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PROCEDURAL GUIDELINE 38-1 Performing a Wound Assessment


Intermediate / Wound and Pressure Ulcer Care / Assessing Wounds
NSO

Wound Care Module / Lesson 1

Wound assessment provides the baseline for planning and evaluating the wound care plan. Normal wound healing occurs in an organized fashion, and evaluating the wound status provides an ongoing assessment of wound healing and aids in determining wound treatments. The frequency of the wound assessment depends on the patients overall condition, the policy of the health care setting, type of dressings used, and the overall patient goals (Nix, 2007). There are a variety of wound assessment tools; use will depend upon the facilitys policy.

Routine wound assessments provides valuable information regarding the status of the wound. For example, is wound healing progressing as expected, or is it delayed; is there new drainage? Sometimes a wound increases in size. This often occurs in a wound with necrotic tissue. Removal of the necrotic tissue may result in a larger wound. This is not a negative nding. Obtain physicians order, (when needed) for consultations, such as a wound, ostomy and continence nurse or clinical nurse specialist (CNS) to discuss ndings. If there is an increase in the amount

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PROCEDURAL GUIDELINE 38-1 Performing a Wound Assessmentcontd


and consistency of the drainage and if there is new presence of odor, these factors may indicate a wound infection, and a wound culture is often necessary to support appropriate antibiotics. The following parameters are included in a wound assessment: Location: Note the anatomical position of the wound on the body. Type of wound: If possible, note the etiology of the wound surgical, pressure, trauma. Extent of tissue involvement: Full-thickness wound involves both the dermis and epidermis. Partial-thickness wound involves only the epidermal layer. If it is a pressure ulcer, use the staging system of the National Pressure Ulcer Advisory Panel (NPUAP) (see Chapter 18). Type and percentage of tissue in wound base: Describe the type of tissuegranulation, slough, escharand the approximate amount. Wound size: Determine facility policy on how to measure dimensions, which will include width and length and, in some cases, depth. Wound exudate: Describe the amount, color, and consistency. Presence of odor: Note the presence or absence of odor. Periwound area: Assess the color, temperature, and integrity of the skin.
8 Perform hand hygiene, and apply glean gloves 9 Use the agency-approved assessment tool, and assess the fol-

lowing features:
a The anatomical location of the wound on the body. b Extent of tissue loss: Determine if the wound is full or

Delegation Considerations
The skill of wound assessment cannot be delegated to nursing assistive personnel (NAP). It is the nurses responsibility to assess and document wound characteristics. The nurse directs the NAP by: Instructing the NAP to report drainage from the wound that is present on sheets or as strike through from the dressing. Discussing the importance of reporting the presence of odor in the area of the wound.

Equipment
Protective equipment: clean gloves, gown, and goggles if splash/spray risk exists Agency tool to document assessment: measuring guide Cotton-tipped applicator Dressing supplies Disposable garbage bag

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partial thickness. A partial-thickness wound heals by reepithelialization, whereas a full-thickness wound heals by the creation of scar tissue and will take longer to heal (Doughty and Sparks-Defriese, 2007). c The type and the percentage of tissue, noting granulation tissue, slough tissue, and/or eschar. d Size of wound in centimeters: Measure length, width, and depth (Nix, 2007) (see illustration). (1) Insert a cotton-tipped applicator into the deepest section of the wound to measure depth. Discard applicator in biohazard bag. e Presence of exudate from wound (amount, color, and consistency). Indicate amount of exudate by using part of dressing saturated or in terms of quantity (e.g., scant, moderate, copious). Expect amount to decrease as healing takes place. Serous drainage is clear like plasma; sanguineous or bright-red drainage indicates fresh bleeding; serosanguineous drainage is pink; purulent drainage is thick and yellow, pale green, or white. f Odor: State whether or not there is odor. A change in wound odor may indicate the presence of a wound infection (Stotts, 2007). g Periwound skin integrity: Include color, texture, temperature, and a description of any areas that are open, stripped, or have a rash. Periwound assessment gives clues on the effectiveness of the wound treatment, as well as possible wound extension (Nix, 2007). Reassess patients pain and level of comfort. Reapply dressings as per order. Discard biohazard bag, soiled supplies, and gloves as per agency policy; perform hand hygiene. Record wound assessment ndings, and compare assessment with previous wound assessments to monitor wound healing.

Critical Decision Point Once you compare the wound assessment to


previous assessment, determine progress toward healing. If there is no movement toward healing, or if you notice deterioration, consider a wound care consultation. Lack of wound healing is often related to infection. Notify physician and wound care nurse or team.

Procedural Steps
1 Determine the facilitys approved assessment tool, and review

2 3 4

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the frequency of wound assessment. Examine the last wound assessment to use as comparison for this wound assessment. Assess comfort level or pain on a scale of 0 to 10, and identify symptoms of anxiety. Explain procedure of wound assessment to patient. Close room door or bed curtains, and position patient. a Position comfortably to permit observation of wound in a well-lighted room. b Expose wound only. Perform hand hygiene, and form a cuff on waterproof biohazard bag and place near bed. Apply clean gloves, and remove soiled dressings. Examine dressings for quality of drainage (color, consistency), presence or absence of odor, and quantity of drainage (note if dressings were saturated, slightly moist, or had no drainage). Discard dressings in waterproof bag. Discard gloves.

Length

Width

STEP 9d Measuring wound length and width.

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REFERENCES
Autio L, Olson KK: The four Ss of wound management: staples, sutures, Steri-Strips, and sticky stuff, Holist Nurs Pract 16(2):80, 2002. Barr JE: Principles of wound cleansing, Ostomy Wound Manage 7A(suppl 41):15S, 1995. Beshara M and others: Practice development in acute and long-term care settings. In Bryant RA, editor: Acute and chronic wounds: nursing management, ed 2, St. Louis, 2000, Mosby. Bryant RA, editor: Acute and chronic wounds, ed 2, St. Louis, 2000, Mosby. Bryant RA, Nix DP, editors: Acute and chronic wounds: current management concepts, ed 3, St. Louis, 2007, Mosby. Centers for Disease Control and Prevention: Part II: recommendations for isolation precautions in hospitals, 1997, http://wonder.cdc.gov/wonder/prevguid/p000049/ p0000419.asp. Dochterman JC, Bulechek GM: Nursing interventions classication (NIC), ed 4, St. Louis, 2004, Mosby. Doughty DB: Preventing and managing surgical wound dehiscence, Adv Skin Wound Care 18(6):319, 2005. Doughty DB, Sparks-Defriese B: Wound-healing physiology. In Bryant RA, Nix DP, editors: Acute and chronic wounds: current management concepts, ed 3, St. Louis, 2007, Mosby. Fellows J, Crestodina L: Home-prepared saline: a safe, cost-effective alternative for wound cleansing in home care, J Wound Ostomy Continence Nurs 33(6):606, 2006. Frantz RA and others. In Bryant RA, Nix DP, editors: Acute and chronic wounds: current management concepts, ed 3, St. Louis, 2007, Mosby. Gallagher-Camden S: Skin care needs of the obese patient. In Bryant RA, Nix DP, editors: Acute and chronic wounds: current management concepts, ed 3, St. Louis, 2007, Mosby. Krasner DL and others: Managing wound pain. In Bryant RA, Nix DP, editors: Acute and chronic wounds: current management concepts, ed 3, St. Louis, 2007, Mosby. Nix DP: Patient assessment and evaluation of healing. In Bryant RA, Nix DP, editors: Acute and chronic wounds: current management concepts, ed 3, St. Louis, 2007, Mosby. Ramundo J: Wound debridement. In Bryant RA, Nix DP, editors: Acute and chronic wounds: current management concepts, ed 3, St. Louis, 2007, Mosby. Ratliff CR, Fletcher KR: Skin tears: a review of the evidence to support prevention and treatment, Ostomy Wound Manage 53(3):32, 2007. Rolstad BS, Ovington LG: Principles of wound management. In Bryant RA, Nix DP, editors: Acute and chronic wounds: current management concepts, ed 3, St. Louis, 2007, Mosby. Stotts NA: Nutritional assessment and support. In Bryant RA, Nix DP, editors: Acute and chronic wounds: current management concepts, ed 3, St. Louis, 2007, Mosby. Sylvia C, Perla J: The team approach to total education and management, J Wound Ostomy Continence Nurs 31(3S):S21, 2004. Whitney JD: Acute surgical and traumatic wounds. In Bryant RA, Nix DP, editors: Acute and chronic wounds: current management concepts, ed 3, St. Louis, 2007, Mosby. Wound, Ostomy and Continence Nurses Society: Guideline for prevention and management of pressure ulcers, WOCN clinical practice guidelines series, Glenview, Ill, 2003.

RESEARCH REFERENCES
Campany E and others: Nurses knowledge of wound irrigation and pressures generated during simulated wound irrigation, J Wound Ostomy Continence Nurs 27:296, 2000. Granick MS and others: Comparison of wound irrigation and tangential hydro dissection in bacterial clearance of contaminated wounds: results of a randomized, controlled clinical study, Ostomy Wound Manage 53:46, 2007. Miller J, Petro-Nustas W: Context for care of Jordanian women, J Transcult Nurs 13(3):228, 2002. Moscati RM and others. A multicenter comparison of tap water versus sterile saline for wound irrigation, Acad Emerg Med 14:404, 2007.

From Perry AG, Potter PA: Clinical nursing skills & techniques, ed 7, St. Louis, 2010, Mosby.