Wound Assessment

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Wound Assessment Documentation

• Anita Hedzik
• CDN Ward 5B/C
• Princess Margaret Hospital

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Wound Assessment

• Holistic Approach
• General assessment

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Determine Type of Wound

• Acute
• Traumatic
• Abrasions, lacerations
• Burns
• Surgical
• Infective

• Chronic
• Vascular
• Neoplastic
• Metabolic
• Neuropathic
• Pressure Ulcers

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Acute Traumatic Wound
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Chronic Wound
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Determine Mode of Healing

• Primary intention
• Delayed primary intention
• Secondary intention
• Graft
• Flap

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Determine Mode of Healing

• Primary Intention (Closure)

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Determine Mode of Healing

• Delayed primary intention

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Secondary Intention
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Grafting
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Determine Tissue Loss

• Superficial
• Partial
• Deep Partial
• Full Thickness
• OR
• Stages I - IV

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Superficial
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Partial Thickness
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Deep Partial Thickness
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Full Thickness
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Clinical Appearance

• Necrotic
• Sloughy
• Granulating
• Epithelialising
• Infected

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Wound Location

• Wounds in areas of increased mobility friction
  may be slow to heal
• Healing promoted in areas with good
  vascularisation
• Areas at risk of pressure shearing forces will
  have delayed healing

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Wound Dimensions

• Allows assessment evaluation of healing rate
  and wound management strategies
• Two dimensional width length (ruler)
• Three dimensional measure depth or tracking (use
  sterile tipped probe)
• Wound measurement tool
• Serial Clinical photography

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Wound Exudate

• Type
• serous, haemoserous, serosanguinous, purulent
• Amount
• major losses can affect fluid electrolytes,
  peri-wound maceration
• Colour
• May indicate bacterial load (Pseudamonas)
• Consistency
• Odour

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Surrounding Skin

• Inspect palpate
• Observe for signs of cellulitis, oedema,
  dermatitis, eczema, allergic reactions,
  maceration, foreign bodies
• Palpate for warmth, capillary refill, oedema
• Is there evidence of wound healing?

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Pain

• Determine cause of pain
• Is pain local or systemic?
• Is pain related to wound care practices?
• Manage pain appropriately

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Wound Infection

• Wounds are classified as clean, clean
  contaminated, contaminated, infected
• Microbiological assessment
• Assess on an individual basis
• Ask the patient/parent/staff about symptoms
• Consider the patients general health in your
  assessment

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Wound Infection
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Psychological Implications

• Self esteem body image
• Alteration in body functions
• Socialization
• Impact on family

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Implement Management Plan

• What is wound care goal?
• What is most important for the patient?
• Select appropriate dressing/ treatments
• Ensure all treatments/dressings are documented
  accurately
• Evaluate regularly

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Documentation - Accountability

• Client Self
• Community Institution
• Professional

ACCOUNTABILITY
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Documentation

• Consistent
• Clear
• Concise
• Legible
• Accurate

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Assessment Wound description

• Format
• Standardised document or chart
• Narrative (Descriptive)

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Wound Assessment Tool

• Trial Wound assessment tool currently being
  developed at PMH

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Narrative (Descriptive) Documentation

• Wound centrally sloughy with necrotic eschar at
  medial corner, proximal third pale with
  epithelial buds and distal third granulating OR
• 20 necrotic, 40 slough, 20 granulating 20
  epithelialising

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Documentation in notes

• Wound 70 pink and granulating, 30 pale slough.
• OR
• Wound pale on left arm and left lateral side of
  chest, pink and granulating at distal left trunk
  and over right side of chest