Wound Assessment & Documentation Anita Hedzik CDN Ward 5B/C Princess Margaret Hospital

Wound Assessment Holistic Approach General assessment

Determine Type of Wound Acute Traumatic Abrasions, lacerations Burns Surgical Infective Chronic Vascular Neoplastic Metabolic Neuropathic Pressure Ulcers

Acute Traumatic Wound Acute Wound

Chronic Wound

Determine Mode of Healing Primary intention Delayed primary intention Secondary intention Graft Flap

Determine Mode of Healing Primary Intention (Closure)

Determine Mode of Healing Delayed primary intention

Secondary Intention

Grafting

Determine Tissue Loss Superficial Partial Deep Partial Full Thickness OR Stages I - IV

Superficial

Partial Thickness

Deep Partial Thickness

Full Thickness

Clinical Appearance Necrotic Sloughy Granulating Epithelialising Infected

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

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

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

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?

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

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 patient’s general health in your assessment

Wound Infection

Psychological Implications Self esteem & body image Alteration in body functions Socialization Impact on family

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

Documentation - Accountability Client Self Community Institution Professional ACCOUNTABILITY

Documentation Consistent Clear Concise Legible Accurate

Assessment Wound description Format: Standardised document or chart Narrative (Descriptive)

Wound Assessment Tool Trial Wound assessment tool currently being developed at PMH

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

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