Week 2 | Wound Assessment (17180-SP)

Photo of wound on a foot.

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Content Outline

  • 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 
    • Incontinence 
    • 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 
    • 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. 
      • Consistency 
      • 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. 
      •  Induration 
      • Pain at wound and surrounding skin 
      • Fever 
      • 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 
      • ​Erythema 
      • Maceration: Tissue bathed in fluid, need to focus on exudate management 
      • Induration: Firmness to palpation 
      • Pigmentation 
      • Edema 
    • Pain (at rest and during dressing changes) 

Objectives for Learning Outcomes

After completing this session, you will be able to:

  1. Identify the essential elements of a comprehensive wound assessment. 
  2. Describe a structured approach for patient and wound assessment. 
Course summary
Available: 
04/07/2017
Expires: 
07/02/2018

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

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