VOL: 99, ISSUE: 42, PAGE NO: 66
Claire Wright, RGN, is senior sister, Elderly Frail Unit, Chilton Meadow Nursing Home, Stow Market, SuffolkThe wound assessment process can be informed by accurate wound measurement; it also enables the effects of treatment to be monitored (Plassmann and Peters, 2001; Collier, 2000). However, wound measurement techniques need to be consistent (Pudner, 2002; Bryant, 2001; Plassmann and Peters, 2001) as the information is shared and interpreted by different members of the health care team.
The wound assessment process can be informed by accurate wound measurement; it also enables the effects of treatment to be monitored (Plassmann and Peters, 2001; Collier, 2000). However, wound measurement techniques need to be consistent (Pudner, 2002; Bryant, 2001; Plassmann and Peters, 2001) as the information is shared and interpreted by different members of the health care team.
As a senior sister in a nursing home, I began to reflect on the methods used in practice to measure wounds. In our nursing home, these are carried out as part of an initial assessment, and then at monthly intervals. The records have proved a useful means of monitoring healing, enabling us to identify changes in wound size.
However, it was evident that the methods we were using to measure the surface area of wounds were inconsistent, not necessarily evidence-based or, indeed, best practice. Some nurses preferred to measure the wound directly with a ruler, while others used a clear film with a printed grid, or even sketched the wound from memory.
Defining best practice
Cooney (1999) states that there is always a danger that nursing practice can become a habit or ritual. The goal of reflection is to challenge and, ultimately, change practice.
Attendance on a tissue viability wound care course prompted me to explore and identify a systematic method of obtaining meaningful measurements of wounds in the nursing home. I also needed to address my colleagues' and my own learning needs and skills.
Playle (2000) notes that knowledge consists of numerous smaller pieces of information collected by a range of methods. I decided to investigate the issue of wound measurement by:
- Carrying out a literature search;
- Visiting other clinical areas, such as a leg ulcer clinic and leg ulcer club, to identify best practice;
- Surveying the 12 students on the tissue viability course about their wound-measurement practices.
Banks (1998) highlights the need for continuity of care in nursing homes, as patients may be admitted from, or discharged to, a variety of care settings. For a wound measurement to be of any value, it must be possible to repeat it so that a comparison can be made between consecutive assessments.
Charles (1998) notes that if the surface area of a leg ulcer is not measured at regular intervals, treatment will simply become a series of dressing changes, and improvement or deterioration may not be identified.
Wound volume and depth
Healing of deep wounds usually begins at the base rather than at the edges and in deep wounds surface-area measurements do not reflect the early changes in wound shape (Plassmann, 1995). So if wound measurement is used as a tool to detect healing changes then the importance of the wound bed needs to be acknowledged.
Although it would be useful to measure wound volume, most methods appear to be time-consuming, complex and depend on too many variables, such as the patient's position, the wound size and the practitioner's skills (Pudner, 2002; Morison, 2001; Plassmann and Peters, 2001). Morison (2001) states that there is probably enough precision in wound-depth measurement for it to be useful in clinical practice. Pudner (1998) also identifies the need to measure depth as well as length and width of diabetic foot ulcers.
McConnell (2000) suggests measuring wound depth using a sterile cotton-tipped applicator. However, the use of this method calls into consideration issues such as patient comfort, cross-infection and the possibility of debris from the applicator remaining in the wound.
The response to the survey distributed to fellow course students revealed that only a small number performed depth measurements. This may be indicative of the lack of practical techniques available for volume/ depth-measurements in a variety of practice settings.
The visits to other practice settings - the leg ulcer club and leg ulcer clinic - also showed that wound volume/depth measurements were not carried out. Leg ulcers were, on the whole, shallow and it was apparent that nurses found that the photographs provided them with enough information. Charles (1998) acknowledges that it is difficult to measure accurately the volume of shallow wounds such as venous leg ulcers.
Reflecting on the evidence, it appeared that complicated wound volume and depth measurements - that are unlikely to give meaningful results - were not appropriate in the nursing-home setting. This led me to investigate the methods we used in the nursing home - direct measurement with a ruler and tracing the outline of the wound on a clear film with a superimposed grid.
Using a ruler
A review of the literature revealed that the head-to-foot method of wound measurement offers the most accurate and consistent approach. This involves viewing the wound as a clock, with the 12 o'clock position in the direction of the patient's head. Length is measured from 12 to 6 o'clock and width from 3 to 9 (Bryant, 2001; Morison, 2001; McConnell, 2000).
Measurements using a ruler were not performed at the leg ulcer clinic or the leg ulcer club, but my survey showed that it was a popular method of monitoring wound size among the course members. However, more accurate methods, such as tracing could be used effectively in nursing homes.
Tracing the wound size on clear film with the aid of a grid appears to be a reasonably accurate method of measuring wound size (Plassmann and Peters, 2001). It is practical, readily available and recommended for use alongside other methods such as photography (Charles, 1998). It is advisable to use a thin marker pen when tracing the borders of a wound to ensure consistency and accuracy (Charles, 1998).
The survey results showed that tracing with a grid was popular, when used alongside another method such as photography or ruler measurement. At the leg ulcer clinic it was used in addition to photography.
Photography is a non-contact objective method of recording wound measurements, which provides a systematic, evidence-based approach. This method appears to offer the continuity that had been lacking in the nursing home. Collier (2002) states that 'a systematic approach can help ensure the patient receives the most appropriate evidence-based interventions currently available'.
Photography also has the advantage of enhancing documentation by providing a visual record of any changes in a wound (Culley, 2000). Photographs are a valuable addition to the methods available to health professionals, whose duty is to document objective and meaningful parameters related to healing (Collier, 2002).
The pros and cons of photographic records - In the nursing home setting, it was felt that obtaining photographic images of wounds would be useful for:
- Communicating with staff from overseas who may struggle with descriptive language;
- Showing to doctors who may wish to see the wound at an inconvenient time, for example, when the patient is having a meal or when a dressing has just been renewed.
However, the use of photography has its limitations and is only as consistent as the person taking the photograph. To enable meaningful comparisons, it is important to ensure that each photograph of a wound is directly comparable with others (Swann, 2000; Bellamy, 1995). Achieving consistency requires control over as many variables as possible, such as using standard lighting and background conditions (see p48).
The visits to the leg ulcer club and the leg ulcer clinic provided the chance to discuss and see photography being used to record wound measurements in practice.
A strategy for wound photography - The nursing home company running our home provides documentation to support a wound measurement strategy that includes photography. This comprises:
- Photograph consent forms - which are used when photographs of patients are required for purposes of identification for administering medicines;
- The pressure ulcer register;
- Wound assessment sheets.
This has made it easier to implement changes in practice. However, the wound measurement strategy also needed to address issues such as costs, patient consent, staff training, storage of photographs and suitability of existing documentation. We also needed to devise a protocol, based on the best available evidence, for making measurements (length, width and depth), tracings and photographing wounds.
Charles (1998) notes that once a standard protocol for periodic wound measurement is introduced, it helps to safeguard the repair process and enables any changes to be detected within a prescribed time period.
The frequency with which measurements are taken is crucial for ensuring consistency and a systematic approach. The RCN clinical practice guidelines (2002) for the care of patients with leg ulcers recommend taking measurements at first presentation and at least at monthly intervals thereafter. I noted that the leg ulcer club and the leg ulcer clinic carried out measurements every month, unless otherwise indicated.
It was decided that care assistants (who often assist at wound dressing changes) at NVQ levels 2 and 3, as well as trained staff, would be involved in training sessions designed to explain the changes. A 10-minute video from a camera manufacturer explaining how to use the camera was made available to all staff who may be required to use it.
It is important to acknowledge that wound measurement is only a small component of a holistic wound assessment - it should also address not only social and psychological factors but also physical issues relating to a patient and his or her wound. Hek (2000) points out that although something may be effective and evidence-based a patient will not necessarily accept it.
So it is important to listen to patients, work with them and reflect in order to offer an improved high-quality service (Gethin, 2002). With this in mind, it is hoped that the new strategy will enhance the measurement of wounds in our nursing home. But it will require regular feedback and reflection from colleagues and patients to enable us to monitor progress.