Week 2 | Wound Assessment (16181-SP)
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- Patient Assessment
- Onset and duration of wound
- Treatment History
- Co-morbid conditions
- Factors affecting healing
- Family History
- Current medications
- Recent lab values/culture results
- Nutritional and hydration status
- Functional status
- Psychosocial issues
- Focused Wound Assessment
- Anatomic Location
- Wound Measurement
- Wound Base (% tissue type, color, consistency, adherence)
- Slough: Soft moist avascular (devitalized) tissue; may be white, yellow, tan, or gray, may be loose or firmly adherent.
- Eschar: Black or brown necrotic, devitalized tissue; tissue can be loose or firmly adherent, hard or soft, dry or wet.
- Granulation tissue: Pink/red, moist tissue composed of new blood vessels, connective tissue, fibroblasts, and inflammatory cells, which fills an open full-thickness wound when it starts to heal. Typically, appears deep pink to red with an irregular, “berry-like” surface.
- Nongranulating: Absence of granulation tissue; wound surface appears smooth and red as opposed to cobblestone or berry-like.
- Epithelialization: Regeneration of the epidermis across a wound surface. Pink, fragile-looking layer of new cells, may appear as islands.
- Wound Classification
- Partial thickness/Full thickness
- Partial thickness: Confined to the skin layers; skin damage that does not penetrate below the dermis and may be limited to the epidermal layers only.
- Full Thickness: Tissue damage involving total loss of the epidermis and dermis extending into the subcutaneous tissue and possibly into muscle or bone.
- Staging System for Pressure Ulcers
- Partial thickness/Full thickness
- Wound Edges/Margins (degree of attachment to the wound base, distinctness, thickness). Record location using the face of a clock and extent in cm.
- Undermining: Tissue destruction extending under intact skin along the periphery of a wound; commonly seen in shear injuries.
- Tunneling: Course or path of tissue destruction occurring in any direction from the wound surface or edge of the wound; results in dead space.
- Epibole: Edges of top layers of epidermis have rolled down to cover the lower edge of epidermis, including basement membrane, so epithelial cells cannot migrate from wound edges. Presents clinically as a sealed edge of mature epithelium. Wound edge may present clinically as hard/thickened and/or discolored ( e.g.yellowish, gray, white). Also known as closed wound edges.
- Presence and Character of Exudate
- Color: (serous- clear fluid without blood, pus or debris, serosanguineous- thin, watery pale red to pink, sanguineous- bloody, bright red, purulent: thick, cloudy, yellow or tan.)
- Odor: with dressing in place: no odor at close range, faint odor at close range, moderate odor in room, strong odor in room.
- Volume: Wound dry-no exudate, Moist wound- small, Wet/saturated- moderate, Saturated, wound bathing in fluid- large.
- Presence or absence of symptoms of infection
- Erythema: Normal in the inflammatory phase of wound healing.
- Pain at wound and surrounding skin
- Purulent exudate
- Odor: pungent, strong, foul or musty
- Delayed healing
- Discoloration - dull appearance of granulation tissue
- Friable granulation tissue
- .Increase in wound drainage
- Condition of the periwound skin
- Maceration: Tissue bathed in fluid, need to focus on exudate management
- Induration: Firmness to palpation
- Pain (at rest and during dressing changes)
Objectives for Learning Outcomes
After completing this session, you will be able to:
- Identify the essential elements of a comprehensive wound assessment.
- Describe a structured approach for patient and wound assessment.
Renee Anderson, MSN, RN, CWON
Certified Wound Ostomy Nurse; Co-Director, Wound Management Education Program (WMEP) and Wound Management Fundamentals Course (WMFC), Continuing Nursing Education, University of Washington School of Nursing, Seattle; President, Rainier Clinical Consultants, Inc, Seattle, WA