Wound Classification in Long-Term Care

What is wound classification, and why is it essential when caring for older adults? Let’s first dive into the basics of wound classification. 

Wounds can vary in shape, size, and how they happen. Therefore, healthcare professionals must understand how to classify them into the correct wound categories:

• Surgical wounds: The Centers for Disease Control and Prevention (CDC) classifies surgical wounds into four types, determining how the wounds are cleaned and treated:
  • Class one – clean: These wounds are very clean and are not infected or inflamed. They are usually closed wounds, meaning the skin is still intact. They also do not involve body parts like the respiratory system, gastrointestinal tract, or genitourinary tract. 
  • Class two – clean contaminated: These wounds are still clean and infection and inflammation free. However, there is an increased chance of infection. 
  • Class three – contaminated: Wounds in this class can result from an injury, operations with breaks in sterile techniques, or spillages from the gastrointestinal tract.
  • Class four – dirty contaminated: These wounds came into contact with feces or pus during the surgery. They can also include traumatic wounds that were not correctly taken care of.
• Open wounds: These are wounds where the skin is broken, usually because of something from outside the body. There are two types of open wounds: surgical wounds—which happen during surgery, like when a doctor cuts the skin for an operation—and non-surgical wounds, usually caused by accidents. 
• Closed wounds: These are usually wounds on unbroken skin but with some damage underneath, such as:
  • Contusions (discolored skin, usually red or blue)
  • Hematomas (wounds filled with blood under the skin or deeper inside the body)
  • Crush injuries (minor bruises to more severe injuries)
  • Blisters (pockets of fluid, blood, or pus on the upper layer of the skin)
• Ulcers: Ulcers develop when our cells do not get enough blood and oxygen to work correctly. The most common type of ulcer in nursing homes is a pressure ulcer, which develops when someone stays in one position for too long. Oftentimes, these ulcers stem from spending long periods in bed, which is common for older adults and those who just underwent surgery. This lack of motion leads to too much pressure on specific body parts, which reduces blood flow and makes the skin vulnerable and painful. 

By understanding how wounds are classified, healthcare professionals can better know what kind of care and treatment older adults need.

What areas do pressure ulcers affect?

Pressure ulcers are most common in elderly adults due to decreased mobility and sensitivity to pressure and can affect different body parts. Technically, they can appear anywhere on the body, like on the nose, ears, back of the head, or even inside the mouth if a resident has poorly fitted dentures, tubes in the throat (intubations), or a ventilation machine to help them breathe.

Still, pressure ulcers typically develop in areas where the bones are close to the skin, such as the:

• Ankles
• Back
• Buttocks
• Elbows
• Heels
• Hips
• Tailbone

Wound care specialists in long-term care facilities

Specialized healthcare professionals are called wound care specialists. This group includes registered nurses, wound care nurses, and physicians in rehabilitation and skilled nursing facilities with wound care services. 

These specialists are trained to spot warning signs, like redness or swelling around the wound, that indicate an infection or slower healing. In such cases, they take action by cleaning and dressing the wound more carefully and often. If needed, they can give antibiotics to fight the infection. 

Wound care specialists are also involved in the healing process, as they

• Inform patients as to what to expect
• Take specific steps to make sure wounds heal properly
• Advise on how to prevent wounds from happening again in the future
• Teach residents and their families how to care for wounds at home

Qualifications of wound care specialists

To be a wound care specialist in a long-term care facility, proper training and qualifications are required. The path to that training depends on the role. Here we will provide brief summaries of the various training options.

• Certified Wound Care Associate (CWCA): This is a healthcare professional with at least three years of experience in wound care. They can be nurses, medical assistants, or people who work in sales and marketing for wound care products. 
• Certified Wound Specialist (CWS): A CWS is a licensed healthcare professional with a Bachelor’s, Master’s, or Doctorate and at least three years of wound care experience. They can be registered nurses, nurse practitioners, or veterinarians. 
• Certified Wound Specialist Physician (CWSP): The CWSP is for medical doctors (MDs), doctors of osteopathic medicine (DOs), and doctors of podiatric medicine (DPMs) with three or more years of experience in wound care. Additionally, they need a full and unrestricted professional license in the states where they practice.

These certifications are necessary because they show that these professionals have the right training and experience to provide specialized care for wounds.

11 steps to wound care 

Qualified wound care specialists should follow these 11 general guidelines to treat wounds properly:

1. Assess the resident by reviewing important information, such as their medical history, previous surgeries, current medication prescriptions, and social background.
2. Examine the resident by looking at their whole body and focusing on the wound. Wound specialists should observe the wound’s size, depth, shape, and type of tissue present. This initial assessment provides essential information about the wound’s characteristics.
3. Document the wound via the long-term care software system. Wound specialists must record accurate documentation for effective wound classification. This allows them to track the wound’s progress and enable comparisons over time.
4. Conduct additional tests (when necessary), such as blood tests, x-rays, scans, or cultures, to gather additional information about the wound. These tests provide valuable insights to support accurate wound classification and help with the treatment. 
5. Determine what type of tissue the wound has, like if it’s a cut, a scrape, or something else.
6. Ensure proper collaboration and communication between the team. This allows the interdisciplinary team (wound care specialists, nurses, or physicians) to share their knowledge and expertise and develop a comprehensive treatment plan using the long-term care EHR software system.
7. Decontaminate the wound. 
8. Apply appropriate wound dressings, such as non-adherent saline wraps (saline-soaked gauze) and absorbent materials to prevent infection. 
9. Secure the dressing with soft gauze tape to prevent further contamination of wounds.
10. Teach the resident or their family how to care for the wound, stressing the importance of keeping it clean.
11. Monitor the resident’s wound and check on the wound regularly to see how it’s healing.

By following these steps, wound care specialists can provide the best care for wounds, maximize the resident’s recovery, and improve their overall health and well-being. Next, we will explore the unique challenges and considerations specific to older adults with unstageable pressure ulcers. 

What Are Unstageable Pressure Ulcers?

An unstageable pressure ulcer is a wound type that cannot be classified using the traditional wound classification system above. These pressure ulcers are sores that occur when a body part is pressed against something hard for a long time. They usually form between a bone and the surface it’s pressed against. 

Sometimes, these ulcers have a layer of dead tissue called “slough” or a hard, dark covering called “eschar.” When that happens, the ulcer is classified as unstageable because healthcare professionals cannot tell what stage the wound is. 

There are several factors that contribute toward the development of unstageable pressure ulcers in older adults, such as:

• Reduced mobility and activity levels
• Thinner, fragile, or dry skin
• Poor circulation
• Nutritional deficiencies
• Fecal or urinary incontinence
• Altered mental status
• Chronic health conditions like diabetes or vascular disease 

Treating unstageable pressure ulcers

The treatment goal for unstageable pressure ulcers is to remove the covering (eschar) safely, so wound care specialists can adequately understand the stage and treat them correctly. However, if the ulcer is a stable heel ulcer with dry eschar, it is best not to remove it, because it protects the wound.

To prevent pressure ulcers and minimize complications, wound care specialists in long-term care facilities should take the following precautions:

• Reposition the resident regularly based on their activity level, mobility, and ability to move independently. It is advisable to turn residents every two hours. 
• Keep the resident’s skin clean and dry.
• Avoid massaging bony areas.
• Make sure the resident gets enough protein and calories according to the dietitian’s recommendations. 
• Encourage the resident to stay active with organized activities to maintain mobility and motion range.
• Use specialized equipment like pressure relief mattresses, overlays, and cushions to position the resident and relieve pressure on bony areas.
• Keep the head of the bed as low as possible to reduce the risk of sliding down.
• Keep bedsheets dry, smooth, and wrinkle-free.

What information is documented?

When pressure ulcers become unstageable, it is hard for wound care specialists to accurately document them because they cannot see how deep the wounds are. However, there are certain signs to look for and, consequently, document:

• Size: Measure how big the ulcer is (usually in centimeters), including the width and length. 
• Tissue: Examine for hard (slough), dark (eschar), or dead tissue around the wound. 
• Drainage: Examine if any liquid or pus is coming out of the ulcer, such as its color and how much there is. 
• Edges: Examine the edge of the ulcer to see if it’s hard, wet, rolling, or red. 
• Skin around the ulcer: Examine the skin around the ulcer to see the color, texture, and temperature. Look for a  healthy appearance. 
• Passages and destruction: Look for any tunnels or passages that go from the wound into the deeper tissues and if there is any tissue destruction around the edge of the wound. 
• Pain: Ask the resident if there is any pain around the ulcer
• Odor: Note if the ulcer has any smells or if it’s odorless. 

By documenting these details, wound care specialists will better understand what treatment is needed for a wound. 

Complexities of managing unstageable pressure ulcers

Managing unstageable pressure ulcers can be challenging for wound care specialists because of the complexity of the wounds. The presence of necrotic tissue requires careful treatment to promote healing. 

Additional factors that make it more difficult to manage wounds include:

• Immobility
• Nutrition
• Circulation issues
• Wound dressings
• Repositioning schedules
• Pressure redistribution 

Furthermore, proper wound care management requires a multidisciplinary approach involving specialists, caregivers, and family members to carry out and support a resident’s care and wounds.  

Contact us here to see how our user-friendly long-term care software improves documentation processes for pressure ulcers and deep tissue injuries. 

Deep Tissue Injury and Preventive Measures 

Like an unstageable pressure ulcer, a deep tissue injury (DTI) in a senior is complicated to treat because of its hidden nature, leading to severe injuries. So upon identifying a possible wound, specialists must first conduct a wound classification to determine the type and severity of the wound. This means they must perform a wound assessment and management procedure like the one mentioned above to create a tailored wound care plan for the resident. 

Besides identifying a wound, it is also essential to understand how the wound can potentially impact residents’ overall health and well-being. Studies show that wounds like unstageable pressure ulcers can cause severe pain and discomfort, decreasing mobility, poorer quality of life, and increased mortality. 

Additionally, a Healthcare Cost and Utilization Project (HCUP) report conducted between 1993 and 2003 discovered a 63 percent rise in pressure ulcers. The report also highlighted the cost of hospitalizations during this period, with each hospital stay costing approximately $37,800. 

These findings have led to calls to improve wound care, including unstageable wounds, and decrease the likelihood of pressure ulcers from developing. There has also been a recent effort by the U.S. Agency for Healthcare Research and Quality to provide guidelines on preventing pressure ulcers. These guidelines serve as a foundation for taking care of residents and highlight the different steps to reduce the chances of developing pressure ulcers. 

It’s important that wound specialists, nurses, and other caregivers have the sufficient knowledge and skills necessary for effective wound prevention and management. So education and training programs must cover skin assessment, proper positioning, turning techniques, recognizing early signs of deep tissue injuries, and appropriate wound care practices. 

Facilities should also provide regular training updates to ensure the team stays informed about the latest research, wound prevention, and care practices.

Why Proper Wound Classification Matters

Proper wound classification and management of wounds are fundamental in long-term care facilities. Wound care procedures can be complex, especially when dealing with unstageable pressure ulcers and deep tissue injuries. But they are clearly worth the time and effort, as the health risks and financial ramifications of potential hospitalizations make such preventative matters necessary. 

Facilities offering wound care must ensure their specialists are qualified to spot and treat wounds properly. For this reason, it is imperative to provide ongoing education and training for wound care specialists and the entire care team. This ensures the team is up-to-date with the latest research and best practices in wound prevention and care, ultimately improving the residents’ overall health, well-being, and mobility. 

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