TOOLSFOR WOUNDHEALING · Example:Mrs.JM PUSHTool ScoresatAdmission: ... tissues fail to resume previous position and an indentation appears. Induration is abnormal firmness of tissues
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Wound healing should be determined by using validatedassessment tools. There are several tools available thatevaluate the progress of a wound using objective, ratherthan subjective, data. Wound healing should never bemeasured by reverse staging, by a decrease in size alone,or any other solitary parameter.
Pressure Ulcer Scale for Healing
A useful tool for monitoring the change of a pressure ulcerover time is the Pressure Ulcer Scale for Healing (PUSH) Tool,developed by the National Pressure Ulcer Advisory Panel(NPUAP). Although this is an excellent tool, it should beused in conjunction with good clinical judgment. Thistool is intended for use only with pressure ulcers. Othertypes of wounds should be evaluated using a different tool.
To use the PUSH Tool, the pressure ulcer is assessed and scoredon the following three elements:• Length x Width is measured and scored from 0 to 10.• Exudate Amount is scored from 0 (none) to 3 (heavy).• Tissue Type is assessed and scored from 0 (closed) to 4
(necrotic tissue).In order to ensure consistency in applying the tool to monitorwound healing, definitions for each element are supplied atthe bottom of the tool.
Step 1: Using the definition for length x width, a centimeterruler measurement is made of the greatest length (head to toe).A second measurement is made of the greatest width (side toside). Multiply these two numbers to obtain square centimetersand then select the corresponding category for the size on thescale. Record the patient’s score.
Step 2: Estimate the amount of exudate after removal of thedressing and before applying any topical agents. Select the cor-responding category for none, light, moderate or heavy.Record the patient’s score.
Step 3: Identify the type of tissue present in the wound bed. Ifthere is ANY necrotic tissue, it is scored a 4. For the PUSH Tool,necrotic tissue refers to eschar and not slough. If there is ANYslough, it is scored a 3, even though most of the wound maybe covered with granulation tissue. Granulation tissue is repre-sented by a score of 2. If there is evidence of epithelial tissue,the score is 1. Once the wound is closed, the score becomes 0.
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Step 4: Add up the scores of the three elements to determine atotal PUSH Tool score.
Step 5: Transfer the total score to the Pressure Ulcer HealingGraph. Changes in the score over time provide an indicationof the changing status of the ulcer. If the score decreases, thewound is improving or healing. If the score increases, thewound is deteriorating.
Example of the PUSH Tool in Use
Mrs. JM was admitted to the hospital with a Stage IV pressureulcer. The wound is located on her coccyx and measures 3.4 x3.6 x 2.0 cm. There is a moderate amount of drainage and themajority of the wound bed is covered with granulation tissue.However, approximately 25 percent of the wound is coveredwith a thin layer of slough. Without knowing anything elseabout Mrs. JM, the PUSH Tool can be completed for monitor-ing the condition of her wound.
Her hospital stay includes a nutritional consult with dietarymodifications and working with a physical therapist to in-crease her mobility. Mrs. JM receives a thorough assessmentand is placed on a bladder program for incontinence. Withprompted voiding, she remains continent. Wound care in-cludes topical dressings that manage the wound condition.After one week, the wound measures 2.8 x 3.1 x 1.8 cm withslough covering approximately 10 percent of the wound bed.A moderate amount of drainage remains.
After another week and the addition of an antimicrobial dress-ing, the wound measures 2.5 x 2.8 x 1.0 cm with no slough. Amoderate amount of drainage remains.
By week four of treatment, the drainage has decreased to lightand the slough has been removed to reveal an adequatelygranulating wound bed with evidence of epithelialization atthe wound edges. The wound measures 2.2 x 2.4 x 0.8 cm.
The following week, the wound measures 1.6 x 1.8 x 0.2 cm.There is no drainage and the wound bed is granulating nicelywith evidence of epithelialization.
Mrs. JM is discharged and a home health agency is assistingher. They continue to use the PUSH Tool to document the
Example: Mrs. JMPUSH ToolScores at Admission:
L x W = 12.2 or “9”Moderate Drainage = 2
Slough = 3Total = 14
Example: Mrs. JMPUSH ToolScores at Discharge:
L x W = 0.8 or “3”No Drainage = 0
Closing = 1Total = 4
progress of the wound. After one week the wound is almostcompletely closed and measures 0.8 x 1.0 x 0.1 cm with nodrainage.
Mrs. JM’s wound is completely closed after week two with thehome health agency.
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Wagner Scale for Diabetes
The Wagner Scale is designed specifically for the patient withdiabetes mellitus. It gives the clinician the ability to assess thefoot based on the degree of involvement with skin and woundissues. It is a grading system from 0 to 5, with 5 being theworst possible situation.• Grade 0 ulcers have intact skin.• Grade 1 ulcers are superficial.• Grade 2 ulcers are deeper, and may extend to
tendons or bones.• Grade 3 ulcers contain an abscess or osteomyelitis.• Grade 4 ulcers have gangrene of the forefoot.• Grade 5 ulcers have gangrene of a major portion of the foot.
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Grade 0(Zero)
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
• The patient has diabetes.• There are no signs of any damage or ulceration on the feet.• It is appropriate to evaluate the patient annually with the Semmes-
Weinstein monofilament to determine if there are any changesin sensation.
• The patient has developed a superficial ulcer.• The ulcer does not involve any deep tissue or full-thickness tissue
destruction.• The patient should be able to close this wound with appropriate
management of the diabetes, wound care and offloading pressure.The patient should be reassessed every 3 months
• The ulcer involves deep tissue destruction that may involve muscle,bone or tendon.
• Aggressive treatment is necessary to prevent complications such asamputation.
• The aggressive management of diabetes mellitus includesoff-loading and prevention of osteomyelitis.
• Again, additional assessment for other wounds is necessary.
• The ulcer involves gangrene or a deep tissue abscess.• There is potential for the loss of a limb.• Diabetes control as well as aggressive topical wound care is necessary.
• The ulcer involves gangrene of the forefoot.• Limb salvage is the goal of treatment.
• The ulcer involves gangrene of a major portion of the foot.• The possibility of limb loss increases.
Wagner Scale for Diabetes Grading System
This scale provides the clinician with a mechanism to describe the degreeof damage and gangrene when communicating with other clinicians.
Semmes-Weinstein Monofilament Exam
Testing for protective sensation, such as the feeling a persongets when a blister forms or when stepping on a small pebble,is one of the best ways to screen for neuropathy. You cantest quickly and reliably with the Semmes-WeinsteinMonofilament Exam (SWME). This test uses a single,calibrated, untwisted 5.07 (10 gram) nylon monofilament(similar to a strong “Fishing Line”). It is usually mountedon a plastic or cardboard holder, and is standardized to delivera 10-gram force when pushed against an area of the foot.
Monofilament Exam Instructions:1) Explain the procedure to the patient.2) Position the patient in a comfortable position, for ease of
performing the exam.3) Demonstrate the use of the monofilament on the patient’s
hand so that he or she will know what to expect.4) Hold the probe by the plastic or cardboard “handle.”5) Apply the monofilament perpendicular to the skin. Use
sufficient force to cause the monofilament to buckle or bend,using a smooth, not jabbing, motion.
6) Ask the resident to respond with a “yes” each time he orshe feels the monofilament touching the skin.
7) Touch the monofilament to the appropriate areas asindicated on the following documentation illustration.
8) Apply the monofilament along the margin of a callus, ulcer,scar, or necrotic tissue. DO NOT apply the monofilamentON the lesion.
9) Record the results on the documentation form by placinga dot (•) in the circle if the patient felt the monofilament,and a dash (–) in the circle if the patient did not feel themonofilament.
8Testing Sites Illustration
Place the tip of the monofilamentperpendicular to the skin, bend and release.
Sussman Wound Healing Tool
The Sussman Wound Healing Tool (SWHT) was developed bySussman and Swanson in 1997 specifically to measure pressureulcer wound healing. The focus of the tool is to track a changein tissue status and wound measurement, assess whether thewound is healing, and track the impact of physical therapytechnologies for wound healing.
The tool contains two forms that are completed together.Part I of the SWHT assesses ten variables that addresswound tissue attributes. The attributes are classified as“not good for healing” or “good for healing.”
• The attributes that are “not good for healing” include:• Hemorrhage• Maceration• Undermining/tunneling• Erythema• Necrosis
• The attributes that are “good for healing” include:• Adherence at the wound edge• Granulation tissue• Appearance of contraction• Sustained contraction• Epithelialization
The scoring system is simply marked with a “1” if theattribute is present or a “0” if the attribute is absent.
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The second part of the SWHT evaluates the wound depth andlocation, and measures the phases of wound healing. Thedepth and undermining are assessed at various points in thewound bed and recorded. The location of the wound is basedon orientation such as “left” and “right” and anatomicalmarkers such as “C” for coccyx and “H” for heel. The phasesinclude inflammation, proliferation, epithelialization andremodeling. To obtain a copy of the Sussman Wound HealingTool contact Aspen Publishers, Inc.
Bates-Jensen Wound Assessment Tool (formerlyknown as the Pressure Sore Status Tool)
The Pressure Sore Status Tool (PSST) was developed by BarbaraBates-Jensen to enhance communication between healthcareclinicians regarding pressure ulcers. The tool is now known asthe Bates-Jensen Wound Assessment Tool. Thirteen assessmentparameters are measured on a scale of 1 to 5. Two additionalparameters are measured in a simple check system.
The wound location is assessed, recorded and marked on abody diagram. The shape of the wound is described by itsoverall pattern, such as round or oval and linear or elongated.
The tool will help you track individual categories as well as anoverall score. Once the numbers are recorded and the scale iscomplete, a total is calculated using all thirteen parametersand then placed on a linear chart. The total ranges from 1(Tissue Health) to 13 (Wound Regeneration) to 65 (WoundDegeneration). Data is collected on a routine basis, usuallyweekly. Results are compared to previous assessments andtreatment plans may be adjusted accordingly.
Anna and Harry Borun Center for Gerontological Research. The Bates-JensenWound Assessment Tool page. Available at: borun.medsch.ucla.edu/modules/Pressure_ulcer_prevention/puBWAT.pdf. Accessed January 29, 2007.
Bates-Jensen BM, Vredevoe DL, Brecht M-L. Validity and reliability of thepressure sore status tool. Decubitus. 1992;5(6):20-8.
Sussman C, Swanson G. Utility of the sussman wound healing tool in predictingwound healing outcomes in physical therapy. Advances in Wound Care.1997;10(5):74-77.
Woodbury GM, Houghton PE, Campbell KE, Keast DH. Development,validity, reliability, and responsiveness of a new leg ulcer measurement tool.Advances in Skin & Wound Care. May 2004;17(4):187-196.