Patient Assessment

  • Risk Assessment
  1. mental status
  2. mobility
  3. activity
  4. nutrition/hydration
  5. circulation
  6. moisture exposure

 

  • Assess patient's general status
  1. wound disrupts patient's entire life
  2. patient disease state that affects wound status
  3. wound etiology and type (acute vs. chronic)

 

  • Wound Assessment
  1. Measure the wound in centimeters · Length (head to toe) X width (side to side) X depth
    • Indicate deepest point using clock method (e.g. 6:00 5 cm)
    • Depth cannot be accurately measured in the presence of necrotic tissue
    • Measure depth and tunneling with a cotton swab
    • Sketch wound in notes and place digital picture with date and time in chart
  2. Assess phase of wound healing
    • Reaction
    • Regeneration
    • Remodeling
  3. Wound location, color of wound bed, condition of wound margins, integrity of surrounding skin
  4. S/S infection
  5. Drainage: amount, color, consistency, odor
Wound Assessment + Charting Patient Assessment
Local Factors
Systemic Factors
  • Location
    describe or indicate on diagram
  • Size in CM
    use measuring device or do tracing
  • Drainage - Exudate
    amount
    type
    odor
  • Signs of Infection
    Induration
    Fever Erythema
    Edema
  • Tissue Present
    epithelial
    granulation
    necrotic
         slough
         eschar
  • Nutritional Status
  • Chronic Illnesses
  • Oxygenation/Circulation
  • Medications
  • Age
  • Stress
    family support
  • Immune Status
    oncologic process
    chemotherapy
    corticosteroids
    HIV
  • Continent Status
Granulation Tissue Epithelial Tissue Slough Eschar
Measurement of wound
using plastic measurement
device		 Tracing outline of
wound using plastic bag		 Using a swab to
measure depth		 Undermined Wound
If signs of infection are present (redness, swelling, purulent drainage, fever), consult a physician or wound care specialist.

Resources:

DermatologistsRX.com
http://www.dermatologistrx.com/freeadvice/WoundandUlcerCare.asp

skinwound.com
http://www.skinwound.com/