Patient Assessment
- Risk Assessment
- mental status
- mobility
- activity
- nutrition/hydration
- circulation
- moisture exposure
- Assess patient's general status
- wound disrupts patient's entire life
- patient disease state that affects wound status
- wound etiology and type (acute vs. chronic)
- Wound Assessment
- 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
- Assess phase of wound healing
- Reaction
- Regeneration
- Remodeling
- Wound location, color of wound bed, condition of wound margins, integrity of surrounding skin
- S/S infection
- Drainage: amount, color, consistency, odor
Wound Assessment + Charting | Patient Assessment |
Local Factors
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Systemic Factors
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Granulation Tissue | Epithelial Tissue | Slough | Eschar |
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Measurement of wound using plastic measurement device |
Tracing outline of wound using plastic bag |
Using a swab to measure depth |
Undermined Wound |
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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.aspskinwound.com
http://www.skinwound.com/