To ensure that patients and or the patient’s caregiver are aware of restrictions and symptoms, necessary to report following hyperbaric oxygen therapy.

1. Assess the patient’s knowledge base related to the underlying condition.
2. Discuss with patient and or the patient’s caregiver basic principles of wound healing and hyperbaric oxygen therapy’s effects on healing.
3. Discuss with patient and or the patient’s caregiver the effects of smoking on wound healing.
4. Discuss with patient and or the patient’s caregiver the impact of nutrition on wound healing.
5. Consult the necessary specialist as indicated by the hyperbaric physician.
6. Provide the patient or the patient’s caregiver instruction in wound care procedures and supplies.

HYPERBARIC WOUND CARE AND ASSESSMENT

Assessment is to be completed by the HBO staff on each problem wound patient prior to the patient beginning a course of HBO therapy. Outpatients treated for problem wounds will have daily dressing changes, unless otherwise indicated by the HBO or the referring MD, with the assessment form completed daily. Inpatients having dressing changes on the floor, will have wound assessed and form completed weekly by HBO staff with photos of wound taken at this time.

Wound Size: Wound size will be measured and documented initially before patient begins HBO therapy and weekly thereafter. A digital photograph will also be taken.

Wound Color: Wound color/color change will be documented. A more narrative description of wound appearance is to be included in the nurses' notes as indicated.

Skin Color: Appearance of surrounding skin will also be documented. If an area of erythema/discoloration is present, a measurement of the extent will be documented.

Drainage: Assessment of color, odor, amount, and type of drainage will be documented.

Cleansing of Wound: Document method of wound cleaning (if any) per physician order (include debridement).

Dressing: Document type of dressing used per physician order (i.e., absorbent pad, Unna boot, adaptic, etc.)

Nursing Assessment: Objective assessment of wound progress with further documentation in nursing notes, if necessary.

Patient Response: Subjective assessment of overall wound progress.

WOUND PHOTOGRAPHY

Goal: To provide medical record photo documentation of wound, lesion, or injury responses throughout the course of hyperbaric oxygen therapy.

Policy Elements

Photographic documentation of wounds is frequently an important part of a patient’s case management process. In conjunction with direct wound measurements, serial photography permits a more accurate and permanent assessment of wound evolution. Photography eliminates much of the guesswork in a busy service, with large numbers of patient evaluations and follow-ups, involving several different clinicians.

As part of the medical record, wound photography can play an important role in the claim filing and reimbursement process. Some insurers specifically require photographic evidence of the diagnosis (radiation-induced soft tissue breakdown, for example). Well-documented wound photography can have a significant positive impact in terms of insurance company case audits.

Informed Consent

Informed consent is mandatory before any patient photography. Following a discussion of the rationale for photographic documentation of a wound with the patient (and family members, where appropriate), a signed consent must be obtained, and maintained within the medical record.

Emergent consents for hyperbaric oxygen therapy can be obtained from other clinicians in circumstances where a patient or family member is unable to provide consent. This is not necessarily the case with wound photography. Check the Hospital’s policy.

Photographic Procedure

The following procedures will serve to optimize the quality and consistency of wound photographs:

1. Provide a blue background where possible. This can take the form of a reverse “chux”, pillowcase, or sheet. 
2. Prepare an identification and measurement guide. A 6” ruler with the scale evident in the upright position is preferred. Use an adhesive label to identify the patient with their ID number, the date, and the number of hyperbaric procedures completed. For initial consultations, note PRE-HBO. For follow up, note HBO x, then insert the number of procedures, i.e. HBO x 14. Ensure that the label does not obscure the scale. Identify left (L) or right (R) extremity in cases of bilateral wounds. Use a black marker, not a ballpoint pen. Print the information clearly; avoid longhand
3. Use a gloved hand to hold the ruler adjacent to the area to be photographed.
4. Center the photograph over the wound, not the ruler. If the ruler is not on the same plane as the wound, and occupies the center of the picture, the camera will focus on the ruler. 
5. The initial photograph is to be maintained in the patient HBO chart. Prior to each subsequent wound photograph, the initial photograph is reviewed. This assures continuity of image. In some wounds, it is possible that more than one view will be necessary.
6. The frequency of wound photography will vary with the condition being treated. Daily photographs may be required in certain conditions, such as a compromised flap or a necrotizing soft tissue infection. As a minimum, all wounds should be photographed at least once weekly.