Wound Care: Moving Toward HealingPage 4 of 13

2. Comprehensive Assessment

Wound healing involves assessing many different areas that affect your patient. The patient’s living environment, medical status, nutrition plan, pain level, wound etiology, and psychosocial situation all contribute to effective or difficult wound healing. Caregiver education can greatly reduce patient stress and increase wound healing while preventing breakdown.

Preventing and treating wounds is much like solving a puzzle. As healthcare providers and caregivers, we find multiple pieces affect and predict how we care for patients and their caregivers in the home health, assisted living, and nursing home environment. Wound prevention and treatment play a major factor in quality of life for our patients. We need to communicate the goals of care and any daily/weekly changes to other caregivers as soon as possible in order to prevent further complications or breakdown.

Healthcare issues can be overwhelming to many people and, without effective education about the healing process, often patients will not heal efficiently or quickly, if at all. Simple, concise language is welcomed in times that can be overwhelming; it is easier to receive and more likely to be remembered. A comprehensive and individualized plan of care addresses any skin changes or comorbidities, as well as emotional, psychological, financial, and support system needs. It is vital to educate the patient’s caregivers because prevention is important for maintaining quality of life.

The Skin

Our skin is the biggest organ of the body, weighing approximately six pounds. The major functions of the skin are protection, immunity, thermoregulation, sensation, metabolism, and communication. Our skin affects our health in multiple ways. Throughout the aging process our skin becomes more prone to trauma and breakdown. This is due to a decrease in subcutaneous fat between the epidermis and dermis and a decrease in cell turnover rate. In young adults, epidermal turnover takes approximately 21 days. However, by 35 years of age, this turnover time is doubled, lengthening our healing rates (Bryan & Nix, 2015).

The skin, like all other organs, is fed by the body’s blood supply. When a patient stays in one position too long without moving, the blood supply is no longer able to reach the skin and this causes breakdown. The ability to reposition and mobilize oneself also decreases as we age, putting patients at risk for increased pressure leading to this breakdown of skin. With aging, vision changes and dexterity issues affect how patients are able to assess their skin as well as their ability to perform proper wound treatment and identify risks.


A thorough assessment during the first visit with a wound care patient is the initial step in prevention and treatment. A patient with a large number of comorbidities is at higher risk for skin breakdown due both to fragility and to how certain health issues can delay the skin’s healing ability.

Did You Know. . .

The average wound care patient has three comorbidities.

As an effective healthcare provider, it is critical to the patient’s success for you to look at how other issues will impact overall health. Prevention and protection are critical for keeping patient’s safely at home.

A fully comprehensive history helps determine possible causes of skin breakdown. Certain comorbidities will automatically guide you in determining a plan of care to handle the wound treatment; for example, conditions that impact tissue perfusion, reducing blood flow and oxygen to the tissue, paralysis, neuropathy, immunocompromised conditions, and chemotherapy and radiation will all delay wound healing rates.

Other conditions impacting healing times are diabetes mellitus, congestive heart failure, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), and obesity. Diabetes Mellitus has the biggest impact on skin care and treatment. When diabetes mellitus is uncontrolled, patients are at an increased risk for skin breakdown and delay in healing. Certain medications will also change the normal wound healing process.

Steroids and blood thinners can make the skin more prone to injury, with an increased risk for injury and trauma. A patient who has been on steroids for a long period of time will have what clinicians refer to as steroid skin, which looks paper thin and can easily tear with the smallest impact. Patients’ histories can guide the plan of care, and collaboration with primary care providers (PCPs) and those in other disciplines is necessary to determine a wound healing protocol.

Patients who smoke need proper education on the effects of the body’s ability to heal. Cigarette smoking constricts the blood vessels, affecting both perfusion and oxygenation, and limiting circulation in the feet. The less blood supply to extremities, especially when wounds are present, the longer the healing time and the more risk of infection.


Adequate nutrition can be easily over looked or neglected as we collaborate with patients and their families. In long-term care settings, malnutrition is seen in 21% to 51% of the population and in the outpatient and home-care population malnutrition is between 13% and 30% (Ryan, 2017). Much of the body’s ability to heal comes from proper nutrients that feed the new skin cells. Protein is a building block for the skin. Discussing daily/weekly protein choices underscores the importance of good nutrition. Written information with pictures of protein foods can be beneficial for the patient.

Wound care patients need increased protein in the diet. Because many people are unsure what correct protein choices are, be sure to review acceptable food choices with the patient. Try asking patients what they ate today rather than simply asking if they ate protein. Avoid yes and no questions in order to provide learning opportunities for the patient/caregiver when they report on meals; often, they simply lack knowledge of correct food choices.

Source: Bryan & Nix, 2015.

Lab Values Related to Wound Healing


Normal range


3.4–5.4 g/dL

Total protein

6.0–8.3 gm/dL


18–45 mg/dL


Under 7

Laboratory values for total protein, albumin, and pre-albumin are indicators for protein deficits and should be requested from the physician in a wound care patient. You can use the lab results in educating caregivers about the importance of protein to wound healing. Impaired wound healing results in patients with albumin levels lower than 2.0 and indicates compromised nutritional status (Bryan & Nix, 2015).

In diabetic patients, the ideal goal for hemoglobin A1c (HgA1c) is to remain equal to or less than 7. This blood test is done every 3 months to maintain diabetes control.

Educate your patient’s caregivers to report weight loss, poor appetite, gastrointestinal problems, or constipation that may interfere with eating. Ask the caregiver to keep a food diary for several days to create a detailed assessment of the patient’s intake. Monitoring the patient’s input and output will assist in determining if nutritional supplements should be added; this must be discussed with the physician. You can engage the patient and caregiver with questions regarding appetite and food choices to provide additional choices of protein and/or calories. A referral to a dietician for additional education and resources may be beneficial for the patient and caregiver.


Proper hydration of the body is necessary at every stage of life. Water keeps the skin healthy, flushes toxins from the body, regulates the bowels, lubricates and cushions the joints, regulates body temperature, reduces the risk of urinary tract infection (UTI) and improves mental function. As the body ages there is a decrease in its water content due to the loss of lean muscle tissue. Inadequate hydration in older adults can lead to UTIs, pneumonia, pressure ulcers, confusion, and disorientation (Simon Foundation, 2017). Caregivers need to be educated on these facts to understand the need to assist the patient in remaining hydrated.

Provide various tips for the caregiver to increase the patient’s water consumption such as keeping ice water at the bedside, lemon slices or flavors in the water, and increasing the size of the cups when taking medication to encourage more water input. Teach the patient and caregivers simple signs of dehydration (eg, yellow urine with a strong odor, dry mouth or skin). Have the patient aim for approximately six 8-ounce glasses of water per day as a basic guide. This is adjusted gradually based on the current intake of fluids (start with a small increase to promote success) and note if the patient may be on any fluid restrictions.


Not only do we work with patients and caregivers who may be illiterate but there are also situations where we are working with cognitive impairments. Language choice then becomes especially important and we must adjust education techniques to fit the needs of the aging patients and/or their caregivers. Forgetfulness and confusion may play a part in the way patients are able to execute instructions appropriately. Your knowledge of wound prevention and treatment helps to ease a stressful situation for the patient and caregiver and to build a trusting relationship with the healthcare team.


Unfortunately, many people lack the basic necessities to care for their hygiene properly; when you are seeing an outpatient, be aware that they may live without running water. Even though most patients have modern amenities, washing, bathing, and showering gradually become more difficult with age. When patients lack basic hygiene, it can exacerbate the situation should any skin care problems occur. Personal hygiene and skin preservation are integral parts of the nursing practice.

Obesity is also a factor in hygiene difficulties. Both age and obesity make it difficult for patients to reach certain areas, especially feet and perineal areas. Encourage daily bathing or hygiene care as an important step for skin care, prevention, and treatment. Soap choices are related to skin health. The natural pH of healthy skin is 4.5 to 5.5, where water is neutral at a pH of 7. An acidic pH level of the skin is important for two reasons. The acidity helps the skin retain moisture and keeps the skin supple and moist; also, the acidic layer helps protect the skin against bacteria and other germs. Recommend washing with a pH balanced cleanser that is gentle to the skin without drying it or changing the proper acidic balance.

When patients wash daily, it not only allows them to feel relaxed and refreshed but also promotes circulation. Daily mouth care is equally as important because “if you look better, you feel better.” In the home health setting, you may sometimes see inadequate hygiene as a major issue. The inability to sufficiently cleanse and moisturize skin can cause breakdown and injury. Assess the patient’s ability to inspect all areas of the skin and the caregiver’s motivation to help the patient with washing these areas.

With each visit, remind the caregiver and patient that bathing is necessary to keep our skin cells healthy, hydrated, and strong, and to keep the proper pH balance, fight infection, and regulate body temperature. Teach a basic skin care regime that includes cleansing with pH balanced products followed by topical moisturizing products to maintain and improve the skin’s barrier function and integrity.

In the obese population, hygiene to areas with skin folds (eg, pannus, breasts, groin) should be cleansed daily to reduce excoriation or breakdown from moisture and friction. Obese patients must be treated with extra care because they are at increased risk for skin breakdown and delayed wound healing. Obese patients have restricted activity and impaired blood flow, with difficulty turning and repositioning, and are unable to effectively relieve pressure on body tissue, which increases the risk for pressure injuries. It is estimated that 30% of adult Americans are obese with BMI >30 kg/m (Smith & Schub, 2017).

Microorganisms grow in the moist skin folds, and skin-on-skin friction leads to breakdown. Pressure injuries develop from poorly vascularized adipose tissue and increased skin surface area (Smith & Schub, 2017). Utilize wider beds to promote ease of repositioning and low-air-loss surface to reduce pressure. Equipment such as a Hoyer lift or trapeze bars can assist patient and caregiver with repositioning and transfers. Skin folds must be inspected frequently, cleansed, dried carefully and protected with absorbent padding to control moisture and comfort.

In homes with pets, great care must be taken to keep wounds clean of animal hair and dander. Caregivers often overlook pets in the home as a source of infection. Education needs to be reiterated on the necessity of keeping the wounds clean and covered when there are pets in the home; hair and dander are possible causes of infection that can lead to hospitalization.

Did You Know. . .

No matter how much people love their pets, they are a great risk for wound infection.

If pet hair and dander become a problem in the home, look for ways to promote a cleaner environment:

  • Utilize plastic containers for storing wound care supplies.
  • Do not allow animals in the room when performing a wound dressing change.
  • Encourage caregivers to keep pets off furniture or tables until the wounds are healed.

People can be more concerned with the well-being of their pets than their own health. One way to discuss the importance of a clean wound is to remind the patient that, if they do require hospitalization due to an infection, their pet will be without them during the length of the hospital stay. People do not want to leave their pets alone and this discussion can encourage patient compliance. Finally, the importance of handwashing can never be stressed enough in any home and at every visit.


Evidence has shown a correlation between falls and incontinence. Teach your patient’s caregivers ways of assisting the patient in voiding. Fifty-three percent of homebound elders are incontinent; this is the single biggest reason why older adults are moved from home into nursing home (NAC, 2014).

Inquire whether the patient has any bladder or bowel difficulties. Remember this can be a sensitive topic and very embarrassing for the patient. You may notice that pants are soiled or a diaper is used and can lead into a respectful and nonjudgmental discussion with the patient. Help them to understand that they are not alone. Offering tips to deal with this difficult situation may actually come as a relief for both the patient and caregiver. During an early visit, gently ask questions about incontinence. Instead of asking “Do you wet your pants, have accidents?” you could ask “How many pairs of underpants do you use a day?” “Do you sometimes have a little leaking with activity?”

Sometimes a patient is embarrassed to answer honestly, even though you can see stains on clothing or wet marks on chairs. Remember that it is important to maintain the patient’s dignity. Never persist if it will make the patient feel embarrassed or ashamed. When you have established a trusting and protective environment the patient and caregiver may feel safe to begin sharing difficult information.

Incontinence is a physical, financial, and psychological stress for patients and caregivers. Being able to assist with it can be an enormous relief and make a positive impact by offering support. Educate all parties on the differences between stress, urge, and functional incontinence. Functional incontinence has to do with the environment and is the biggest factor related to home falls. Assess for any obstacles that could keep the patient from safely getting to the bathroom and the toilet.

Thorough assessment of the home will provide valuable information on patient safety. Proper lighting of hallways and rooms is an easy fix. Rugs and carpeting inhibit walkers and canes or a shuffling gait and may need to be adjusted. Suggest grab bars on the walls in the bathroom, or a raised toilet seat, to assist with easier transition on and off the toilet.

Clothing sometimes affects continence issues. Assess patients for clothes that are easy to remove should they have urge or functional incontinence. Do they have the dexterity to handle buttons or belts easily? Perhaps elastic-waist pants or Velcro shoes would be more beneficial. Proper clothing selection is a great first step to assist with ease of toileting and reduce accidents.

A bladder diary over a 3-day period is valuable for you to see how much, when, and how often the patient is going to the bathroom. Medication review can offer information on incontinence as well. For example, having cleared it with the physician, instruct the patient to avoid taking diuretics in the evening to prevent getting up in the middle of the night and risking falls in the dark.

Diet and nutritional choices effect bladder (and bowel) health. Once information has been gathered in a bladder diary, you can review nutritional choices that may increase bladder health. Food and beverages that are known bladder irritants include caffeine, chocolate, carbonated beverages, alcohol, spicy food, citrus fruits; in addition, irritation can be caused by dehydration from lack of water intake. Offer substitutes and encourage a gradual reduction in the consumption of known irritants.

These lifestyle changes may not be easy for some people. Support new decisions and act as a cheerleader to encourage progress. For patients with constipation trouble, encourage fluid, fiber, and activity to assist in peristalsis. Question caregivers about the number of times per day they change patients or their bed sheets and tell them you would like to make their life easier.

Educate the caregiver on timed voiding by taking the patient to the toilet on a timed schedule, starting with every 2 hours; the hope is the patient may respond by thinking that since they are in the bathroom they might as well void. The caregiver is then motivated to take the patient to the bathroom regularly since it decreases the amount of incontinent episodes and reduces the need to continually change the linens or clothes.

Incontinence-associated dermatitis (IAD) is a result of continued incontinence, which damages the skin top-down through inflammation caused by exposure to stool and/or urine. This can be difficult to differentiate from a Stage 2 pressure injury and calls for assessment of the patient history plus bladder and bowel habits. It is important for caregivers to understand that the risk of developing a pressure ulcer is increased in patients with IAD (Beeckman et al., 2015).

These incontinent questions are important not only for documentation purposes of the home health agency OASIS (Outcome and Assessment Information Set) but also to provide a risk assessment for skin breakdown and falls in these patients. IAD has been associated with certain clinical outcomes including pain, depression, discomfort, sleep disturbances, loss of independence, and poor quality of life. Accurate assessment will determine the plan of care for patients with IAD (Beeckman et al., 2015).

The best treatment is to change the undergarments as soon as they are soiled to prevent moisture from remaining on the skin; next, to apply a moisture barrier product containing zinc oxide. The barrier should be applied at least BID and with incontinence episodes. Once there is proper treatment to the patient’s IAD skin, you should notice visible improvement and reduction in pain within 1 to 2 days. During each visit, solicit patient and caregiver feedback on the new lifestyle changes to determine if the adjustments are helping and if the caregiver and patient are in fact trying to include these adjustments in daily life (Beeckman et al., 2015).

Many caregivers think incontinence is a normal part of the aging process but this is not true. Just because patients are getting older does not mean they should be incontinent. A skilled clinician will investigate the cause of the incontinence. It could be simply that the patient is afraid to fall when getting up alone and would rather wait until help arrives. Ask the patient why they did not get up on their own. The solution could be additional strength and balance exercises to make the patient stronger and confident enough to get up independently.

Home Support System

A patient’s support system—or lack thereof—can be the best or worst issue for you to work with. A positive, engaged support system can make all the difference in how patients heal, react, recover, and engage in their own health. You need to assess the support system, determine if they will do what they promise, and evaluate whether they are as involved as they claim to be and will actually help once the patient is home.

Anxiety, stress, financial strain, and burnout are all issues that vary with support system and caregivers. Common feelings are:

  • How am I going to be able to do this at home?
  • How am I going to afford this?
  • Who is going to help me if I need to ask questions?

As healthcare providers, we must give patients as many resources as possible so they can thrive once discharged from the hospital. Conduct a review of existing resources including home health support, wound center referral, WOC (wound, ostomy, continence) nurse, physical therapy, occupational therapy, and others that may apply. Providing an array of resources to caregivers opens up opportunities to succeed.

Not everyone learns by the same teaching methods. It is important to deliver messages in several ways to family, friends, and patients. It will take several educational sessions to provide enough information for the caregivers to feel satisfied and confident that they can care for their loved one at home. Most people will only retain a small portion of the information they receive in the hospital due to stress and overwhelming emotions, along with the unexpected change in their lifestyle that have just been presented to them.

Home care, outpatient services, and long-term care providers build off of what the acute care facility has begun, so determining how these caregivers learn best and respond to unforeseen situations leads to quality patient outcomes. Break down instructions into sixth-grade language and keep it simple to avoid overwhelming your hearers.

Other factors include determining support system capacity to follow written instructions and physician orders, noting forgetfulness, ensuring adequate vision to help with wound dressings and dexterity to perform duties required. Finally, be sure the support system is motivated to help the patient and remain with them throughout the healing journey. If a caregiver is not motivated, the patient will have a high likelihood of failure, readmission, infection, or deterioration. Your backing is just as important for the support system as it is for the patient.