Educational Webinar: Knowing what you’re looking at: Wound assessment & documentation

Good afternoon. My name is Brandon Martin customer engagement analyst and I'm pleased to welcome you to Clinical Connection. Our monthly educational webinar series. Today's program is knowing what you're looking at, assessment and documentation. Uh Before we get started, just a couple of housekeeping items, uh Please note um the customs product information disclaimer. Um Give me just a couple of moments. Our speaker for today is Michelle Moore, Senior Director of Clinical Affairs at Enova Incorporated. Michelle has been a practicing clinician for over 30 years specializing in wound care and advanced wound care product design and development. Michelle is a consultant to Innova um Innova as well as an instructor for the wound certified credential nationally and internationally. Today's conference is being recorded and you will receive a link to the replay in the coming days to ask a question during today's program. Please locate the Q and A panel in the lower left corner of your console. We will do our best to answer your questions but feel free to ask throughout the presentation and uh we can reach out to you after the event if we run out of time. Uh We have a full hour of content today. So let's go ahead and get started. I am pleased to welcome Michelle Moore. Thank you so much. Hey, you guys. I am so glad to be here with you on this uh somewhat rainy overcast day here in California. Um This is uh all about wound assessment and a little bit about documentation and I'm excited to share this with you today. So, um as he had mentioned, this is gonna be a great way for you and I to talk back and forth at the very end of the slide is um uh photos that I wanna be able to talk to you about and tell me where you guys are, but let's just jump into it. Um I've got some really great pictures. So I'm excited to share some of those with you as well when, when we talk about wounds and, and when I say wound assessment immediately, we're going to um talk about all kinds of wounds because they do come in all shapes and sizes. Uh Whenever I say the word wound, a lot of times people immediately think the worst, whether it's pressure or fating wounds or d his surgical sites. But what I want, what I want you guys to always remember when, when you hear the word wound, it's any break in the skin. So any time that there is a break in the skin, we have a wound there. And the reason that, that, that I bring that up is because when I go to facilities and I say, tell me about the wounds in your building, the first thing they tell me is that they don't have any. And then I go, ok. Well, tell me about the skin tears. You have skin tears in your building. Oh, yeah. Sure. We do. How about Venus? Oh, sure, we do diabetic. Sure. Ok. Great. Then you got wounds in your building. Um, so when you, when you have that mindset of any break in the skin, it makes it a little bit easier to, to kind of swallow the fact that, yeah, you have wounds. It doesn't mean it's any, any nosocomial or anything other than that, there's breaks in the skin. But knowing that these wounds themselves are complex in nature, even something that is simple as a, a scrape and a scratch. And the reason why I say that is because I had a patient who had scratched themselves on a wire and in your mind, you're thinking that's nothing major. And then they had necrotizing fasciitis. So it went from something that was nothing major to really a true complex wound in a very quick fashion. So knowing what we're looking at, knowing what possibilities are there, can it can really help us assess that wound plan on the, the correct plan of care for that patient or interventions that need to be taking place. So when we think of really what we need to do for our wound patients. And when we're truly assessing, I want to continue to push the fact of the team approach. When you're gathering that information on that patient, and when I say be gathering the information, what we're gonna talk about initially is even before that dressing comes off, what things that we need to know is the clinician that's going to make us better caring for that specific patient. And when we look at the true wound team, I want to especially put the patient aspect. When we include the patient in that team approach, we need to make sure that they have like the ability to understand what is asking what we're asking of them, especially when they're at home and we need their help when we're not there taking care of them. But what, what can they do? Can they understand that what you're being at? What is asked of them? Do they have the mobility or the dexterity to do it? Are they gonna adhere to that plan? Um Do they have help? And does does that help? Understand? And then we look at like the wound itself. Where is that? What kind of wound is it? Do we know? And what other complications that may be there? Not even complications like bio burden or a biofilm or just some, some over drainage in that wound. But but disease state that goes along with it, that's going to delay a wound from getting better or not. And then you, the clinician, the care provider, what's your skill set? And what's your comfort level? A lot of times when I talk about wounds, there's a handful of you all that are like, oh, I don't like wounds. Well, guess what? You better get to liking them because it's all part of our job. Right. It's all part of our job to be able to have some type of comfort level and confidence in taking care of that wound bed. So all of that goes into play when we are looking at what truly is going to be assessed and what we're looking at and assessment, no matter what. And and when I say assessment, I know that there's certain certain types of nurses quote unquote that are not allowed to assess. But at the end of the day, when we look at things, we're assessing something we're looking with our own eyes. So, uh that is in, in my opinion, one of the most important skill sets that a clinician can, can possess is the ability to know what you're looking at. Now, whether or not you can document it or make it, make a statement off of it. I I'm not here to debate that, but I am here to debate your ability to assess and know what, know what you're seeing. So when you are truly looking at it, um and knowing what to assess this is where you get to choose and, and have a good idea of what dressings to be incorporated. Um What who's gonna pay for it? Is it something that your facility has access to all these factors come into play before we're taking this dressing off? And all of this is our baseline data that we're collecting before we get to take that dressing off. And so we start with a lot of things besides learning about the patient besides your skill set, but we gotta go into the chart and even start asking questions. Um I like this being able to do like the 20 questions of history taking and that is really going through the patient and talking about um, what surgi surgical procedure did they have? Uh have they ever had wounds before? Are they allergic to certain things? Um I even ask questions as far as what are their religious connotations because if they have certain religious components, when it comes to certain products that are made, maybe made from bovine or pig, I'm gonna steer away from those just because that's against their religious beliefs. But grabbing all kinds of history is really going to help make me have a better idea of what products I'm going to incorporate in their treatment, print in their treatment plan. And so getting all of that. But a lot of times I look into that medical record that will tell you so much of information of their history, their mobility, their incontinence, all those things that could help me assess that wound bed, assess what kind of interventions are gonna be put into play and then get me ready to take that dressing off. So grab all those informa that all that information, all of that is needed. They're up to date. Lab works to see where we're at. Um and and see what additional things needs to be ordered um to make sure that we have the right plan in place and then we get to get into that loop bed and see what's there. So, understanding how wounds heal and knowledge of product is part of you too. Um And I always say the same thing, get with your sales rep if you're, if you're unsure of what new products are out there. And I always say this, this comment, a good sales rep knows their product and a great sales rep knows everybody else's product because when we're dealing with wounds that are maybe a little bit different, maybe non healing, maybe you've tried all kinds of things. Your sales rep may say, hey, it's not my product today, but uh let's look at this product. I saw it at a show II, I have a friend who sells this one and, and play around with different products. But knowing through your, your really good strong assessment skills is going to make these wounds heal faster, less pain for your patients, etcetera. So all of that moving forward gets us to really looking at the assessment that is needed. And there are so many different moving parts when you're truly doing an assessment. And so we're gonna go over those parts today. And what is, what is there, what is in your way, what are barriers to healing for you? So let's get into it first things first when you're doing a full assessment, explain to the patient why you're in there, explain to the patient who you are, what you're gonna do. If there's gonna be any pain during this dressing change. This is when you premedicate for pain and wait the allotted time that is needed for that pain medication to go into play. It is not, hey, my name's Michelle. This is gonna hurt rip, right? We don't do that. We go in, we, we take care of our patient. We medicate like we're supposed to, I understand that time is of the essence we're short staffed. I get all that. But some of these dressings that we do and these assessments that we do can hurt, hurt our patient. So let's medicate and then we're gonna get ready to truly see what we're looking at. So now we get to take the dressing off and when we take the dressing off, this is what's gonna happen. We're gonna do the full assessment and when, when we go through this lecture today, and I say I want you to look at this and I want you to look at that. I know. It sounds like a lot, but you're doing it anyway. You're, you're doing it and it's a, it's a fast pace. So you're still going to be a fast pace. But I want you to just get a little bit more comfortable with other things that may be in your way. So when we're doing an assessment, we've already looked at the chart, we kind of had some ideas if they've had a wound before and you knew what was working for them in the past, it may be time to go to that same well and do it again. But ask the patient, talk to them about, you know how they're feeling and what's happening. So we're gonna look at the wound bed, we're gonna look at what is inside that wound bed as far as barriers to healing or tissue type, um odor of that wound bed. What those wound edges look like if there's that risk for infection or whatever, we're looking at all of that. We're also gonna look at that dressing that you're taking off. That dressing is gonna tell you a whole bunch of things. Hopefully it tells you it was changed in an orderly fashion. Hopefully it was removed when there, there was a shower. So it wasn't wet and soupy and you're not sure if it's a whole lot of ex date or if it was just a whole lot of shower. But we're gonna look at all kinds of things when we take that dressing off. So one of the things that we wanna do, first and foremost is when we take that dressing off, we're gonna put that patient in a certain position. We wanna know where on that, on that wound or excuse me, where on that patient is that wound bed? And we wanna use true directional terms. True uh medical standardized terminology, there's no such thing as a butt crack. So you need to use that true anatomical term. Um There's no hip, there's a tr cancer. So as as we start getting really comfortable in doing one assessments, our documentation also needs to grow with us. So use directional terms, medial lateral maoli, where on our body, these things are so that we can have a clear concise manner in our description. So use those standardized terms. Um you can have these in there. Uh If you guys need a list of all these, I'm happy to send those to you as well. So we kind of get into the habit of being a little bit more lax in our documentation and and I'm telling you now it's time that we just really kind of step that up. But when we've taken the dressing off and we see where that wound bed is, we have our descriptor terms. You need to put that patient in the position to properly measure that wound bed. So where the patient is, we wanna put that patient in the position. Um If we're doing measurements, the rule of thumb is that you wanna put them in that same position each and every time. Uh And that's because as we age and we start, start losing the, the fattiness in tissue, certain things fall one way when it's positioned on one side versus when you position it on the other. So your measurements may be different if they're not placed in the same position each and every time. So we wanna make sure that they are in the same position each and every time when, when, when we document, if you know what caused that wound bed, then we're gonna, we're gonna capture that too. If it's a vascular insufficiency and these are venous issues, we're gonna call it what it is if it is um a diabetic patient and they have a callous ring and it's on the tips of the toe, common places where we would see that we have determined those causes. That's gonna help us put together some interventions that may be in me may be needed into play a little bit of compression. So for some Venus and offloading for diabetic, etcetera. So knowing where it is, they're kind of looking at what the wound bed itself is, clue wise is given to you. But we're gonna measure this one bit. And unfortunately, there's no universal standard for measurement. As far as that says, measuring tools, there's all kinds of tools out there. Um If you guys went to the to the Wocn last week, there was tons of companies giving away bullets and rulers and I don't care which one you use as long as we're using them correctly. So we're gonna gather that information and, and the way that we do it is always the same as far as that goes, we go and we measure and we do it by link times with time step. And the reason that that assessment and true measurement is needed is that whether or not I see the patient, I may never see the patient. I know the patient is getting better because your documentation is going to tell me. So, um your measurement, if it doesn't change, it just means the wounds kind of stalled out. If it is getting smaller. I know it's healing out. If it's getting bigger, we've got some problems going on now. It doesn't necessarily mean it's deteriorating. It could have just gotten debrided. Um If you have a diabetic patient that has a callous ring around something and you've measured it a certain way and here comes the podiatrist and they cut off that callous ring, your measurements just get bigger and bigger and it doesn't mean that there was poor care or anything, just means the callous ring was removed. So we just need to know what, what's going on there. There was a callous there, there's no, no call it not there. So measuring it is what is needed and then we do it by the clock method. So length times width, time step. So the length is head to toe. Um We want it to be the longest part of the body or the longest part of the wound bed, I should say, then we wanna do the widest part of the womb bed. And then with depth, there's many different depths to the wound bed. We wanna find the deepest part of our wound bed and measure the depth of that bed. So you can have more than one measurement inside your documentation. If you have, you know, a weird area, weird measurement, a couple tunnels, we're gonna capture all of those. Um And that just gives the person who may never see that wound with their own eyes, an idea of what they're seeing because your documentation is going to be so clear and concise that we do know what we're looking at. You're drawing a picture without us ever seeing it. I do wanna say that when we talk about doing the clock method, head to toe when we're using the foot or the bottom of the foot, especially for diabetic wounds, I want you to think of a ballerina up on their tippy toes because the heel would be the 12 o'clock position and the toes would be the six o'clock. So that's kinda hard with a lot of people. They gotta get confused with that. So I want you to think of a ballerina up on their tippy toes and that's how we use the face of the clock on the bottoms of the foot. You guys do have an opportunity to take photos and I love photo documentation. I'm all about it. But if we're gonna do photo documentation, my, my little tricks of the trade, make sure that light is on that. You have good lighting that your camera that you utilizing specifically for wounds. Um that is in good focus. And most importantly that you have a measuring device in that photo when we do photo documentation, which I love because the photo tells a whole lot. If we had to go to court, a photo can also tell a whole lot. So we wanna make sure that no matter how big a photo gets blown up, the measuring device will still stay consistent. So keep a measuring device in play, it does become part of the medical record. Um So you are utilizing that and um it's very easy to take a photo, just make sure that what you're utilizing is HIPAA appropriate. But let's get inside that wound bed, right? We have learned all about our patient, kinda have some good ideas. We've measured our patient. Now it's time for us to get in the wound bed. Let's see what's inside that wound bed. So the first thing that we're gonna do is we're gonna check inside that bed when you measure a wound and you're looking straight on, on a wound bed, there's so much stuff that could be happening inside that bed that you wouldn't know unless you got in there. And when I say get inside your bed, don't be afraid to take a moistened Q tip applicator and gently palpate inside that wound bed, that wound base and see if there is any softness, if there's any areas of tunneling that you may not have seen from the surface of the wound bed. And so when you see a tunnel or you feel a tunnel, this is just where you have a pathway that extends past your wound bed, your wound base and it can go a very short period or it can go all the way down to muscle tendon and bone, it can go deep into that tissue layer resulting in that dead space. If you do have a tunnel in the moon bed, it is OK. As long as you acknowledge that it was there, you're going to measure that tunnel as well. So you're gonna take that moist and Q tip, you're gonna put it inside that tunnel and you're going to pinch it at the end where it came to the base. And then you're also going to measure that tunnel. So putting a clock on your wound, say you have a tunnel. And if you look at this picture, the second one, they have a tunnel, let's say it's in the one o'clock position. So I'm gonna measure it and I'm gonna say I have a tunnel in the one o'clock position that measures whatever that is. There can be more than one tunnel in that wound bed, so gently palpate all around. Ok. Um So we wanna measure all of them, but one thing that I do want you to know is we gotta heal that out first, ok? We wanna make sure that we heal from the farthest part of the wound granulate it back in and then fill in from the base up. If we don't take care of that tunnel first and we fill that wound, we still have dead space in there and that dead space can abscess that wound and bust back open. So um when you, if you can, we put product in there, um if you overfill or over pack a tunnel, it will not heal, it will actually turn circular in nature inside that one bed. And that's just a big clue that you have over packed that tunnel. So we wanna fluff it, not stuff it, we wanna fill it as much as we can without over stuffing. It still have to allow for that contraction to occur. So that that wound can granulate inside, but measure all of them. Then you also have something called undermining and this is tissue loss parallel to the surface of the skin. So a tunnel goes into the body and an undermining is tissue disruption. Parallel to the surface of the skin. So you have tissue on top that you can see, but there is tissue missing underneath it. So I like to say it's kind of like a cliff. You can, you can't see underneath that cliff. Uh unless you get into that wound bed and then you may see that there's um some tissue destruction underneath that. And we're also gonna measure that too, wherever that undermining is inside that bed, it can also actually encourage tunneling to occur. So we wanna make sure that we have filled in that undermining as much as we can. So we have gotten inside of our bed check to see if there was any tunneling or undermining. And now we're gonna get into what we may see inside that wound bed, what other things we may see. So when we, when we look at the wound bed, we wanna see what kind of tissues are in there, where in that wound are those tissues located, how much of that wound bed is covered by whatever type of tissue and if it's sticking inside that wound bed or not, and when I say percentage, you're gonna get me to 100%. So when you get to um a wound and you see picture of wound bed and I say get me to 100% just tell me how much of that wound bed is covered with. What kind of tissue up to 100% So let's look at what kind of tissue types you may see. So inside your wound bed, you may see all kinds of stuff. You may see granulation tissue, which is what we want. That's nice beefy red. We love granulation tissue as long as it's nice, healthy granulation tissue, red tissue is what we want. But we also may see other things as well. We may see slough, which is yellow in nature. Um It is dead tissue, it has to come out slough. I like to say is like melted cheese, little cheese like in color, OK? You also may have necrotic tissue inside that wound bed that is dry, dead tissue, brown, black, hard leathery texture gotta come out. So all of these things could be a barrier to healing. The only color we wanna see inside of a wound bed is red. Anything else other than that, we've got to get rid of it outside of our wound bed. So we may have sr slough granulation granulation tissue. We may even have epithelial tissue is what we want to have happen too. But all of these things may be barriers to our healing or just tissue types that we see inside of our bed. So here's some fluff melty cheese like in color. Hypergranulation can also occur inside that wound bed. And we talked about how we want to have beefy red, beautiful granulation tissue. Sometimes our body goes. Oh yeah, I'm making it. I'm making it well, and then they make too much of it and it goes up and above the surface of the wound bed. Well, that's not gonna help my wound bed from finishing up and, and having epithelial cells migrate across. So there can be too much of a good thing. So all of these things can be tissue types that we see inside that bed. Ok. When we have done everything humanly possible, there's no sar inside that bed, there's no sluff tissue. We've removed it by ways of debridement. And there's many ways we can debride necrotic and sluff tissue. We could do it by enzymatic debrider, autolytic mechanical maggot therapy, cutting it out if it's within your scope of practice. But when we have had that beautiful granulation tissue and it's ready, we have filled up that wound bed and now we're hanging out with those epithelial cells to migrate across. We're gonna have this nice sheen of epithelial tissue that migrates across that wound bed. And that's the final healing process that we're looking for. That tissue is really soft and fragile, but we wanna make sure that it just stays nice and moist so it can migrate across nicely. But whatever tissue types inside that bed, knowing what you're looking at color wise is going to help you pick product to either address it and get rid of it like slough or necrotic tissue or granulation tissue where we wanna keep it nice and moist and keep it um to continue that process of healing. So whatever kind of tissue it is, tell me all about it, tell me what kind of tissue it is and where it is inside that wound bed. So we may have all kinds of tissue in there and just where in that wound bed and how much of it is there. So that's the whole thing is how much tissue is inside that bed. And why do we wanna document because it's going to help dictate what products we need to utilize. So if there's necrotic and stuff, tissue, we need products to address those. Um and, and how much of that wound bed is taking over? Remember when we have necrotic or soft tissue in that bed that is a barrier to us to heal out. So we have to address things that we're going are going to prevent us from healing our wound bed out. So where is it, how much of that wound bed is covered by? What kind of tissue? And then we get into how mu how much or how well it's sticking inside that bed. If it is laid in there, if it's hardened in there, like hard ear, we've gotta be able to get that out of there. So we need to know the color of it, the consistency of it and, and how well it's sticking. And the reason why is because when there is that heavy level of debris, we have to help that out, whether it is through enzymatic debris and cutting it out, if we can, removing it easily, if it can be something that can be picked up and picked out of the way, but we've gotta get rid of that. But you may also see some other structures as as well that you see inside that wound bed. So besides tissue types that are in there, there can be other things that are in your wound bed way. Let's go over some of those, ok. You may see muscle inside your wound bed and muscle when healthy looks like beef, it's red, it's bloody. It is a beefy red in color. And we want that, we want mussel to be still beefy red in color because that means that it's still a healthy piece of, of meat. So our job is to keep it nice and moist and and keep it that way if it starts to turn and it starts to brown up, um we can't fix that. And so we, our job is to keep it nice and moist because if we start turning, turning pieces of our wound into stuff that is not viable, it has to come out and then we're dealing with a mobility issue of our patient. So inside this picture that you see, this is a uh a hip that went bad, a de his hip incision. It should have been nice and tight incision line should have been nice and closed, but something bad happened and then the patient de his open. And so not only do we have now we have a wound that we're gonna heal open. We have tissue in there. That is not normally what we would want to see inside of a wound bed. So we see muscle inside there. We can see fashion inside that bed, ok? We can see fascia inside a wound bed most commonly in an acute type wound. And when I say fashion, I want you guys to think of the saran wrap of the body fashion covers all kinds of things, but it's a very uh see through uh you know, it's saran, it's saran wrapping. So we wanna keep that if we can, if not, we're gonna blow right through it. But you may have fascia obscuring some of your wound bed and we're just going to document that it is there. You may also see bone inside of the bed and usually that's a bad, that's a bad day for somebody, but it is obscuring part of our womb bed and we see it and bone when healthy is gleamy white in color. And our job even for a short period of time is to keep that bone moist, not wet but moist until they can go into the surgical suite and help out. Now, sometimes in you all who have been on this call, sometimes you guys have seen pressure injuries that they are bone present. They're not going back into the surgical suite. We're taking care of a wound bed that has bone in the bed. And our job there is again to keep it moist. So still to keep it gleamy white in color. If not, these things can turn. And again, we lose mobility, we can get osteo in there. But you may also have foreign objects, whether it's hardware from like a hip that went bad and we still have hardware present to something as simple as foreign objects inside that that bed. Sometimes when we pack with the wrong type of gauze or the wrong product, pieces of that product can be left inside that wound bed and you get foreign objects left inside your bed. Um Our body is amazing but when there's foreign objects there that aren't meant to be there, the body can actually encapsulate those foreign bodies view them as invaders. And um then you have an abscess room bed. So there could be more challenges just from something as simple as God. So you told me all about what kind of tissues are in there, how well they're sticking or not. Any other structures that you may see inside your bed as you're doing your full assessment on your moon bed. Now you're gonna tell me all about the drainage because I wanna know all about it and drainage is normal part of the healing process. OK? When le let me just put to you this way when you blister yourself and you get a blister and it's filled with fluid. Everybody wants to pop that fluid. Everybody says, oh, we gotta get that liquid out. No, you don't. That's your body. Little bit of exudate. That's there to keep that area clean. Your body is doing amazing things if you just let it. Well, the same thing happens with exudate in a normal flow. If you have a normal amount of exudate that is needed, it's part of our healing process. The challenge comes when there is an over abundance of X date, when we have way too much or not enough and you can get way too much just because of an increased level of inflammatory response, way too much because there's a bio burden in that, in that wound bed, the wrong product is being used. All those different ways, we can have an increased level of extra date that increased level can also cause that wound bed to get bigger and macerate and then you have other problems. So having a certain level of extra date is needed inside that bed. Too much of a good thing. We're gonna macerate and get bad too, too little of it and we're gonna have dry desiccated tissue. So knowing that we have an an amount of extra date, tell me all about it. Tell me what colors that we're looking at. If ceres is just thin clear plasma, then we start getting into things that are are a concern like a pin, a sick pussy ness. So with ex date, all kinds of great things can be in it. You you have nutrition going in there, you have growth factors going in there. But again, when there's too much of a good thing could be the challenge. So tell me all about your ex date, the XU date is helping you clean that bed. It's also helping the body autolytic debri anything that's not meant to be in there. When you have moist environment, it allows those cells to move across and help granulation and reepithelialization and all that great stuff. So we want it but we just wanna be able to control that level of extra date. So there are many different colors of that Xu day. We wanna keep it on a serious level, maybe even a serious, serious per se um sanguineous level where it's just with a little bit of blood to it, a little tinge to it, but nothing major. If it's super bloody, we have a problem. If there's infection, we have a problem, but we just need to kind of know what you're looking at and then document what it is. Now, I will tell you this, there is a however, the however is you need to know what dressings you're utilizing because when you have um different dressings, when, as they start breaking down, if you didn't clean your moon bed well, or you just took the dressing off and did an assessment without cleaning it before you're really looking at it. What you see, color change or tinge wise may actually be just residual um of what type of uh dressing you were utilizing. So, always, always we wanna clean that wound bed really well and, and know that what we're looking at is wound and not anything other than that. So you're gonna tell me all about that all about the date. And again, you wanna know when their last dressing change was, when did they have a shower last, was that removed? Etcetera, etcetera? Because those can also be an indicator that it's really not so much dressing, but it's something else going on. So tissue types, how well they're sticking or not ex you date, tell me all about it and then you're gonna get in there where you're gonna smell your patient. And I always, when I talk about smelling the patient, I always get laughed at by people because what you smell up here up high is way different than when you get at nose level of your, where your wound bed is. Um, and tell me if there's odor or not, if there's none, when you document, you're gonna say there's none because it means that you smelled your patient and that's all. Um, if you can smell your patient before you walk in the door, I'm not asking you to get down there at that level to smell your patient. But if you're unsure, go down there and there's, there's a lot of things that the odor itself can trigger to you. It can trigger if there is an increased level of bacterial load, it can be something as, as medication. You've got necrotic tissue inside that wound that but you can also have something like the patients not taking their shower. It's getting a little yee musty. Um But this is how we know that if there's something else going on inside that bed, if we've got another barrier to healing that's happening. So just tell me yes or no with the odor. There, there is a tool that's used young tool and it just goes by how bad the odor is. And if you wanna utilize that, that's great. Um But we're gonna get into the wound with all that we just talked about, but we also want to get on to the edge of the wound and seeing what's happening on the edge of the wound bed itself because the edge of the wound also tells us things. It can tell us if it's getting too wet and we have some maceration happening where it's too mu too much moisture. Um And, and I always say this drainage drives your dressing. So if you've got too much levels of exudate, you've got maybe the wrong dressing in place. If you're starting to macerate your edges, your drainage is too much for what dressing you have picked and no harm, no pout, no, no foul, just pick a different dressing. Um But you may also see a callous ring very common on diabetics. We wanna capture that. So that when just like I had mentioned before, a doc comes in and cuts that callous off and it goes from, you know, this size to way bigger. You captured it by saying that there was a callous ring around the wound bed already. But you may have that you may also have what is called epibole. And this is a big thing that I wanna talk about when you guys are dealing with your patients and you have these non healing wound beds and you have done everything humanly possible for you guys as your clinician as a clinician in your expertise. And you call me and you're like Michelle, I don't know what to do. I'm gonna ask you this one question. Did the edges roll and if the edges have rolled, no matter if the entire wound has rolled or just a part of that wound bed rolled. Um That wound bed has turned its healing off. And let's talk about that for a second when you have your wound and you have done everything you did. You've there's no necrotic left tissue, you granulated up to the surface of the wound bed. You did what you were trying to do. You're doing your thing that epithelial cells that are hanging out on the side of the wound bed, waiting for you to granulate all the way up for them to migrate across and heal off. Sometimes those tissues start to migrate across the wound bed. When you have not fully granulated up to the surface of the wound bed. And what ends up happening is those cells start to migrate across. They fall into the wound and tissue, epithelial tissue will touch other tissue. The body thinks that it has touched itself and healing has stopped. So when those edges have rolled tissue, touched tissue and the healing process stopped, even though you still have your wound there, the body is not in a healing environment. It doesn't know that it needs to be in a healing environment because those wound edges have rolled. So what needs to happen during that time when you have a rolled edge is that somebody within their scope of practice, whether it is the nurse, the doc, the physical therapist, if it's within their scope of practice will do what we call a burn down and we injure that area again and then the body goes, oh I have a wound. I must go through the phases of wound healing and start that healing process again. So when you guys go back to practice and you're like, oh I've had this patient forever and it's not getting any better. I bet you that there is parts of that wound bed that have rolled over and no healing has has occurred because of it. So check, I'll always check for that because it's a, it's a uh it's a, a neat thing to see and it's even a neater thing to see when you, when you reinjure and you can get a healing process to begin to begin again. So you're gonna tell me all about the edge and then we're gonna go outside of the wound bed and then capture what's happening on that peri wound tissue. That peri wound tissue is where there's any challenges or what, what is surrounding that wound bed that may be considered abnormal outside of the perimeter of the wound itself. Whether it is you've got too much maceration, whether the there's duration or a hardened area where they may have a little bit of edema or redness or something's going on where that surrounding tissue does not look like it. Should. We're gonna capture that too. We're gonna put in um our uh indications or interventions that we can help with that, whether it's a different dressing, whether it's creams or what have you to help out. But we're gonna include all those. And then let's talk quickly about just infection. I just want to reiterate and you guys, I'm sure. No, because we've said it so many times. All wounds, there's no such thing as a sterile wound bed. All wounds are contaminated. They have some type of bio burden in that bed and some type of bacterial load the good thing is hopefully we can get it to just be where there's no problem with the host bacteria is everywhere we get it, we touch our face, we touch our hands. You know, it's, it's there and most of the time we have no, no host response. But when there starts to be more and more bacteria or more and more bio burden in the bed where it starts to overwhelm that hose, that's where we have problems and a lot of times it comes with age, it comes with the amount of dead tissue in that wound bed, disease, state nutritional status, all that stuff can come into play. So making sure that we pick dressings that are appropriate either prophylactically somebody who is constantly getting an infection or if we just do it as needed like we're supposed to um making sure that we address those that are at risk for infection. Um Remember though, just because there is some redness or an increased level of X date does not mean it's infected. There needs to be some really true signs of infection, not just one or two, but really showing true infection. Ok. Now, I do wanna mention biofilm though because it is talked about all over the place and biofilm is present in a majority of these chronic wound beds. So these will delay our wound healing. Um A lot of the products cannot break through biofilm without some assistance. And I would say get an elbow behind it because when we cleanse the bed, it's not just squirt squirt, we need to cleanse the bed. We need to put a little elbow behind that bed so that we can clean it appropriately. So knowing that sometimes these wounds that are delayed in healing also may have a biofilm present. We need to get very comfortable in cleaning with a little bit of elbow behind it and not just spraying a piece of gauze with a cleansing agent and thinking that's enough. Um Again though, with pain with our patients, a lot of these things hurt medicate like we're supposed to, ok. Um Always check with your patient before you're doing the dressing change if they're having pain during it and after and sometimes it's just the sheer scariness of what you're doing. Again, talk to your patients about what you are asking of them. So taking all of that, putting it all into play. If there's anything that your patients are saying to you, please put that in your documentation as well. We don't alter what our patients say, put it in quotes and say our patient states that but when it gets to documentation, making sure that we have communicated everything that's in there, do not be afraid to call your doctor. Um It is what you see, not what somebody else sees, it's you and your license and your clinical comfort level. And again, this is our communication tool. This is how we all know what's going on. Um When you're documenting, just avoid inconsistency, making sure that you round with somebody, you guys can round together in a perfect world. It's not just you all one single person out there doing the the wounds for your entire building. I wish that wasn't true. But I know some of you are like, yeah, it's just me but talk to each other. We all have a different level of expertise. Um The next few slides are just review slides. I want you guys to look at and let's talk about. Um So in this picture, I want you to tell me what kind of tissue type is in there. Is this a good looking wound bed or not a good looking wound bed? What products would you recommend to put into play? Um So let me see, let me, let me open this up and see what we got. So I got somebody telling me this is all dead, it's gotta come out. So if it is all dead and gotta come out and I'm telling you to get me to 100%. Would you say this is 100% necrotic tissue that's gotta come out? Yep. You bet it's all gotta come out. That patient is not gonna heal with these barriers to healing. It's telling you something's wrong. All this tissue is not right. It's all gotta come out and we can do this many different ways like I said, we're gonna Debre it as much as we can and then hopefully we can get all of that out of the way and then have a cleaner bed. But this is on, this is on somebody's bottom. So this is on, on a, a sacred coccyx area who's telling you that it's probably a pressure injury and we need to get them up and off that surface as much as we can in this one. We've got same thing we're dealing with over bony prominence, 100% with necrotic and fluff tissue inside that bed. That's all gotta come out. These wounds will not heal in this capacity. So if we need to um debri, we're going to, and then our final photo is a diabetic wound on the bottom of the foot pretty common that you see that it has a callous ring, the edge is not completely attached. So we're gonna measure it and then I'm gonna wanna know what's in that unattached area. So we're gonna measure, we're also going to include how, how wide or how thick of that callous ring is also there. So we wanna capture all kinds of things when we're looking at these W beds. So do you guys have any more questions? You can throw them up here because I can see them. I will send you the list of some uh descriptor tools. Somebody had asked me if I would send that list of descriptor words for you guys for your documentation and I'm happy to do that. Sometimes we get a little bit relaxed in what we document and there's actually true terms that we need to use in our documentation. It protects us legally and, and I like that as well. So for this quick session that at the end of it, I just want you to know, please document what you see, be clear and concise, knowing what you're looking at what those tissues are really, really called. And um don't be afraid to ask for help. You guys have a team approach for a reason. All your patients should be treated individually, individualized plan of care. And one of the last things I wanna leave you with is there is no recipe book for treatments. Um You can have five people here. We all have a stage four wound bed. We all get to be treated with different products because our disease state requires it, our patients, the mobility, the the incontinence all require different treatment protocol based off of what's going to work for that patient and what will not? So um you guys have three minutes left of questions if you want it. I'm always available if you if you have them, if you wanna talk offline, but I do appreciate you spending this quick hour with me learning about what kind of things are inside of a wound bed. Thank you so much Michelle. I really appreciate it. Um As she was saying that we're gonna leave the Q and A open for the next few minutes. Um I do want to just direct your attention uh quickly to our, our um disclaimer here. Uh And also if you needed to reach a member of the medical surgical team, there's a phone number available for you there again. Uh Michelle, thank you so much for your time and expertise today. We really appreciate it. Um I wanna thank everyone out there for attending today's webinar. You can find a list of upcoming webinars on our website at M ms.mckesson.com/educational dash webinars. And uh in most cases you can register there as well, uh We will be sending you a recording of today's presentation uh and including additional uh materials. And uh again, Michelle, I really can't. Thank you enough and, and thanks to everyone who attended today. All right. Thank you. I did get a lot. Sorry. There was a lot of requests for uh additional information to be sent. I see you all sending them in. I will take care of that after this call. OK. Thank you so much Michelle and thank you to everyone. Uh We hope to see you at a future webinar and I hope everyone has a great rest of your day.