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ffective wound management in extended care and home healthcare includes recognition and management of nonhealing wounds. When we are able to identify a wound as nonhealing, we are more effective at establishing realistic goals and providing compassionate care to our patients. This article will focus on wound assessment in palliative care. For the purposes of this article, we will define nonhealing wounds as those with no realistic potential for healing. Identifying nonhealing wounds is critical to effective wound care for several reasons. Nonhealing wounds are all too common in extended and home care due to the large number of frail, elderly patients we serve. Many of these patients have unstable diseases that impact wound healing and cannot withstand the rigors of a comprehensive treatment plan. Unless we identify these patients during admission, we create plans of care with impractical goals that foster unrealistic expectations from patients and families.
       Though identifying nonhealing wounds is important, it can be difficult to do, because the healing potential of wounds is often not known when we are admitting a patient. This may be due in part to the fact that our information is incomplete, or because the patient and family want to be optimistic despite deteriorating conditions. Even if nonhealing wounds are not recognized on admission, we can often identify them during the course of our care through consistent wound assessment, documentation, and case conferencing. Case conferencing is the time when the care team re-evaluates each patient’s condition to ensure that progress toward goals is being made. For a patient with wounds, we may adjust topical therapy as wound conditions change or add other disciplines and treatments to manage underlying diseases. When our best efforts fail, we should consider the possibility that the wound is nonhealing and, if so, modify the plan of care toward realistic goals.
       So what are the essential components of wound assessment needed to determine if wounds are improving, and what are the timeframes in which we can expect to see change?

Essential Components of a Complete Wound Assessment

       Although we lack standardized wound assessment tools, consensus among clinicians on the essential components of a complete wound assessment is emerging and includes wound location, size, appearance, and exudate.
       Wound location is an important component when multiple wounds are present, because it helps ensure assessments on each wound can be tracked accurately over time. Location is also important, because it may be suggestive of underlying disease not yet identified. If the wound is located on 1 of the boney prominences of the pelvis (ie, the sacrum, coccyx, left or right ischium, or trochanters), we should determine if pressure during lying, transferring, or sitting is the underlying problem. If the wound is located on the medial aspect of the lower leg, we should determine if venous stasis is the underlying problem. If the wound is located on the plantar foot in a patient with diabetes, we should determine if loss of sensation due to peripheral neuropathy is the underlying problem. If the wound is located on the dorsal foot in a patient with a cardiac history, we should determine if peripheral arterial disease is the underlying problem. Wound location also affects dressing selection. If the wound is located in the perineal area, managing external moisture can be important to keep the dressing in place between changes.
       Wound size is an important component of complete wound assessment and should be recorded as length, width, and depth in centimeters. Information on the location and depth of any tunneling or undermining should also be recorded. While most clinicians agree that documenting wound size is critically important, expert opinion is divided on which method of measurement is most effective. Experts do agree, however, that using a consistent method within an organization is critical. This suggests that all clinicians who care for wounds in your facility or home health agency should be trained to measure the same way.
       Wound size is important for selecting the type of dressing to apply and for ensuring services provided will be covered by the payer. In home care, wounds that are very shallow may not require the skills of a nurse to perform the dressing changes, and therefore, visits to provide dressing changes may not be covered under the US Centers for Medicare and Medicaid Services (CMS) guidelines or those of other payers as well.
       Wound appearance, which includes the condition of the wound bed and surrounding skin, is an important component of wound assessment, because it provides information on necrotic tissue and infection. Any necrotic tissue noted in the wound bed can be described in terms of color and/or viability with percentages noted. This information is critical to determining if the current method of debridement is effective and if necrotic tissue is present. Necrotic tissue is sometimes called avascular or nonviable tissue and typically presents as black eschar or yellow slough. Any redness, warmth, or tenderness of the surrounding skin can be described in terms of width and location using the clock face. These signs of inflammation should be monitored closely to ensure that any systemic antibiotics or topical antimicrobial dressings ordered by the physician are effective.
       Wound exudate is important for selecting the type of dressing to apply and for ensuring effective management of the bacterial burden. The assessment of wound exudate should always include information on both the amount and the type of drainage. The amount of wound exudate is important for selecting the optimal dressing, because if you select a dressing with too little moisture retention ability, wounds producing small amounts of exudate will dry out, and healing will likely be slowed. On the other hand, wounds producing large amounts of exudate will overwhelm the dressing and leak, macerating surrounding skin, and the dressing may even fall off between scheduled dressing changes if you select a dressing with too little absorptive capacity. The type of exudate is important in managing the bacterial burden, because it helps to identify wounds when bacteria overgrowth is occurring. When the number of bacteria gets excessive or they are particularly virulent, the body’s immune system may not be able to cope, the drainage may develop a foul odor, and healing may be delayed. If systemic antibiotics or topical antimicrobial dressings are added quickly, the trend of bacterial overgrowth can often be reversed, and healing can often resume.
       Most experts agree that, regardless of care setting, complete wound assessments should be documented on admission, weekly, and on discharge. They should also be documented with any significant change in patient condition.

Realistic Timeframes for Wound Improvement

       The time that it takes to see wound improvement depends on where the wound is along the continuum of wound healing. Healing in full-thickness wounds generally begins with an inflammatory phase lasting a few days, followed by a proliferation phase lasting a week or more as the wound fills in with granulation tissue and covers over with new epithelial layers. The final phase, known as maturation or remodeling, lasts several months to a year as structural components in the granulation tissue known as collagen are reorganized and durability is restored to levels near that of uninjured skin.
       Acute wounds in the inflammatory phase should improve within a few days; look for a decrease in redness and purulence. Some chronic wounds in this phase contain necrotic tissue in the wound bed, and if so, expect things to improve within a week or 2; look for a decrease in the percent of the wound bed covered with black or yellow necrotic tissue. Necrotic wounds may increase in size while they are improving, because the necrotic tissue is breaking down and being removed during dressing changes and cleansing. A wound in the proliferative phase should improve within a few weeks, depending on the depth of injury and systemic factors like nutrition and hydration; look for a decrease in size. Answering questions about wound progress should be based on wound assessments found in the patient’s medical record, because they are the basis of ongoing changes to the patient’s plan of care.

Conclusion

       Documentation of a series of complete wound assessments provides the objective basis for asking the key question: “Is this wound making progress?” And when wounds treated by a comprehensive approach fail to progress within a reasonable timeframe, it is appropriate for members of the patient’s care team to ask, “Is this a nonhealing wound?” Just asking the question will allow the patient’s care team to explore alternative goals and ensure compassionate care for each patient we treat.