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

2. Wound Assessment
Holistic Approach
General assessment

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

4. Acute Traumatic Wound
Acute Wound

5. Chronic Wound

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

7. Determine Mode of Healing
Primary Intention (Closure)

8. Determine Mode of Healing
Delayed primary intention

9. Secondary Intention

10. Grafting

11. Determine Tissue Loss Superficial Partial Deep Partial Full ThicknessOR
Stages I - IV

12. Superficial

13. Partial Thickness

14. Deep Partial Thickness

15. Full Thickness

16. Clinical Appearance Necrotic Sloughy Granulating Epithelialising
Infected

22. 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

23. 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

24. 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

25. 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?

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

27. 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

28. Wound Infection

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

30. 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

32. Documentation - Accountability
Client Self
Community Institution
Professional
ACCOUNTABILITY

33. Documentation
Consistent
Clear
Concise
Legible
Accurate

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

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

36. 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

37. 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