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L Berezecky 010133535.Pdf Wound Care Assessment i WOUND CARE ASSESSMENT CAUSED BY CHRONIC VENOUS INSUFFICIENCY Larissa C. Berezecky RN, BSN Nursing 702 A non-thesis submitted in partial fulfillment of the requirements for the degree of MASTER OF NURSING WASHINGTON STATE UNIVERSITY Intercollegiate College ofNursing JUNE 2008 Wound Care Assessment ii To the Faculty ofWashington State University: The members ofthe Committee appointed to examine the non-thesis of LARISSA C. BEREZECKY find it satisfactory and recomnlend that it be accepted. ~ -----­ Chair: LOUiS~lan, PhD, ARNP ePhD,ARNP Wound Care Assessment iii WOUND CARE ASSESSMENT CAUSED BY CHRONIC VENOUS INSUFFICIENCY Abstract By Larissa C. Berezecky RN, BSN Washington State University June 2008 Chair: Louise Kaplan Wound care assessment for patients with chronic venous insufficiency (CVI) is often a subjective practice that lacks the structure needed to make an appropriate diagnosis. Adequate guidelines exist, but are not universally used in practice, often leading to misdiagnosis and mistreatment. Using existing instruments such as The Bates-Jensen Wound Assessment Tool, The Color Classification Scale, and The Odor Scoring Assessment Tool can help guide the Nurse Practitioner to make a thorough assessment. Wound care assessment can be categorized according to: patient history, location of ulcer, skin and leg assessment, vascular assessment, diagnostic testing, staging, size, wound edges and wound bed. Accurate and in-depth wound care assessment is discussed in the article. Wound Care Assessment iv , TABLE OF CONTENTS Page ABSTRACT " .iii INTRODUCTION 1 PATHOPHYSIOLOGY OF CVI. '" 2 ASSESSMENT 3 ASSESSMENT TOOLS 3 PATIENT ASSESSMENT 4 LOCATION OF ULCER 5 SKIN AND LEG ASSESSMENT 6 VASCULAR ASSESSMENT 8 DIAGNOSTIC TESTING 8 STAGING 9 SIZE 10 WOUND EDGES 11 WOUND BED 12 PREVENTION OF CVI ULCERATION 14 CONCLUSION , 15 LIST OF TABLES 17 REFERENCES.............................................................................. 22 Wound Care Assessment v (" LIST OF TABLES THE BATES-JENSEN WOUND ASSESSMENT TOOL. 17 THE CLINICAL APPEARANCE OF WOUNDS-COLOR CLASSIFICATION 20 ODOR ASSESSMENT SCORING TOOL. 20 ULCERATION HISTORy 21 ANKLE-BRACHIAL INDEX 21 CLASSES OF COMPRESSION HOISERy 21 , Wound Care Assessment 1 Wound Care Assessment Caused By Chronic Venous Insufficiency Clinical Practice Introduction Leg ulcers caused by chronic venous insufficiency (CVI) commonly affect the elderly and can profoundly reduce their quality of life (Romanelli, Dini, Bertone, & Brilli, 2007). CVI results from long-standing inadequate venous return that is often associated with underlying patholology such as obesity, diabetes, deep vein thrombosis (DVT), auto-immune disorders and connective tissue disease (Dean, 2006; Hampton, 2006). When prevention fails and ulcerations occur, the nurse practitioner (NP) should focus on adequate assessment and treatment. New treatment options have improved ulcer management, but methods ofassessing and monitoring wounds have not kept pace with the progress in treatment (Romanelli et aI., 2007). Accurate assessment requires knowledge and skills and is the foundation and necessity for treatment therapies. Assessment establishes the diagnosis, serves as the basis for selecting appropriate treatment, and provides baseline information for re-evaluation (Benbow, 2007a; Bates­ Jensen, 1999). Ulcers are often incorrectly treated due to inadequate assessment (Morris & Sander, 2007). The purpose ofthe article is to provide NPs with recommendations and tools to objectively assess leg ulcers caused by CVI. There are also recommendations for prevention ofthese debilitating wounds. Leg ulceration is a chronic, debilitating condition that requires an objective assessment which is not commonly performed (Briggs & Flemming, 2007). In one study, for example, sixteen wound therapists, eight physicians and eight nurses, described the same ulcer in a wide variety of ways with little consistency (Stremitzer, Wild & Hoelzenbein, 2007). Inaccurate assessment leads to inaccurate management, prolonged Wound Care Assessment 2 (., treatment, and unnecessary burden for the patient while increasing the cost ofcare (Stremitzer et al., 2007). The treatment cost for chronic venous ulcers is estimated to be $1 billion per year and the average cost for one patient over a lifetime can exceed $400,000 (Khan & Davies, 2006). Venous ulcers are not only a financial burden but can result in multiple medical problems and negatively affect an individual's quality oflife. Chronic leg ulcers can lead to depression, low self-esteem, social isolation, reduced mobility, as well as multiple medical problems like infection, amputation and pain (Benbow, 2007b; Morris & Sander, 2007). Assessment ofulcers is primarily visual assessment (Romanelli et aI, 2007; Stremitzer et aI, 2007). Accurate assessment and overall better patient care can be achieved using a standardized assessment instrument such as the Bates-Jensen Wound Assessment Tool (Bates-Jensen, 2001). Chronic leg ulcers are routinely treated in the (., primary care setting and the NP should familiarize herself with proper assessment techniques. Pathophysiology The lower extremity venous system consists ofsuperficial and deep veins which are joined together by perforating, or communicating veins (Hampton, 2006). Healthy communicating veins contain one-way valves that prevent backflow by allowing blood to flow from superficial to deep veins where the blood is then returned to the heart (Hampton, 2006). Damage or disease to this system results in progressive interruption of normal blood flow in the lower extremities causing backflow and stasis which can lead to venous ulcer formation. Wound Care Assessment 3 Venous hypertension from inadequate venous return and a defective valvular system are thought to be the main causes ofvenous stasis disease (Worley, 2006). Increased venous pressure stretches the vessel walls eventually causing incompetent valvular closure and venous stasis (Calianno & Holten, 2007). The pressure from the pooled blood allows fluid to leak from the damaged capillary system causing venous hypertension and edema (Morris, & Sander, 2007). Valvular and capillary damage are the main underlying conditions that cause minor injuries, such as scratches or punctures, to transform into serious venous ulcers (Morris & Sander, 2007). Assessment Ulcer assessment is more comprehensive than an in-depth description ofthe wound itself. A thorough assessment ofchronic leg wounds caused by CVI includes many variables that are evaluated and monitored to provide proper assessment and treatment ofthe ulcer. Accurate assessment ofchronic leg ulcers includes the following at each patient visit: patient history, evaluation ofco-morbid conditions, medication review, description ofthe ulcer and surrounding skin and vascular assessment (Dean, 2006; Hampton, 2006; Worley, 2006; Benbow, 2007a; Benbow, 2007b; Morris & Sander, 2007). The cornerstone ofwound assessment is the use ofa standardized assessment tool. The Bates-Jensen Wound Assessment Tool (Figure 1), the Color Classification Scale (Figure 2) and the Odor Assessment Scoring Tool (Figure 3) are examples oftools that can assist in assessment. The Bates-Jensen Wound Assessment Tool is straight forward to use and allows for an objective, comprehensive assessment. This is in contrast to the Color Classification Scale and the Odor Assessment Scoring Tool which assess only one aspect Wound Care Assessment 4 (., ofthe wound. The user completes a form to assess the status ofa wound. Each item is rated by choosing the definition that best describes the wound. A numerical score is given based on the rating scale: the higher the total score, the more severe the wound status. The Color Classification Scale and Odor Assessment Scoring Tool examine a portion ofthe wound by providing guidelines for color assessment and the presence of malodor. However, the Odor Assessment Scoring Tool is the most subjective ofthe three tools due to differences in identifying odors. All three tools help standardized wound assessment, yet the Bates-Jensen Wound Assessment Tool is the only one ofthe three validated for all chronic wounds (Romanelli et al., 2007; Bolton et al., 2004). Nonetheless, it is still not universally used in practice. These three assessment tools will be discussed with a recommendation for use ofthe Bates-Jensen Wound Assessment Tool. Patient History An accurate history must be conducted with the patient and/or caregiver. The history provides the healthcare team with data that can be used as a baseline throughout the course oftreatment. The history should systematically collect relevant data summarized in figure 4. A careful history is the basis for differentiating between a venous or arterial cause ofulceration and influences how a wound should be managed (Benbow,2007b). For example, venous ulcers are more painful when the leg is dependent, whereas arterial ulcers are more painful when the leg is elevated (Morris & Sander, 2007; Benbow, 2007b). Diagnostic testing, discussed below, can also be used to Wound Care Assessment 5 (" differentiate between venous and arterial ulcers. A review ofco-morbid conditions and medication review should be conducted. Location of Ulcer The location ofthe ulcer is associated with the cause and helps determine ifthe ulcer is venous, arterial or pressure in origin. Ninety-five percent ofvenous ulcerations occur medially between the ankle and knee, near the medial malleolus (Dean, 2006; Grey, Harding & Enoch, 2006). Venous
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