Arizona Association for Home Care

1. Arizona Association for Home Care Treatment, Care and Prevention of Wounds

2. Documentation of Wounds Judith A. Perron, RN, MSN Clinical Quality Specialist

3. Assessment of Wounds • Site/location of wound(s) • Stage of pressure ulcer • Size (length, width and depth measured in centimeters) • Appearance of wound bed (describe type of tissue) • Undermining • Drainage/exudates (amount, color or type and odor). • Periwound tissue (palpate, and describe erythema, induration, edema, maceration or warmth). • Pain or tenderness

4. Does This Patient Have a Skin Lesion or an Open Wound? (MO440) • Pressure Ulcer (MO445) • Stasis Ulcer (MO468) • Surgical Wound (MO482)

5. Pressure Ulcer (MO445) • Any lesion caused by unrelieved pressure resulting in damage of underlying tissue. Pressure ulcers are usually located over bony prominences and are staged to classify the degree of tissue damage observed.

6. Wound Staging • Stage I: Non-blanchable erythema of intact skin, the heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators.

7. Wound Staging • Stage II: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents as an abrasion, blister, or shallow crater.

8. Wound Staging • 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 clinically as a deep crater with or without undermining of adjacent tissue.

9. Wound Staging • Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g.. tendon, joint capsule). Undermining and sinus tracts may also be associated with Stage IV pressure ulcers.

10. Wound Staging • Non-observable: Wound is unable to be visualized due to an orthopedic device, dressing, etc. A pressure ulcer cannot be adequately staged until the deepest viable tissue layer is visible; this means that wounds covered with eschar and/or slough cannot be staged, and should be documented as non-observable.

11. Status of Most Problematic (Observable) Pressure Ulcer MO464 1 Fully Granulating 2 Early/partial granulation 3 Not healing NA No observable pressure ulcer

12. Fully Granulating • Wound bed filled with granulation tissue to the level of the surrounding skin or new epithelium; no dead space, no avascular tissue; no signs or symptoms of infection; wound edges are open.

13. Early/Partial Granulation • > 25% of the wound bed is covered with granulation tissue; there is minimal avascular tissue (I.e., < 25% of the wound bed is covered with avascular tissue); may have dead space; no signs or symptoms of infection; wound edges open.

14. Non-healing • Wound with > 25% avascular tissue OR signs/symptoms of infection OR clean but non-granulating wound bed OR closed/hyperkeratotic wound edges OR persistent failure to improve despite appropriate comprehensive wound management.

15. Stasis Ulcer • MO468 Does the patient have a stasis ulcer? • MO470 Current number of observable stasis ulcer(s). • MO474 Does this patient have at least one stasis ulcer that cannot be observed? • MO476 Status of most problematic (observable) stasis ulcer/

16. Surgical Wound • MO482 Does the patient have a surgical wound? • MO484 Current number of (observable) surgical wounds. • MO486 Does the patient have at least one surgical wound that cannot be observed due to the presence of a non-removable dressing? • MO488 Status of the most problematic (observable) surgical wound.

17. Wound Healing • Healing by Primary Intention (i.e. approximated intention). • Healing by Secondary Intention (i.e. healing of dehisced wound by granulation, contraction and epithelialization).

18. Healing by Primary Intention • Fully granulating/healing: incision well-approximated with complete epithelialization of incision; no signs or symptoms of infection; healing ridge well defined. • Early/partial granulation: incision well-approximated but not completely epithelialized; no no signs or symptoms of infection; healing ridge palpable but poorly defined. • Non-healing: incision separation, necrosis, signs and symptoms of infection or no palpable healing ridge.

19. Things to Remember • A new Stage 1 pressure ulcer is reported on OASIS as not healing. • Counting wounds???????????

20. Health Services Advisory GroupClinical Quality Specialists National Home Health Quality Initiative Judith Perron, RN, MSN Phone: 602-665-6167 E-mail: jperron@azqio.sdps.org Peggy Milmine, RN, BSN Phone: 602-745-6284 E-mail: pmilmine@azqio.sdps.org