Week 2 | Wound Assessment (17181-SP)
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- Patient Assessment
- Onset and duration of wound
- Treatment History
- Co-morbid conditions; past medical and surgical history
- Factors affecting healing
- Pertinent family history
- Current medications, allergies
- Recent lab values/culture results
- Nutritional and hydration status
- Functional status
- Psychosocial issues
- Knowledge base
- Focused Wound Assessment
- Anatomic Location
- Wound Measurement (in cm.)
- Surface area
- Wound shape
- Wound Classification
a. Partial thickness/Full thickness
- Wound Base (% tissue type, color, consistency, adherence)
a. Viable tissue (%): granulation, clean, non-granulating, epithelial.
- 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.
- Clean, 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.
b. Non-viable tissue (%): eschar, slough = full thickness damage
- 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.
c. Tissue quality
- 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.
- Non-proliferative wound edges/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
- Volume: Wound dry-no exudate, Moist wound- small, Wet/saturated- moderate, Saturated, wound bathing in fluid- large.
- Presence or absence of symptoms of infection
- Local signs
- Increased amount and/or change in character of exudate
- Increased local warmth
- Edema or induration
- Pain or tenderness
- Systemic signs
- Elevated glucose in patient with diabetes
- Pain in a neuropathic extremity
- Criteria for Critical Colonization and Infection
- Critical Colonization: NERDS
- Deep tissue infection: STONES
- Local signs
- Condition of the periwound skin
- Induration: Firmness to palpation
- Maceration: Tissue bathed in fluid, need to focus on exudate management
- Hyperkeratic rim/callus
- Pain assessment (at rest and during dressing changes)
Key elements of wound management documentation
- Reason for consultation
- Brief medical history
- Wound history
- Factors impacting healing
Tissue perfusion and oxygenation
Poor nutritional status
- Focused wound assessment
- Short and Long Term Goals
- Treatment recommendations
- Plan for follow-up
Objectives for Learning Outcomes
After completing this session, you will be able to:
- Identify the essential elements of a focused wound assessment.
- Describe the types of tissue that may be visualized in the wound.
- Describe a structured approach for wound management that begins with a comprehensive 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