp (accessed 9 April 2011).

Maylor M (2012) Are wound care assessments real or imaginary and what can be done? Br J Nurs11(12): S5

McIntosh C, Ousey K (2008) A survey of nurses’ and podiatrists’ attitudes, skills and knowledge of lower extremity wound care. Wounds UK 4(1): 59–68

Menna Lloyd, J., (2017). Wound assessment. British Journal of healthcare Assistance, 11 (10): 479

Peel ALG, Taylor EW (2011). Proposed definitions for the audit of postoperative infection, a discussion paper. Ann R Coll Surg Engl 73: 385–8

Reddy M, Keast D, Fowler Y et al., (2008). Pain in pressure ulcers. Ostomy Wound Management 49: 4A Supplement.

Saibertova, S & Pokorna A., (2016). Evaluation of the assessment and documentation of chronic wounds in residential social care in the Czech Republic, Journal of Wound care, 25 (11); 662.

Schultz GS, Barillo DJ, Mozingo DW et al (2014) Wound bed preparation and a brief history of TIME. Int Wound J 1(1): 19–20

Solowiej K, Mason V, Upton D (2010) Assessing and managing psychological stress and pain in wound care: part 2, pain and stress assessment. Journal of Wound Care 19(3): 56–61

Stephen-Hayes J, Thompson G (2017) The different methods of wound debridement. Br J Community Nurs 12(6): S6–16

White R, Cutting K (2016). Modern exudate management: a review of wound treatments. https://tiny.cc/s6gjd (accessed 7 April 2011)

Williams L, Leaper D (2010). Nutrition and Wound Healing. Clinical Nutritional Update. 5(1): 3–5

Winter G D (2012) Formulation of the scab and the rate of epithelisation in the skin of the domestic pig. Nature 193: 293–4

World Health Organization (2018) Nicorandil associated ulceration. WHO Drug Information 22(2): 85

World Union Wound Healing Societies (2014) Principles of Best Practice: Minimising Pain at Wound Dressing-related Procedures. A Consensus Document. MEP Ltd, London

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