Wound Assessment and Documentation

Holly Hovan's picture
woundwound assessment - skin tear on arm assessment - skin tear on arm

By Holly M. Hovan MSN, APRN-ACNS-BC, CWOCN-AP

After determining our goals of wound treatment (healing, maintaining, or comfort/palliative), we need to choose a treatment that meets the needs of the wound and the patient.

Wound Assessment: Using Your Senses

When assessing a wound, we typically use three of the five senses:

Martin Vera's picture
sickle cell anemia testing - atypical wound etiology assessment

By Martin D. Vera LVN, CWS

As devoted clinicians to the field of wound management we take a responsibility to educate ourselves and others about wound etiologies and characteristics, as well as management of barriers to achieve positive outcomes. We spend a great deal of our careers learning about the most common offenders, such as pressure injuries, diabetic foot ulcers, venous stasis ulcers, arterial wounds, amputations, and traumatic wounds, to name a few. However, as our careers unfold we are faced with extra challenges, and atypical wounds are among them.

Holly Hovan's picture
patient repositioning

By Holly Hovan MSN, APRN, CWOCN-AP

Friction and shear… what’s the difference and how do they cause pressure injuries? Are wounds caused by friction and shear classified as pressure injuries? What’s the easiest way to explain the differences between these critical components of the Braden Scale for Predicting Pressure Sore Risk® that are not always understood? How do I know if my patient is at risk?

Temple University School of Podiatric Medicine's picture
Wound Care Journal Club Review

Temple University School of Podiatric Medicine Journal Review Club
Editor's note: This post is part of the Temple University School of Podiatric Medicine (TUSPM) journal review club blog series. In each blog post, a TUSPM student will review a journal article relevant to wound management and related topics and provide their evaluation of the clinical research therein.

WoundSource Editors's picture
tunneling wound assessment

By the WoundSource Editors

Perhaps the most difficult type of wound for health care professionals to treat is a tunneling wound. Tunneling wounds are named for the channels which extend from the wound, into or through subcutaneous tissue or muscle. These tunnels sometimes take twists or turns that can make wound care complicated. Tunneling is often the result of infection, previous abscess formation, sedentary lifestyle, previous surgery at the site, trauma to the wound or surrounding tissue, or the impact of pressure and shear forces upon many tissue layers causing a “sinkhole-like” defect on the skin. Tunneling wounds need careful wound assessment and management.

WoundSource Practice Accelerator's picture
pressure injury risk assessment

By the WoundSource Editors

Pressure ulcers/injuries pose a major risk to patients by increasing morbidity and mortality and causing significant discomfort.1 They are also prevalent, particularly in long-term care facilities, where patient populations may be at higher risk of developing pressure injuries as a result of factors of age, immobility, and comorbidities.2 To reduce the incidence of pressure injuries effectively, nurses and other health care professionals should be aware of the risk factors and the means to evaluate patients. This will allow caregivers to take steps to prevent problems before they develop and treat them more effectively if they do.

Holly Hovan's picture
Moisture on Skin

By Holly Hovan MSN, APRN, CWOCN-AP

When nurses hear the term moisture, they usually almost always think of urinary or fecal incontinence, or both. There are actually several other reasons why a patient could be moist. Continued moisture breaks down the skin, especially when the pH of the aggravating agent is lower (urine, stomach contents—think fistula, stool). When there is too much moisture in contact with our skin for too long, we become vulnerable to this moisture, and our skin breaks down. Increased moisture places a patient at risk for a pressure injury as the skin is already in a fragile state.

WoundSource Editors's picture
Surgical wound drainage

By the WoundSource Editors

In normal wound healing, exudate plays an important role in allowing the migration of cells across the wound bed, facilitating the distribution of growth and immune factors vital to healing. Managing wound drainage involves making sure that exudate production is not too much or too little, and making sure the exudate does not have pus which would indicate an infection. Proper wound drainage management improves the patient's quality of life, promotes healing, and enhances health care effectiveness.

WoundSource Editors's picture
wound healing

By the WoundSource Editors

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. The wound healing process can be seen as an overlapping healing continuum, which can be divided into four primary phases:

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.