Vol. 7 Issue 7
The Learning Scope
Skin & Wound Assessment
Thorough, routine wound evaluation and care support successful treatment
This offering expires in 2 years: March 14, 2007
The goal of this continuing education offering is to provide nurses with current information about skin and wound assessment they can apply to practice. After reading this article, you should be able to:
1. Discuss the importance of incorporating a wound-risk scale to predict high-risk patients.
2. Compare and contrast the differences between the Norton, Braden and Waterlow risk scales.
3. Describe the components of a wound prevention protocol.
You can earn 1 contact hour of continuing education credit in three ways: 1) For immediate results and certificate, go to www.advanceweb.com/nurses. Grade and certificate are available immediately after taking the online test. 2) Send this answer sheet (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. Make checks payable to Merion Publications Learning Scope (any checks returned for non-sufficient funds will be assessed a $25 service fee). 3) Fax the answer sheet (available with credit card payment only) to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.
Merion Publications Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 011-3-H-04), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. also is approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).
The number of wound-care products has increased in the past decade, but the assessment tools to identify patients at risk for developing a wound have not kept pace with product development. Controversy and confusion concerning wound measurement and assessment prevail.
Certainly, prevention of wounds is the key to decreasing morbidity and mortality. This is especially true for individuals at risk for developing a pressure ulcer. However, there are many different types of wounds, and the development of any wound travels the lifespan from neonate to geriatric patient. Therefore, it is imperative to assess and screen all populations and individualize their treatment after a thorough assessment.
Although assessment tools exist to measure and evaluate existing wounds, predictors for wound development are limited to pressure ulcers. Perhaps the lack of development of these predictors of other wounds is related to the national focus on pressure ulcers, and/or healthcare professionals' frustration regarding an inability to maintain the patient's intact skin.1
Multiple Factors of Causation
The development of a pressure ulcer involves multiple factors, but the two major factors in the formation of a pressure ulcer involve shearing and friction.2 However, there are numerous other intrinsic and extrinsic factors that contribute to development of a wound.
Braden and Bergstrom identified the patient at increased risk for development of a wound with intrinsic factors that include nutrition, continence, age, gender, skin moisture and medical conditions.3 There are other intrinsic factors to consider, such as comorbidities, underlying diseases, polypharmacy and the effects of smoking.4
Extrinsic factors that affect the individual at risk for wound development include ability to change position, the amount of mechanical pressure exerted while sitting or lying, and the home environment.5
Wound Risk Scales
Three evidence-based predictors of pressure ulcers are the Norton, Braden and Waterlow scales (Table 1).
The Norton scale was the first tool developed for predicting the patient at risk. This tool was initiated in 1962 and includes five items to assess the patient's physical condition, mental status, activity, mobility and continence. The Norton scale score was reconfigured in the 1980s, with the reliability score lowered to capture the at-risk population, which has changed since the tool's inception. The older adult population has doubled in the past 20 years. The lowering of the Norton scale now captures the older adult.
The maximum score for this five-part tool is 20. The patient at risk scores 16 or less.6 Each of the five areas is scored from 1 to 4. The lower the score, the higher the risk. A score of 1 is considered very bad, while a score of 4 is good.
The Braden scale was developed in the mid-1980s and currently is the most frequently used tool. The Braden scale has been found to be a highly reliable instrument, as its subscores provide predictors to the bedridden or chairfast indvidual.
This tool includes six areas of assessment: sensory perception, skin moisture, mobility, activity, nutrition, and friction and shearing. The maximum score for this six-part tool is 23. A score of 4 is high for each area assessed, except friction and shearing, which has a high score of 3. The patient at risk scores 16 or less.7 Although the Braden scale now has added scoring for low, medium and high risk, the numeric scale is still utilized more frequently.
Braden has also developed a tool for consideration of the pediatric patient at risk for wound development. This scale is identified as the Braden Q scale. This scale includes the six assessment items and tissue perfusion/oxygenation as a seventh assessment item. All assessment items have a maximum score of 28. A low score identifies pediatric patients at high risk for wound development.
The Waterlow scale was developed from the Norton scale in the 1990s. This scale takes eight factors into consideration: build/weight for height, visual assessment of the skin at risk, sex and age, continence, mobility, appetite, medications and special risk factors. In this scale, the highest and lowest scores of each item may vary. Each area has a value ranging from 0-3 to 0-5.
The Waterlow scale identifies the patient with the higher score at risk for wound development. This is in contrast to the Norton and Braden scales, which identify patients with lower scores at risk. Utilizing the Waterlow scale, a patient with a score above 19 is at high risk.8
Once patients are identified at risk for wound development, they should be reassessed at regular intervals. In an acute care facility, patients should be re-evaluated every 3-7 days to determine if there is a change in their risk score. Patients also should be reassessed when there is a change in condition, i.e., the patient is admitted with a diagnosis of new onset atrial fibrillation and, 2 days after admission, falls and sustains a hip fracture. In a long-term care facility, the resident should be reassessed 2 weeks after admission, and at least monthly depending on their risk score and change in condition.9
Even if a valid, reliable, evidence-based tool is utilized routinely for assessment, this tool will be irrelevant unless a preventive protocol is instituted for at-risk patients. For all patients at risk, a turning/repositioning schedule must be implemented into their daily care. If the patient is emaciated or unable to move (i.e., spinal cord injury), turning/repositioning should occur more frequently than every 2 hours. Simple shifts in their position as frequently as every 15 minutes should be considered.
The patient or resident should be turned no further than 30 degrees side to side and have the head elevated no higher than 30 degrees. Friction and shearing will occur with turning greater than 30 degrees or a higher head elevation.9 A higher head elevation is necessary for feeding, but the patient should be lowered to a 30-degree head elevation 1 hour after eating.
Caregivers also must implement pressure reduction surfaces for at-risk patients. Numerous products and surfaces are available, but remember pressure reduction also must be in place when the patient is sitting out of bed. Without pressure reduction for the chair, prevention reduction for only the bed is an incomplete pressure reduction protocol. Also, remobilization of the patient must be considered. An immobile patient will lose skin integrity more rapidly than a mobile patient.3
Other areas to address in prevention protocol include monitoring and managing moisture. Patients with urinary or fecal incontinence must be toileted or cleaned at least every 2 hours, or more frequently depending upon their condition. Adult briefs create a humid environment and change the pH of the skin. The change in pH will contribute to skin breakdown.
Also consider perspiration and any elevated temperature the patient may be manifesting. To maintain skin integrity, the patient must be kept clean and dry.4 Van't Hoff's law states a 1º C rise in a patient's body temperature will cause 10 percent tissue death. This is significant for the individual already experiencing a wound.
Nutrition also must be considered. Both short- and long-term problems in nutrition affect skin integrity. Protein supplements should be considered for the patient with poor dietary intake.9
When Wounds Occur
Despite the best efforts, prevention protocols may fail, or the patient may present with a wound upon admission. Certainly, a major consideration would be to re-evaluate a current patient if a wound occurs and evaluate a new patient who presents with a wound. Most important is to evaluate and institute interventions for wound healing. Accurate assessment and implementation of interventions will improve patient outcomes, decrease length of stay and increase timely reimbursement for care.10
Prior to the incorporation of any interventions for wound healing, the wound must be assessed to determine factors contributing to wound development. One essential element to assess is the potential for comorbid conditions and underlying, undiagnosed diseases.11
Any wound disrupts normal anatomic structure and function. Various assessment tools for different types of wounds now will be discussed.
Assessing Pressure Ulcers
Guidelines for pressure ulcer assessment were initiated in the 1990s. The National Pressure Ulcer Advisory Panel created a staging system to be used only for pressure ulcers. It includes four stages:
Stage I Pressure ulcer is an observable, pressure-related alteration of intact skin. Indicators, as compared to an adjacent or opposite area on the body, may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues.
Stage II Partial-thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.
Stage III Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents as a deep crater with or without undermining adjacent tissue.
Stage IV Full-thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structure (e.g., tendon, joint, capsule). Undermining and sinus tracts also may be associated with stage IV pressure ulcers.
Diabetic Neuropathic Ulcers
There are various classification systems for assessment of diabetic ulcers. The University of Texas and Meggitt-Wagner diabetic ulcer classification systems are valid, evidence-based systems to determine the extent of destruction (Table 2, Table 3).
The Meggitt-Wagner scale is the most widely used tool to assess the diabetic neuropathic wound. This scale is subjective in nature, as it does not utilize measurement of the wound, only visualization.12
Beyond the pressure ulcer and diabetic neuropathic ulcer, all other wounds are identified as either partial- or full-thickness wounds. A wound may occur for numerous reasons and may be from multiple causes. As an individual ages, a combination of venous and arterial insufficiency may lead to development of a stasis ulcer. A patient with spinal cord injury or injuries from a motor vehicle accident may present with major wounds with associated organ damage.
Anyone who presents with a wound must be thoroughly assessed to determine the cause and any comorbid factors that would impede healing. Once the wound's cause is determined, measurement, description and documentation are incorporated into assessment of all labeled disruption of skin integrity.
A partial-thickness wound extends through the epidermis into various portions of the dermis. A full-thickness wound involves the epidermis, all of the dermis and extends into the deeper structures of the hypodermis (subcutaneous tissue).13
Additionally, wounds are categorized as acute or chronic. Acute wounds move through the healing phases in a rapid, orderly fashion. Chronic wounds are defined as wounds that do not demonstrate healing for longer than 30 days. This definition was developed by the Centers for Medicare and Medicaid Services.
Whether the wound is staged, graded or identified as partial or full thickness, a clinical assessment of the wound must be conducted to incorporate the appropriate treatment modalities. Accurate assessment will help determine the progression, deterioration or stagnation of the wound.10
One of the first elements of wound assessment is to correctly document the anatomical location of the area involved and the length of time the patient has had the wound. If the wound is on the left greater trochanter, identify this as the location rather than the left hip. An anatomical drawing of the human body also will help locate the wound.9
The length of time the patient has experienced the wound is a predictor of the type of healing to be expected. Orderly wound healing progression does not occur in chronic wounds, and healing is a slower process obtained by contraction and granulation.14
It is imperative to measure the wound throughout the treatment utilizing a reliable tool. The measurements are done in centimeters and always are length (from head to toe), width (from hip to hip) and depth. Measurement is performed from the outermost portion of all healing or insulted tissue. Numerous standard tools are available through product vendors.
Many times, the depth cannot be determined due to the presence of slough, eschar or necrotic tissue in the wound. The hard eschar and necrotic tissue will inhibit penetration of the wound with a cotton swab. The slough must be irrigated from the wound to allow the assessor to probe the wound for depth. Pressure ulcers containing eschar and necrotic debris are considered unstageable.5
When the wound is probed for depth, it is important to determine if a fistula, sinus tract, tunneling or undermining is present. Fistulas are named for their point of origin to a connecting point of exit (e.g., rectal fistula). Sinus tracting and tunneling occur when any portion of the wound passes through subcutaneous tissue and muscle. The tracting or tunnel may present as a small opening at the surface but turn out to be much larger in the deep tissue with abscess formation.
Undermining may give the illusion of a small wound, but major destruction of underlying intact skin surrounds the wound. It should be documented using the illustration of a clock (i.e., undermined determined from 2 to 8 o'clock).9
The exudate in the wound also must be assessed and documented. Exudate assessment must include the amount, consistency and color. Consistent documentation terms should be incorporated into the routine assessment. This includes standard descriptors such as serous, serosanguineous, sanguinous or purulent. The amount should be identified as absent, minimal, moderate or heavy.4
Assessment of the tissue bed will be revealed through observation of all these components and by tissue color and the presence of epithelialization. Check a wound for color and document whether the wound bed is pale pink, pink or red. A clean, granulating wound may be described as beefy red. Also note any new tissue growth, granulation and the appearance of the wound edges. At this time, determine the amount of moisture in the wound bed and the type of tissue in the wound (eschar, slough or granulation tissue). Document the amount of tissue by percentage (e.g., 75 percent eschar, 25 percent slough).5
Next Steps of Assessment
Palpation of the wound is the next step in assessment. Gently, with the tips of your fingers, feel for accumulation of excess fluid, bogginess, induration or fluctuation of the wound surface. This will aid in identifying deeper damage or abscess formation. The surrounding tissue also should be palpated to feel for warmth and note any maceration of the surrounding intact tissue.
At this time, also look at the wound edges to determine if the edges have migrated away from the wound and developed as epithelial rim or epiboly.5 The rolling of the an epithelium, which may look like the finished hem of a pair of pants, will impede healing as the communication of the epithelial cells with each other gives the wound the illusion of intact epithelium; therefore, the wound "thinks" it's healed.
Last, but certainly not least, assess the pain the patient has from the wound. The pain may be episodic during palpation or treatment, but an increase in pain can be a sign of infection. It is important to identify the cause of the pain and institute pain management strategies. When assessment is performed on the wound, also observe for other signs of infection beyond pain. Foul odor, wound edema, increased drainage or a change in drainage are indications of the presence of an infection.10
Consistency Is Key
Always assess and document your wound assessment and healing on a regular basis, utilizing a standardized tool. Wounds must be assessed at each dressing change. Valid documentation tools are available, or your facility may develop its own tool for specific needs. Consistency in assessment and documentation is the key to evaluating or implementing wound healing modalities.
The information obtained from thorough, accurate routine assessment will provide practitioners with data to promote successful treatment modalities. This approach helps create the positive outcome goals of any wound-care treatment program.
1. Pang, S., & Wong, T. (1998). Predicting pressure core risk with the Norton, Brade, and Waterlow scales in a Hong Kong rehabilitation hospital. Nursing Research, 47(3), 147-153.
2. Braden, B., & Bergstrom, N. (1987). A conceptual schema for the study of the etiology of pressure sores. Rehabilitation Nursing, 12(1), 8-12.
3. Agency for Health Care Policy and Research. (1994). Clinical guideline number 15: Pressure ulcer treatment. (AHCPR Publication No. 95-0652). Rockville, MD: Author.
4. Arnold, M. (2003). Pressure ulcer prevention and management: The current evidence of care. AACN Clinical Issues, 14(4), 411-428.
5. Baranoski, S., & Ayello, E. (2003). Wound care essentials: Practice principles. Philadelphia: Lippincott, Williams & Wilkins.
6. Norton, D. (1989). Calculating the risk: Reflections on the Norton scale. Debcutitus, 2(3), 24-31.
7. Braden, B., & Bergstrom, N. (1994). Predictive validity of the Braden scale for pressure sore risk in a nursing home population. Research in Nursing & Health, 17(6), 459-470.
8. Waterlow, J. (1994). Pressure sore prevention manual. Somerset, England: Newtons, Curland, Taunton.
9. Krasner, D., Rodeheaver, G., & Sibbald, G. (2001). Chronic wound care: A clinical source book for healthcare professionals (3rd ed.). Wayne, PA: HMP Communications, 2001.
10. Whittington, K. (2005). Cost-saving wound assessments. ADVANCE for Nurses Service RNs in the Southeastern States, 7(3), 24-25.
11. Kunimoto, B. (2001). Assessment of venous leg ulcers: An in-depth discussion of a literature guided approach. Ostomy/Wound Management, 47(5), 38-53.
12. Smith, R. (2003). Validation of Wagner's classification: A literature review. Ostomy/Wound Management, 49(1), 54-62.
13. Kloth, L., & McCulloch, J. (2002). Wound healing: Alternatives in management. Philadelphia: F.A. Davis Co.
14. Sussman, C., & Bates-Jensen, B. (1998). Wound care: A collaborative practice manual for physical therapists and nurses. Gaithersburg, MD: Aspen Publishers.
Janet R. Hulse is a clinical nurse specialist at St. Luke's Cornwall Hospital, Newburgh and Cornwall, NY.