“Measurement Monday”: One Facility’s Approach to Standardizing Skin Impairment Documentation

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Author(s): 
Suzanne Stewart, MS, RN, CWOCN; Sally Bennett, MS, RN; Angela Blokzyl, BSN, RN, CCRN; Winnie Bowman, RN; Ida Butcher, LPN; Kelly Chapman, RN; Kelly Koop, RNC; Barb Lebo, RN; Diane Siebecker, BSN, RN, BC; Heidi Signs, RNC; Jane Streeter, RNC; Catherine Russo, RN, BC; and Susan Wenzel, RN, CCRN

The first review was conducted to look for a mnemonic. When none was found, a second review was conducted to search for other assessment and documentation strategies. Thus, the literature review was conducted to 1) determine if any particular phrases or mnemonics existed to standardize the wound assessment process, such as a regular day of the week; and 2) find the best evidence addressing the wound assessment process, including measurement and documentation. No date or language restrictions were imposed on the search. Five clinical studies, 10 review articles, two practice guidelines, and one patient safety guideline/study/review publication were used to guide wound documentation improvement efforts.

     Standardization of wound assessment process and wound measurement techniques. One review of the literature described the need for and methods of accurate wound assessment, including a framework for practice and accurate, uniform terms for assessment and documentation and the use of a mnemonic phrase to facilitate the practice of consistent wound assessment.5 No studies related to the designation of a specific day of the week for impaired skin documentation were found.

     Best evidence of the assessment process. The literature identified a lack of consistency in practice and documentation as areas of concern. Subjective measurements of the wound bed — including descriptions of drainage, tissue appearance, edema, wound edges, and the surrounding skin — also were found to contribute to wound assessment inconsistencies.5 The literature review underscored that quantitative measurement of wounds is necessary for consistent documentation and allows the practitioner to evaluate treatment effectiveness.

     Studies describing different wound measurement techniques (eg, rulers, wound tracings or molds, and photographs) affirm that a standardized method of wound measurement is necessary to ensure consistent patient care. Langemo et al11 evaluated four ruler length-and-width measurement techniques using plaster-of-Paris models to determine the closest measurement of actual surface area of a wound, subsequently recommending that clinicians measuring the wounds using a ruler use the same technique each time. The authors also recommended the measurement technique of “longest head to toe and the widest width side to side, perpendicular to length.”

     The literature also noted that initial assessments of impaired skin such as pressure ulcers or wounds should include documentation of the impairment, including location and wound measurements.12 These assessment details must be measured consistently and documented regularly in the chart. Recommendations for measurement frequency vary, from each dressing change to weekly assessments to deterioration of patient condition. Inconsistent assessments and failure to assess and document impaired skin on admission is common.13

     Reports about the use of wound documentation tools and protocols such as the Pressure Ulcer Prevention Protocol Interventions (PUPPI )14 and Barber Measuring Tool15 have been published. No information about tools or protocols that included the use of a consistent day-of-the-week mnemonic to remind staff that wound measurement is due could be found in the literature.

     Within the past decade, imaging has been used to enhance wound measurement documentation. Houghton et al16 evaluated the validity and reliability of wound photography and found wound photographs to be reliable when the photography was completed by persons who had adequate clinical experience in chronic wound care.

References: 

1. Lyder CH, Ayello EA. Pressure ulcers: a patient safety issue. In: Hughes RG (ed). Pressure Ulcers: A Patient Safety Issue. Rockville, MD: AHRQ Publication No. 08-0043;2008:Volume 1, 267–300.
2. Wound, Ostomy, and Continence Nurses Society. Guideline for Prevention and Management of Pressure Ulcers. Mt. Laurel, NJ: Wound, Ostomy, Continence Nurses Society;2003:3.
3. Bergstrom N, Bennett MA, Carlson CE, et al. Clinical Practice Guideline, No.15: Treatment of Pressure Ulcers. Rockville, MD. U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research. 1994. AHCPR Publication No. 95-0652.
4. van Rijswijk L. The fundamentals of wound assessment. Ostomy Wound Manage. 1996;42(97):40–46.
5. Keast DH, Bowering CK, Evans AW, MacKean GL, Burrows C, D’Souza L. MEASURE: a proposed assessment framework for developing best practice recommendations for wound assessment. Wound Repair Regen. 2004;12(3):S1–S17.
6. Flanagan M. A practical framework for wound assessment 2: methods. Brit J Nur. 1997;6(1):6–11.
7. Russell L. The importance of wound documentation and classification. Brit J Nurs. 1999;8(20):1342–1354
8. Goldman RJ, Salcido R. More than one way to measure a wound: an overview of tools and techniques. Advances Skin Wound Care. 2002;15(5):236–243.
9. Hess CT. The art of skin and wound care documentation. Home Health Nurse. 2005;23(8):502–513.
10. Cuzzell J. Wound assessment and evaluation: wound assessment guidelines. Dermatol Nurs. 2002;14(4):265–266.
11. Langemo D, Anderson J, Hanson D, Hunter S, Thompson P. Measuring wound length, width, and area: which technique. Advances Skin Wound Care. 2008;21(1):42–45.
12. Brown G. Wound documentation. Advances Skin Wound Care. 2006;19(3):155–165.
13. O’Brien SP, Wind S, van Rijswijk L, Kerstein MD. Sequential biannual prevalence studies of pressure ulcers at Allegheny-Hahnemann University Hospital. Ostomy Wound Manage. 1998;44(3A suppl):78S– 88S.
14.Catania K, Huang C, James P, Ohr M, Madison M, Moran M. PUPPI: the pressure ulcer prevention protocol interventions. AJN. 2007;107(4):44–52.
15. Barber S. A clinically relevant wound assessment method to monitor healing progression. Ostomy Wound Manage. 2008;54(3):42–49.
16. Houghton PE, Kincaid CB, Campbell KE, Woodbury MG, Keast DH. Photographic assessment of the appearance of chronic pressure and leg ulcers. Ostomy Wound Manage. 2000;46(4):20–30.
17. Dufrene C. Photography as an adjunct in pressure ulcer documentation. Crit Care Nurs Quarterly. 2009;32(2):77–80.
18. Plassman P, Melhuish JM, Harding KG. Methods of measuring wound size: a comparative study. Ostomy Wound Manage. 1994;40(7):50–60.


















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