Understanding the importance of holistic wound assessment

Ousey, Karen; Cook, Leanne

doi:10.12968/pnur.2011.22.6.308

Cited by 24 publications

(18 citation statements)

References 14 publications

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“…A cogent explanation for this is that the sacrum and ischia have a relatively large surface area and, thus, cutaneous manifestations at this particular region are magnified, as opposed to the extremities that have small surface areas, such as the calcanei and malleoli . Another possible explanation may be related to general routine hygiene practices, in which nurses are more inclined to inspect the skin at the pelvic region (sacrum and ischia) for the presence of wetness or moisture associated, for example, with urinary incontinence , in comparison to skin areas less frequently exposed to sources of wetness or moisture, such as the extremities (calcanei and malleoli) .…”

Section: Discussionmentioning

confidence: 99%

“…Clinical skin inspection, particularly over pressure‐prone areas such as sacrum, ischia, greater trochanters and malleoli , forms an essential component of PI risk assessment . In documenting the skin condition of pressure‐prone areas, skin descriptors such as ‘erythematous’ and ‘wet/macerated’ are commonly used , given the well‐recognised role of these clinical characteristics in signalling tissue damage associated with imminent PI development .…”

Section: Introductionmentioning

confidence: 99%

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Comparing visual and objective skin assessment with pressure injury risk

Borzdynski

McGuiness

Miller

2015

International Wound Journal

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Contemporary approaches to pressure injury (PI) risk identification rely on the use of risk assessment tools and visual skin assessment. Objective biophysical measures that assess skin hydration, melanin, erythema and lipids have not been traditionally used in PI risk; however, these may prove useful as a risk assessment tool. The relationship between subjective visual assessments of skin condition, biophysical measures and PI risk warrants investigation. This study used a descriptive correlational design to examine the relationship between measures of skin hydration, colour (melanin and erythema) and lipids at PI-prone areas amongst geriatric persons (n = 38), obtained using biophysical skin measures and visual skin assessment. Twice daily measures of epidermal hydration, colour and lipids were assessed using the SD202 Skin Diagnostic (Courage + Khazaka GmBH, Cologne, Germany) over pressure-prone areas of the body of study participants over seven consecutive days. Concurrent visual assessment of skin hydration and colour was performed. Results obtained using the SD202 Skin Diagnostic were compared with results gathered from visual assessment and examined for their association with participants' PI risk based on scores of the Norton Risk Assessment Scale. While epidermal hydration and skin colour reading scores did not vary significantly over the data collection period, lipid readings could not be registered on any occasion. With the exception of skin dryness, skin parameters via both objective and subjective means had significant, positive correlations. Statistically significant correlations emerged between visual assessment of skin wetness at the sacrum (r = -0·441, P < 0·01) and ischia (r = -0·468, P < 0·01) and Norton Risk Assessment Scale scores. It was found that the objective assessment of epidermal hydration (skin wetness) was also significantly associated with PI risk at the sacrum (r = -0·528, P < 0·01), as well as the right ischia (r = -0·410, P < 0·05) and left ischia (r = -0·407, P < 0·05). Erythema, when assessed objectively, was significantly correlated with PI risk at the sacrum (r = -0·322, P < 0·05). Such findings indicating that the finer measures afforded by the SD202 Skin Diagnostic in the assessment of the subtle red hues displayed in erythematous skin may provide an additional advantage over traditional, clinician assessment.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Comparing visual and objective skin assessment with pressure injury risk

Borzdynski

McGuiness

Miller

2015

International Wound Journal

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“…With regard to the level of their knowledge, nurses need support, particularly in relation to acceptance of their knowledge and competencies by the team . Other published surveys have highlighted deficiencies in the use of objective practices such as scales and maps . It was recognised that wound, localisation, wound depth and wound bed were the basic parameters most commonly assessed in the wound.…”

Section: Discussionmentioning

confidence: 99%

“…They are also a source of information for doctors in making decisions about appropriate therapeutic procedures. This holistic and systematic approach to wound care also involves initial and ongoing wound assessment . An accurate assessment should help nurses to monitor the progress of a wound, and enable them to plan appropriate interventions and selection of dressings according to their competencies.…”

Section: Introductionmentioning

confidence: 99%

Assessment and documentation of non‐healing, chronic wounds in inpatient health care facilities in the Czech Republic: an evaluation study

Pokorná

Leaper

2014

International Wound Journal

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The foundation of health care management of patients with non-healing, chronic wounds needs accurate evaluation followed by the selection of an appropriate therapeutic strategy. Assessment of non-healing, chronic wounds in clinical practice in the Czech Republic is not standardised. The aim of this study was to analyse the methods being used to assess non-healing, chronic wounds in inpatient facilities in the Czech Republic. The research was carried out at 77 inpatient medical facilities (8 university/faculty hospitals, 63 hospitals and 6 long- term hospitals) across all regions of the Czech Republic. A mixed model was used for the research (participatory observation including creation of field notes and content analysis of documents for documentation and analysis of qualitative and quantitative data). The results of this research have corroborated the suspicion of inconsistencies in procedures used by general nurses for assessment of non-healing, chronic wounds. However, the situation was found to be more positive with regard to evaluation of basic/fundamental parameters of a wound (e.g. size, depth and location of a wound) compared with the evaluation of more specific parameters (e.g. exudate or signs of infection). This included not only the number of observed variables, but also the action taken. Both were significantly improved when a consultant for wound healing was present (P = 0·047). The same applied to facilities possessing a certificate of quality issued by the Czech Wound Management Association (P = 0·010). In conclusion, an effective strategy for wound management depends on the method and scope of the assessment of non-healing, chronic wounds in place in clinical practice in observed facilities; improvement may be expected following the general introduction of a 'non-healing, chronic wound assessment' algorithm.

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“…Debridement may also assist in wound assessment or pressure ulcer categorisation as removing nonviable tissue, slough and excess exudate this will help to visualise the wound bed depth and condition more accurately, (Ousey & Cook, 2011). Debridement may only need to be performed once but more commonly episodic or continual debridement may be required over a number of weeks, (Ousey & Cook, 2012).…”

Section: When To Debride?mentioning

confidence: 99%