10/18/2016. Utilizing Photography as Adjunct Documentation in Wound Assessment. Introduction. Overview
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1 Utilizing Photography as Adjunct Documentation in Wound Assessment A PICTURE IS WORTH A THOUSAND WORDS... A M Y M I L L E R, B S N, R N, C W O C N S T A N T H O N Y H O S P I T A L L A K E W O O D, C O L O R A D O Introduction Photography has been widely used in pressure injury documentation. St Anthony Hospital has consistently practiced the use of photography in it s Emergency Department identifying pressure injuries present on admission. So while it is not a new concept, on March 1, 2016 St Anthony Hospital became the first Centura Hospital to formalize photography as part of the wound care assessment process in the in-patient setting for all wounds followed by the wound care department. Overview Comprehensive wound assessment and documentation are essential components of wound care. While all patients with or without wounds require skin assessments, the patient with wounds requires ongoing wound assessments. Identifying underlying causes for the wound Comorbidities/acute illness that may impede wound healing Potential interventions needed ie vascular studies Assure appropriate treatments are being implemented 1
2 Overview St Anthony Hospital Wound Care Assessment Process Wound consult received from staff or physicians through health medical record (HMR). Initial wound care assessment with recommendations for dressing changes, unless otherwise dictated by the physician. Follow up weekly and as needed for complex dressing changes, and with change in condition or by request. Overview The use of photography in conjunction with the narrative documentation can give a visual, subjective interpretation to the reader. Identifies the progression or decline of a given wound during the patient s stay, helping ensure correct interventions are in place. May be particularly helpful when the reader is not as familiar with wound terminology such as slough, granulation tissue and epithelialization. Helps with coordination of care among disciplines. Decreases the number of unnecessary and potentially painful dressing changes. Wound consult to change wound vac dressing to L medial UE. Pt is 34 yr old male admitted 5/19/16 with complaint of bilateral UE pain and altered mental status. He underwent emergent release of compartment syndrome/fasciotomy X4 after being found down for extended period of time. Pt diagnosis/history includes traumatic rhabdomyolosis, toxic encephalopathy, cellulitis, heroin abuse, AKI, hyperkalemia, severe sepsis, thrombocytopenia and acute respiratory failure. On assessment pt received on standard ICU surface in bilateral wrist restraints. Pt with ET tube, orogastric feeding tube, receiving CRT. RN in at bedside. B UEs highly edematous. L medial UE wound presents with large amt sero sang drainage with exposed muscle and areas of early granulation tissue. Noted dusky area to distal aspect of open wound. Covered all with oil emulsion gauze contact layer, placed black sponge, placed 2 track pads. Pump set on 125mmHg continuous therapy. L anterior/lateral aspect, L and R palmar and dorsal hand and R medial UE all present with well approximated incisions, all weeping sero sang drainage. Sutures and staples intact. Cleansed all with wound cleanser, covered with Xeroform gauze, covered R UE with ABDs, wrapped with kerlix and secured with tape. Plan to continue to follow. 2
3 ... L medial UE wound presents with large amt sero sang drainage with exposed muscle and areas of early granulation tissue. Noted dusky area to distal aspect of open wound L anterior/lateral aspect, L and R palmar and dorsal hand and R medial UE all present with well approximated incisions, all weeping sero sang drainage. Sutures and staples intact... L anterior/lateral aspect, L and R palmar and dorsal hand and R medial UE all present with well approximated incisions, all weeping sero sang drainage. 3
4 ... Notified that the wound vac had been removed this past weekend due to increase in swelling. Anterior aspect of L UE re opened by surgeon. L medial aspect of UE with increased biofilm, increased duskiness to discolored mid and distal muscle areas Notified that the wound vac had been removed this past weekend due to increase in swelling. Anterior aspect of L UE re opened by surgeon. L medial aspect of UE with increased biofilm, increased duskiness to discolored mid and distal muscle areas Both anterior and medial aspects showing improvement with increased granulation tissue and decreasing in size. Mid portion of medial aspect continues with area of necrotic muscle-remaining stable at this time... 4
5 ... Both anterior and medial aspects showing improvement with increased granulation tissue and decreasing in size. Mid portion of medial aspect continues with area of necrotic muscle-remaining stable at this time... Pt had been discharged to outside facility 6/9/16 and returned 6/24/ L UE with decreased edema-medial forearm wound with approx 80% granulation tissue and 20% soft eschar. Pt scheduled for debridement 6/30/16. Anterior aspect remains with 100% granulation tissue continuing to decrease in size... Pt had been discharged to outside facility 6/9/16 and returned 6/24/ L UE with decreased edema-medial forearm wound with approx 80% granulation tissue and 20% soft eschar. Pt scheduled for debridement 6/30/16. Anterior aspect remains with 100% granulation tissue continuing to decrease in size... 5
6 First dressing change post debridement.... Medial aspect showing improvement decreasing in size and increased granulation and epithelial tissue... Anterior aspect too showing improvement decreasing in size with 100% granulation tissue and increased epithelial tissue Medial aspect showing improvement decreasing in size and increased granulation and epithelial tissue... Anterior aspect too showing improvement decreasing in size with 100% granulation tissue and increased epithelial tissue L medial forearm continues to improve, decreasing in size with continued increase in granulation tissue. Small areas of necrotic fat remain to medial aspect. Anterior aspect nearly closed with 100% granulation tissue... 6
7 ... L medial forearm continues to improve, decreasing in size with continued increase in granulation tissue. Small areas of necrotic fat remain to medial aspect. Anterior aspect nearly closed with 100% granulation tissue... Pt scheduled for split thickness skin graft 8/5/ L medial forearm slightly smaller in size. Noted undermined area at 9 o clock slightly larger measuring 2.5cm. Area of induration slightly decreased. Anterior aspect continues with small open area, nearly closed with 95% epithelial tissue L medial forearm slightly smaller in size. Noted undermined area at 9 o clock slightly larger measuring 2.5cm. Area of induration slightly decreased. Anterior aspect continues with small open area, nearly closed with 95% epithelial tissue... 7
8 Second dressing change post graft placement 8/5/ L medial forearm graft with 95% take. Small open areas remains at 9 o clock with small amt sero sang drainage... Final assessment with photos 8/19/16 Wound care follow up with dressing change. On assessment pt received sitting at edge of bed-mobility continuing to improve. Pt has been providing own wound care appropriately and without difficult. L medial forearm remains with 2 small open areas with small amt sero sang drainage along medial aspectdistal site with hyper granulation tissue. Placed strip of Aquacel Ag along open areas, applied Hydrocerin moisturizer to all intact graft, placed single 4x4 gauze and wrapped with kerlix. Pt to discharge Monday 8/22/16. Plan to assess 8/22/16 prior to d/c. Final narrative documentation 8/22/16 Wound care follow up. Pt returned from shower with sister in at bedside ready for discharge to New Mexico to live with sister. 2 small open areas remain to the medial aspectdecreased drainage noted. Continuing current tx, cleansed with wound cleanser, placed Aquacel Ag to 2 small areas, applied Hydrocerin to graft site, covered with 1 4x4 gauze, wrapped with kerlix and secured with tape. Both sister and pt able to do dressing changes. No questions at this time. 8
9 Professional Feedback Survey from 8/1/16 9/30/16 Includes 91 participants - 46 physicians Surgeons, Hospitalists, Orthopedists, Trauma, Cardiac and Infectious Disease - 24 floor nurses - 22 PT/OT/dietary staff Professional Feedback Five Questions: ( YES NO NO OPIONION N.O. ) #1. Are you aware of the photo documentation under the wound care notes? YES - 74% NO 26% N.O. 0% #2. Do you refer to these photos to assist in developing your plan of care? YES - 60% NO 37% N.O. 3% #3. In your bedside experience with patient care/interaction do you believe the use of photos has decreased patient discomfort through potentially unnecessary dressing changes? YES - 39% NO 16 % N.O. 45% #4. In your bedside experience with patient care/interaction do you believe the use of photos has increased patient satisfaction through potentially unnecessary dressing changes? YES - 53% NO 7% N.O. 40% #5. Overall do you find photo documentation as asset to St Anthony Hospital? YES - 84% NO 1% N.O. 15% Professional Feedback Additional Comments From Floor RN: I have found the pictures very helpful to see the healing of the wounds. If the wound nurse recently saw the patient, I won t take the dressing down, so it is nice to use the pictures for reference From Trauma PA: Pictures of wound granulation vital tool to help with patients ability to see wounds healing From Trauma DO: We LOVE them and often consider consulting the wound team just to get photos From ID: I would if I saw the pictures (marked NO to #1 the awareness on the charts) 9
10 Policy and Procedure St Anthony has a policy that outlines the process for wound care photography. A competency has been drafted for the anyone taking photos. At St Anthony wound care nurses take the photos. The American Health Information Management Association (AIHMA) suggests that consent for photographs be included in the consent for photographs be included in the consent for treatment upon admission. At St Anthony Hospital this is the consent in place. Best Practice While the National Pressure Ulcer Advisory Panel (NPUAP) and the Wound, Ostomy and Continence Nurses Society (WOCN) neither recommend nor discourage the use of photography with wound assessment, the WOCN recognizes that photography as adjunct documentation serves only to support the narrative assessment. THANK YOU A PICTURE IS WORTH A THOUSAND WORDS... Amy Miller, RN, BSN, CWOCN St Anthony Hospital Lakewood Colorado amymiller@centura.org
11 References Bryant, R. & Nix, D. (2015). Acute and chronic wounds; current management concepts, fifth edition. Elsevier, St Louis MO Calianno, C., & Martin-Boyan, A. (2006). When is it appropriate to photograph a patient s wound? Advances in Skin and Wound Care 19(6) Dufrene, C. (2009). Photography as an adjunct in pressure ulcer documentation. Critical Care Nursing Quarterly 33 (2) Wiedemann, L. (2010). Using clinical photos in HER s. Journal of AHIMA, 81, no. 4, WOCN Nurses Society. (2012). Photography in wound documentation: fact sheet. Retrieved May 2016 from 11
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