Wound assessment - Incorporating the WHASA wound assessment form

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1 Wound assessment - Incorporating the WHASA wound assessment form Abstract Naudé L, BCur(UP), MCur(UP)(ZA), Cert Wound Care(UOFS)(ZA), Cert Wound Care (Hertfordshire)(UK) Wound Healing Association of Southern Africa Correspondence to: Sr Liezl Naudé, Holistic patient Assessment forms an integral part of wound assessment the wound is part of a person with individual qualities and needs that should be considered. A wound can never be treated without considering the unique physiological and psychological aspects of the human being. The Wound Healing Association of Southern Africa developed a wound assessment form in 2007 to facilitate holistic patient assessment in order to aid with quality wound assessment and wound management. 2008;1(1):16-21 Introduction The aim of this article is to enable the practitioner to use the WHASA assessment form with ease. The history of the patient must be very complete as it guides the practitioner to the proper tests and measures to determine the cause of the wound and characteristics that would affect the outcome of different intervention strategies. Demographic data include age, sex, race/ethnicity, and primary language. The age of a patient has an impact on the rate of wound healing whilst the hand and foot dominance are often overlooked unless the wound is located on a hand. With wounds on hands and feet the patient needs to be questioned about activities involving those extremities, and alternatives for accomplishing tasks should be discussed with your patient. The WHASA assessment form is structured in such a way to assist both the practitioner and the medical aid involved in compiling sufficient information to aid in holistic wound management. Patient data All assessment forms have to start with patient demographics. You are required by the South African Medical Aid Schemes to provide the information as set out below in the patient data block. (Figure 1.) All applicable details that identify the patient, main member and the patient dependent code, are necessary for Medical Aid Schemes to process authorisation for wound care. The form has been developed in Excel format with drop down boxes to facilitate ease of use. It is necessary to enable the macro function when downloading the form from the WHASA website at In the section with regards to the type of patient, you need to select whether or not the patient is using an inpatient/hospital or outpatient/ clinic facility. Figure 1: Patient data Medical and surgical history Developmental history should include any disorders that could aggravate the wound, create difficulty in carrying out a home programme or impede the patient s ability to protect the wound. Health history contains information regarding diseases and conditions, such as diabetes, which frequently disrupt or delay wound healing. Functional abilities determine the patient s ability to change his or her own dressings, apply compression stockings or adhere to an antibiotic course of treatment. In Figure 2 the medical and surgical history of the patient is described. The first dropdown box gives you the choice to select either type I or type II diabetes. The second dropdown box gives you the choice to select between no problems, arterial or venous problems. The third dropdown box give you the choice to select between none, sensation, activity or mobility. Included in the medical and surgical history are also components of psychosocial history such as smoking and alcohol usage. 16

2 Figure 2: Medical and surgical history Physical assessment The physical assessment incorporates the various body systems, and also the nutritional, mental and functional status of the patient. (Figure 3.) Observation of vital signs as baseline is important and should include random blood glucose levels and cholesterol status. The mental and emotional evaluation of a patient is important for identification of stress factors that need to be controlled and eliminated to facilitate healing. It is important that patients know their role as a vital member of the multidisciplinary team as it gives a sense of control back to the patient and lessens emotional dependence on the woundcare practitioner. The dropdown box for functional status gives you the choice of selecting between independent, minimal, moderate and total assistance. determining the wound management plan. Venous ulcers should be treated with compression bandages after the arterial flow has been determined by doing an Ankle Brachial Pressure Index (ABPI). Oedema circumference, foot temperature and capillary refill are also indications of the blood flow status as is pulse quality (bounding, strong, weak or barely palpable). The most important diagnostic tool in determining blood flow is the use of a hand-held 8MHz Doppler in determining the ABPI. If you are not able to perform an ABPI or interpret the results yourself, it is imperative to refer the patient to a vascular surgeon or a vascular clinic for evaluation before applying compression therapy. (Figure 5.) Figure 5: Lower extremities The table on the next page indicates some of the clinical differences that can be found in lower leg ulcer presentation. This should enable you to make an informed decision on the diagnosis of the ulcer. Pain assessment Pain is often an underestimated factor in woundcare delivery. In the WHASA assessment form, the pain assessment scale is based on the well-known Wong-Baker scale. (Figure 6.) Figure 3: Physical assessment Medication Medication is a systemic factor influencing the wound healing functions of the body. Medications that have a significant impact on the wound healing phases are indicated in the WHASA assessment form. Immunosuppressive drugs and non steroidal anti-inflammatory drugs as examples, have many detrimental effects on wound healing and would impair the interactive effect of the wound dressing of choice. All current and chronic medication should be documented meticulously. (Figure 4.) Figure 6: Pain assessment Laboratory tests Laboratory studies also aid in the complete patient assessment. (Figure 7.) Special focus should be on the following: Figure 7: Laboratory tests Figure 4: Medication Lower extremities Lower leg ulcers and diabetic foot ulcers are the most common chronic ulcers dealt with in wound management. Specific assessment to identify the type of ulcer is extremely important in When infection is suspected (increase in exudate, pain, redness and swelling) a wound swab should be taken to determine the type of pathogen causing the infection. Systemic antibiotics should be prescribed according to the sensitivity of the organism and the treatment protocol for wound dressing selection adapted accordingly. Make sure that the wound swab is taken after the wound bed is cleansed with saline and dried slightly. The moisture that moves into the wound bed from the underlying tissue can then be collected by doing a rolling motion over the wound bed surface with the wound swab. Prevent contamination from the surrounding skin. 17

3 Chronic lower leg ulcers: a differential diagnosis VENOUS MIXED ARTERIAL DIABETIC SITE AREA Ankle area close to the malleolus or anterior tibial area. Mixed clinical features Lower leg, they occur mainly on the tips of toes, between the toes also on the lateral aspect of the foot and lateral malleolus. Tip of toes, the heels, under the metatarso-phalangeal heads and along the edges of the feet. Ulceration is particularly likely to occur over the dorsal portion of the toes and on the plantar aspect of the metatarsal heads and the heel. PULSES Present/Normal. Weak or absent. Depending on peripheral arterial disease. PAIN Relieved when leg is elevated. Greater at night/with elevation of leg, intermittent claudication. Neuropathic. SKIN Skin pigmentation. Eczema present. Induration. Varicose veins. Scars of previous ulcers. Poor skin perfusion. Dry, glossy, thin, pale, mottled and cold (unless cellulitis is present). Rubor when foot hangs, pallor when elevated. Callus formation on wound edges. OEDEMA Generalised. Localised oedema. Localised oedema. DEPTH Large and superficial ulcers. Mixed features Small, mottled but deep, can be larger if neglected. Deep often punched out due to pressure, also necrotic. WOUNDBED Vascular classification varies between yellow and red wounds. Pale wound bed inclined to scab formation and necrosis. Manipulation causes no or little bleeding. Inclined to high bacterial load. Pale wound bed. WOUND EDGE Diffuse or irregular edges. Clearly demarcated. Clearly demarcated. ABPI > < 0.6 Dependent on vascular supply. PATIENT HISTORY Usually history of deep vein thrombosis or varicose veins. Diabetic, inflammatory conditions associated with immunosuppression. Vasculitis. Absent ankle pulses, limb pain at night, pain improvement when limb hangs. Smoking, diabetes can play a role. Poor skin perfusion. Foot deformities, neuropathy, callosities, cold or hot temperature, atrophic nails, smoking, infection. TREATMENT OPTIONS Moist wound healing according to tissue type and wound healing phase. Compression bandaging. Moist wound healing according to tissue type and wound healing phase. Moist wound healing according to tissue type and wound healing phase. Referral to vascular surgeon. Prevention. Ulcer grading according to the Wagner scale. Moist wound healing according to tissue type and wound healing phase. Referral to vascular surgeon and multi disciplinary health team involving the podiatrist and, if needed, orthopaedic surgeon. Limb salvage is key. Table 1: Chronic lower leg ulcers: a differential diagnosis 18

4 Wound diagnosis An important part of the wound assessment is to ask your patient about prior wound treatment. This should include the previous dressings and also other practitioners involved in the earlier wound care. The assessment form is compiled for the assessment of one wound initially, but any other wounds can be noted on the body chart and described as well. (Figure 8.) Wound description Wound bed Describing the wound bed is essential in determining your treatment plan. You are required to distinguish between the tissues as described below, and to choose the dominant colour of the wound bed tissue. For example the wound may contain black necrotic tissue and granulation tissue at the same time; however the predominant aim of treatment will be to remove necrotic tissue first and should therefore focus the treatment on debridement. (Figures 12 and 13.) Figure 8: Wound diagnosis Figure 12: Wound bed descriptions Type of wound The type of wound is essential in determining the treatment plan. As indicated in the drop down box, you are required to choose between the following types of chronic ulcers (Figure 9): Necrotic Tissue - Dry / dehydrated - Black Slough Figure 9: Chronic ulcer classifications As indicated in the drop down box for mechanical injury you need to select one of the following (Figure 10): - Yellow / gray - Soft - High levels of exudate Granulating - Red - Different levels of exudate Figure 10: Mechanical injury classifications As indicated in the drop down box for mechanical injury you need to select one of the following (Figure 11): Epithelialising - Pink - Different levels of exudate Figure 11: Burn wound classifications Figure 13: A Photographic summary of the different wound bed descriptions 19

5 Wound edges The surrounding skin and wound edges are the keys in successful wound assessment. Surrounding callous is an indication of pressure; macerated skin is an indication of too much moisture; redness and erythema can show signs of inflammation or possible infection. Hairloss can also indicate arterial insufficiency. (Figure 14.) Signs of infection In this section you are able to tick down the different signs present in the wound at the time of assessment. (Figure 18.) Figure 18: Signs of infection ICD 10 coding Figure 14: Wound edges description ICD 10 coding is essential in validation of claims to the medical aids. Refer to our section in the journal on billing strategies. It is advisable for the account to have the same ICD 10 code the referring doctor used to make the referral. You may add more codes thereafter. (Figure 19.) Wound exudate and colour The amount of wound exudate is described internationally as Low/1+, Moderate/2+ or High/3+ according to the specific wound. Exudate colour should also be described as seen below (Figure 15): Figure 15: Exudate description Wound odour Change in wound odour is an important sign of either colonisation of micro-organisms or the existence or Extra-cellular Polymeric Substance (EPS) also known as the biofilm of a wound bed. (Figure 16.) Figure 19: ICD 10 coding Wound location The diagram included in the WHASA assessment form enables you to insert a text box and mark the wound area. If there are more than one wound you can indicate the number of wounds by marking them on the diagram as can be seen in Figure 20. Wound location has an influence on the dressing selection and the type of adhesive, especially in areas of high moisture such as the groin, the sacrum, etc. Figure 16: Wound odour descriptions Wound measurements and duration A baseline assessment on the first consultation is key in determining the healing progress. It is important to note the length, width and depth of the wound. Wound measurement can be done through various methods such as the ruler-based method, tracings and photography. Also indicate when the wound initially appeared and how long it has been present for. The drop down box allows you to indicate between days, months or years. (Figure 17.) Figure 20: Wound location Photo report example (Figure 21.) Figure 21: Photo report example with detailed description Figure 17: Wound measurement and duration 20

6 Treatment plan The treatment plan is essential. Only a full assessment of the wound itself with identification of all factors that may play a role in the healing process, can facilitate the development of a comprehensive patient-specific treatment plan with clear treatment aims. If it is debridement you need to indicate how you are going to achieve this, in other words what method will you choose according to the drop down box. You also need to indicate how you will aim to control the moisture in the wound. (Figure 22.) Conclusion Wound healing is definitely not a simple matter to coordinate, but with a team effort and the use of the various tools for risk assessment and wound assessment available, effective wound management is possible. This,however, can only be achieved through vigilance and consistent assessment and documentation. By recognising red flags that warn of failure to heal, and then also knowing the proper interventions, you are part of the success story and part of a winning team. By doing a proper holistic assessment you are able to plan ahead with regards to holistic wound management. With this assessment form the Wound Healing Association of Southern Africa anticipate ease in completing a thorough wound assessment and giving the right information through to all parties involved. For more information and steps on how to download the WHASA assessment form please visit our website at Figure 22: Methods of debridement and moisture control When there is infection present you need to indicate the antimicrobial dressing of choice and whether or not systemic antibiotics are also used. (Figure 23.) Figure 23: Treatment of infection or EPS Multidisciplinary team involvement The importance of a team effort with patient involvement cannot be emphasised enough. (Figure 24.) A patient who is an integral role-player in the team will be more responsible, compliant and responsive to the care provided. The dietician, physiotherapist and other specialities are all available when needed, but may not be part of the everyday care. A team will depend on patient need. Figure 24: Multidisciplinary team involved 21

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