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hanks to a very special man in my life (my new fiancé), I have found myself back in clinical practice in the long-term care setting in York, Pennsylvania, a small town about 45 minutes north of Baltimore. When Peter Norris, Jeremy Bowden, and Renee Olszewski approached me about writing a column from my new vantage point, I was thrilled--first, for the opportunity to share my thoughts with you, readers of ECPN, on this new venue for me, but also because I have quickly come to realize that for practitioners interested in wounds, ostomies, and incontinence issues, extended care is where it is!
       Extended care is where you get the time to see wounds heal; where patients, families, and significant others are ready to learn ostomy care; where you have the opportunity to implement plans of care and bring them to fruition. Extended care occupies that pivotal position between acute care and home.
       This first column will reflect on the first issues that I have confronted in my new practice: wound assessment, reporting, and documentation--maybe not glamorous but certainly foundational. My thoughts and insights follow. I hope to keep this column practical and issue focused (with an occasional rhetorical question to hopefully stimulate your thinking). I welcome your comments, questions, and suggestions at dlkrasner@aol.com.

Wound Assessment
       As mundane as assessing wounds seems to be to so many novices in wound care, it is critical for success in choosing and proceeding down the proper clinical pathway. There can never be too much attention paid to wound assessment, both initially and on an ongoing basis (but where's the research to guide us in how often we should be assessing wounds in the extended care setting?).
       Trained eyes see more than untrained eyes, so learning wound assessment with a mentor or several members of the wound care team is optimal. In training family practice residents, nursing students, and members of our newly formed Skin and Wound Assessment and Treatment Team (S.W.A.T.--thanks Heather Orsted of Calgary, Canada, for the inspiration), I ask two initial questions:
- What type of wound is it?
- Is the wound healable?
       Only when you have the answers to both of these questions can you determine the correct goals and plan of care for each individual person with a wound.
       One of the negative consequences of the AHCPR pressure ulcer guidelines (1992 and 1994) and the current MDS documentation is that too many practitioners assume that all (or most) wounds are pressure ulcers. They tend to call all wounds pressure ulcers and follow the pressure ulcer guidelines for all types of wounds. (How do you teach the novice practitioner to distinguish between a pressure ulcer and incontinence-related skin breakdown? It's not so easy!) There are several dire consequences to labeling everything a pressure ulcer. For example, if the wound is really a venous ulcer, compression therapy gets missed altogether. If it is a diabetic foot ulcer, offloading is neglected and infection control issues may be missed. In my facility, by far the most common types of wounds are acute wounds, not chronic wounds--abrasions, bruises, skin tears--and the AHCPR clinical practice guidelines offer very little guidance for their prevention and treatment. (Isn't it too bad that we don't have standards of care or best practice statements for acute wounds and chronic wounds?)
       I am trying to help the staff learn wound assessment via a number of approaches:
- Rounding with the treatment nurses to look at wounds and assess them together
- Pulling treatment nurses from their units to other units on occasion to look at particularly "educational" wounds
- Posting photos of different types of wounds monthly in the staff bathrooms
- Giving mini-inservices at the end of each monthly skin integrity team meeting
- Following up on assessments myself if the data reported just doesn't "wash" and then using the opportunity to train staff.
       If you have other approaches for teaching wound assessment, I would love to hear about them and will share them with readers in a future column.

Wound Reporting and Documentation
       Reporting, documenting, and synthesizing the information about wounds in an extended care setting is quite the challenge! On a shoe-string budget with the support of our trusty photocopier and Excel spreadsheets, the skin integrity committee at Rest Haven-York has devised a practical and efficient reporting system that is giving us a clear picture.
       It is amazing how much you can accomplish when you have the buy-in of all staff--from the nursing assistants who know the residents' skin the best and who are the first to spot problems, to our computer support person who helps design (and redesign) the forms and programs we are using to make the system work, to our director of nursing and administrator who monitor and support the entire process. We have a skin/wound reporting form that gets completed by any staff member but mostly by S.W.A.T. team members. I compile the data and share it with the staff and administration on a weekly basis. It's not rocket science, but the power of the data is clear--it guides the development of policies and procedures; it helps explain product usage and determine what new products we must bring in house; it reflects the many hours of staff time devoted to wound care and its support; it clarifies for everyone how complex the residents really are in the extended care setting. These are people who, 10 years ago, might have been in an intensive care unit. Today, they are in extended care, challenging all of us in this setting to bone up on our wound assessment, reporting, and documentation skills. It's truly a challenge...and it's really fun!