Wound Assessment

WoundSource Editors's picture
wound healing

The Wound Healing Process

Promoting the wound healing process is a primary responsibility for most health care practitioners. It can take 1-3 days for a closed wound to actually establish a seal. Infections usually occur in 3-6 days but may not appear for up to 30 days, according to the CDC guidelines for preventing surgical infections.

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Holly Hovan's picture
neuropathy testing for sensory perception (Braden Scale)

By Holly Hovan MSN, APRN, CWOCN-AP

As wound care professionals, the Braden Scale is near and dear to our hearts. With that in mind, our evidence-based tool needs to be used correctly in order to yield accurate results. Working with long-term care and geriatric populations opens up a world of multiple pre-existing comorbidities and risk factors that aren’t always explicitly written into the Braden Scale categories. Additionally, the frequency of the Braden Scale may also contribute to a multitude of different scores; the resident behaves differently on different shifts, for example, asleep on night shift but up and about on days. What is the correct way to score them? I believe that a less frequent Braden Scale assessment yields more accurate results. However, we should still complete a Brade Scale on admission, transfer, receiving, and most importantly, with any change in condition.

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Holly Hovan's picture
comparison

By Holly Hovan MSN, APRN, CWOCN-AP

As wound care clinicians, we are aware that part of the process of consulting requires a comprehensive wound assessment, looking at wound characteristics, causative factors, and drainage. As I've previously mentioned, we've all heard the term, "a dry cell is a dead cell." However, not all wounds are dry.

Cheryl Carver's picture
pressure-injuries

By Cheryl Carver LPN, WCC, CWCA, CWCP, FACCWS, DAPWCA, CLTC

Incorrect staging of pressure injuries can cause many types of repercussions. Incorrect documentation can also be worse than no documentation. Pressure injuries and staging mistakes are avoidable, so educating clinicians how to stage with confidence is the goal.

Holly Hovan's picture
staff education in wound care

By Holly Hovan MSN, APRN, ACNS-BC, CWON-AP

As I am sure we are all well aware, not everyone loves wounds, ostomies, and continence as much as we do. Some nurses just do not have the passion (or desire) to perform wound care and learn about different modalities. On the other hand, some nurses are so eager to learn, obtain certification, and be the unit-based experts! In my experience, taking a hands-on approach to wound care education has been the most successful in terms of teaching wound assessment and dressing changes/techniques.

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Janet Wolfson's picture
delayed wound healing

by Janet Wolfson PT, CLWT, CWS, CLT-LANA

Delayed wound healing: how did it start, what are we doing to prevent delay, and what could we be doing differently when delay is noted?

If you have worked in wound care a long time, there are those wounds we recall that were a real puzzle. Why wouldn't they heal when we were doing everything right? Sometimes it is as simple as finding out that the client has been sleeping in a recliner instead of a bed, in which case edema and sacral wounds will suffer. Or perhaps that the patient has resumed smoking now that their mobility allowed getting outdoors.

Martin Vera's picture
barriers to wound healing

by Martin D. Vera, LVN, CWS

It is critical to understand the phases of wound healing, layers of the skin, and how wounds heal, as well as the different types of tissues present on wounds. We learn to understand the importance of the SWAT team (skin, wound, assessment team) and that this is not a one man or woman job. There is no single "super wound clinician" that can do all this by themselves – without a great team behind them or the support of MDs, DPMs, therapists, the patient, CNAs, family members, environmental team, and basically anyone who comes in contact with the patient.

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Aletha Tippett MD's picture
arterial and vascular disease

by Aletha Tippett MD

This week I saw a patient with terminal peripheral vascular disease (PVD). Seeing him reminded me of how often the severity of this disease is misunderstood. He had had amputation of the toes on his right foot due to gangrene

Samantha Kuplicki's picture
surgical site infection prevention

by Samantha Kuplicki, MSN, APRN-CNS, ACNS-BC, CWS, CWCN, CFCN

Surgical site infections (SSIs) are the most common hospital-acquired infections, accounting for 20% of total documented infections each year and costing approximately $34,000 per episode. SSIs are responsible for increased readmission rates, length of stay, reoperation, patient morbidity and mortality, as well as increased overall health care costs.

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WoundSource Editors's picture
signs of wound infection

by the WoundSource Editors

A break in the skin through injury or surgery allows bacteria to enter the body and begin to multiply. Recognizing the first signs of wound infection enables health care professionals to swiftly intervene with treatment. Here are some of the primary signs of wound infection: