Contents
Pressure Ulcer Scale for Healing . . . . . . . . . . . . . . . . . . . 2 Wagner Scale for Diabetes . . . . . . . . . . . . . . . . . . . . . . . 7 Semmes-Weinstein Monofilament Exam. . . . . . . . . . . . 8 Sussman Wound Healing Tool . . . . . . . . . . . . . . . . . . . . 9 Bates-Jensen Wound Assessment Tool . . . . . . . . . . . . 10
Wound healing should be determined by using validated assessment tools. There are several tools available that evaluate the progress of a wound using objective, rather than subjective, data. Wound healing should never be measured by reverse staging, by a decrease in size alone, or any other solitary parameter.
In order to ensure consistency in applying the tool to monitor wound healing, definitions for each element are supplied at the bottom of the tool. Step 1: Using the definition for length x width, a centimeter ruler measurement is made of the greatest length (head to toe). A second measurement is made of the greatest width (side to side). Multiply these two numbers to obtain square centimeters and then select the corresponding category for the size on the scale. Record the patients score. Step 2: Estimate the amount of exudate after removal of the dressing and before applying any topical agents. Select the corresponding category for none, light, moderate or heavy. Record the patients score. Step 3: Identify the type of tissue present in the wound bed. If there is ANY necrotic tissue, it is scored a 4. For the PUSH Tool, necrotic tissue refers to eschar and not slough. If there is ANY slough, it is scored a 3, even though most of the wound may be covered with granulation tissue. Granulation tissue is represented 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 a total PUSH Tool score. Step 5: Transfer the total score to the Pressure Ulcer Healing Graph. Changes in the score over time provide an indication of the changing status of the ulcer. If the score decreases, the wound is improving or healing. If the score increases, the wound is deteriorating.
Example: Mrs. JM PUSH Tool Scores at Admission: L x W = 12.2 or 9 Moderate Drainage = 2 Slough = 3 Total = 14
Example of the PUSH Tool in Use Mrs. JM was admitted to the hospital with a Stage IV pressure ulcer. The wound is located on her coccyx and measures 3.4 x 3.6 x 2.0 cm. There is a moderate amount of drainage and the majority of the wound bed is covered with granulation tissue. However, approximately 25 percent of the wound is covered with a thin layer of slough. Without knowing anything else about Mrs. JM, the PUSH Tool can be completed for monitoring the condition of her wound. Her hospital stay includes a nutritional consult with dietary modifications and working with a physical therapist to increase her mobility. Mrs. JM receives a thorough assessment and is placed on a bladder program for incontinence. With prompted voiding, she remains continent. Wound care includes topical dressings that manage the wound condition. After one week, the wound measures 2.8 x 3.1 x 1.8 cm with slough covering approximately 10 percent of the wound bed. A moderate amount of drainage remains. After another week and the addition of an antimicrobial dressing, the wound measures 2.5 x 2.8 x 1.0 cm with no slough. A moderate amount of drainage remains. By week four of treatment, the drainage has decreased to light and the slough has been removed to reveal an adequately granulating wound bed with evidence of epithelialization at the 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 nicely with evidence of epithelialization. Mrs. JM is discharged and a home health agency is assisting her. They continue to use the PUSH Tool to document the
Example: Mrs. JM PUSH Tool Scores at Discharge: L x W = 0.8 or 3 No Drainage = 0 Closing = 1 Total = 4 5
progress of the wound. After one week the wound is almost completely closed and measures 0.8 x 1.0 x 0.1 cm with no drainage. Mrs. JMs wound is completely closed after week two with the home health agency.
This scale provides the clinician with a mechanism to describe the degree of damage and gangrene when communicating with other clinicians.
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Place the tip of the monofilament perpendicular to the skin, bend and release.
The scoring system is simply marked with a 1 if the attribute is present or a 0 if the attribute is absent.
The second part of the SWHT evaluates the wound depth and location, and measures the phases of wound healing. The depth and undermining are assessed at various points in the wound bed and recorded. The location of the wound is based on orientation such as left and right and anatomical markers such as C for coccyx and H for heel. The phases include inflammation, proliferation, epithelialization and remodeling. To obtain a copy of the Sussman Wound Healing Tool contact Aspen Publishers, Inc.
Bates-Jensen Wound Assessment Tool (formerly known as the Pressure Sore Status Tool)
The Pressure Sore Status Tool (PSST) was developed by Barbara Bates-Jensen to enhance communication between healthcare clinicians regarding pressure ulcers. The tool is now known as the Bates-Jensen Wound Assessment Tool. Thirteen assessment parameters are measured on a scale of 1 to 5. Two additional parameters are measured in a simple check system. The wound location is assessed, recorded and marked on a body diagram. The shape of the wound is described by its overall pattern, such as round or oval and linear or elongated. The tool will help you track individual categories as well as an overall score. Once the numbers are recorded and the scale is complete, a total is calculated using all thirteen parameters and then placed on a linear chart. The total ranges from 1 (Tissue Health) to 13 (Wound Regeneration) to 65 (Wound Degeneration). Data is collected on a routine basis, usually weekly. Results are compared to previous assessments and treatment plans may be adjusted accordingly.
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N e c r o t i c T i s s u e A m o u n t : Use a transparent metric measuring guide with concentric circles divided into 4 (25%) pie-shaped quadrants to help determine percent of wound involved. E x u d a t e T y p e : Some dressings interact with wound drainage to produce a gel or trap liquid. Before assessing exudate type, gently cleanse wound with normal saline or water. Pick the exudate type that is predominant in the wound according to color and consistency, using this guide: Bloody = thin, bright red Serosanguineous = thin, watery pale red to pink Serous = thin, watery, clear Purulent = thin or thick, opaque tan to yellow Foul purulent = thick, opaque yellow to green with offensive odor E x u d a t e A m o u n t : Use a transparent metric measuring guide with concentric circles divided into 4 (25%) pie-shaped quadrants to determine percent of dressing involved with exudate. Use this guide: None = wound tissues dry. Scant = wound tissues moist; no measurable exudate. Small = wound tissues wet; moisture evenly distributed in wound; drainage involves < 25% dressing. Moderate = wound tissues saturated; drainage may or may not be evenly distributed in wound; drainage involves > 25% to < 75% dressing. Large = wound tissues bathed in fluid; drainage freely expressed; may or may not be evenly distributed in wound; drainage involves > 75% of dressing. S k i n C o l o r S u r r o u n d i n g W o u n d : Assess tissues within 4cm of wound edge. Dark-skinned persons show the colors "bright red" and "dark red" as a deepening of normal ethnic skin color or a purple hue. As healing occurs in dark-skinned persons, the new skin is pink and may never darken. P e r i p h e r a l T i s s u e E d e m a & I n d u r a t i o n : Assess tissues within 4cm of wound edge. Non-pitting edema appears as skin that is shiny and taut. Identify pitting edema by firmly pressing a finger down into the tissues and waiting for 5 seconds, on release of pressure, tissues fail to resume previous position and an indentation appears. Induration is abnormal firmness of tissues with margins. Assess by gently pinching the tissues. Induration results in an inability to pinch the tissues. Use a transparent metric measuring guide to determine how far edema or induration extends beyond wound. G r a n u l a t i o n T i s s u e : Granulation tissue is the growth of small blood vessels and connective tissue to fill in full thickness wounds. Tissue is healthy when bright, beefy red, shiny and granular with a velvety appearance. Poor vascular supply appears as pale pink or blanched to dull, dusky red color. E p i t h e l i a l i z a t i o n : Epithelialization is the process of epidermal resurfacing and appears as pink or red skin. In partial thickness wounds it can occur throughout the wound bed as well as from the wound edges. In full thickness wounds it occurs from the edges only. Use a transparent metric measuring guide with concentric circles divided into 4 (25%) pie-shaped quadrants to help determine percent of wound involved and to measure the distance the epithelial tissue extends into the wound.
! 2001 Barbara Bates-Jensen
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References:
Anna and Harry Borun Center for Gerontological Research. The Bates-Jensen Wound 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 the pressure sore status tool. Decubitus. 1992;5(6):20-8.
Sussman C, Swanson G. Utility of the sussman wound healing tool in predicting wound 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.
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