Wound Assessment

Cheryl Carver's picture
Fairground

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

My approach to wound care education with patients, providers, and nursing staff the last 20+ years has always been to make learning fun while emphasizing that wounds are a serious topic. My strong passion drives me to motivate anyone and everyone who wants to learn. If they don’t want to learn, then I’ll figure out the best way to motivate them! Everyone learns differently; however, hands-on training with added fun usually wins. Education should be ongoing and engaging, and it should create fun ways to experience more of those “aha” moments. We want to impact that long-term memory storage! Every care setting has variances, but my blog will provide you with some ideas that you can alter to fit your needs.

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Shivani Gupta's picture

By Girisha Maheshwari, Pavan Mujawdiya, and Shivani Gupta

Chronic wounds and their management pose a serious challenge to clinicians worldwide and are one of the major public health challenges faced by developing countries. Worldwide, over 40 million people develop chronic wounds, which adversely affects their quality of life. However, epidemiological studies concerning chronic wounds and their management are limited, especially in developing countries. According to the largest community-based epidemiological study on wounds in India by Gupta et al., the estimated prevalence of chronic and acute wounds is 4.48/1000 and 10.5/1000 in India. This study is more than a decade old, and there is no recent data available in the public domain. The lack of organized wound data makes it difficult to formulate new therapeutic strategies, create effective health care policies, or offer efficacious treatment options. Complex wounds take time to heal, and if they are not identified at the earliest stage, the treatment process may be complicated.

WoundSource Editors's picture
post-operative wound drainage

As health care professionals monitor the wound drainage of a patient, it is critical to be able to recognize the different types of wound drainage. Open wounds and incision wounds may both present varying types of exudate, some of which are perfectly healthy and others that can signal an infection or slow healing. Identifying wounds that need a change in care can speed the healing process. Here are the four main types of wound drainage health care professionals need to know:

Holly Hovan's picture

When assessing and documenting a wound, it is important to note the amount and type of wound exudate (drainage). Using our senses is a large part of the initial wound assessment, followed by accurate documentation. Wound exudate or drainage gives us significant information about what is going on with the wound, all the way down to a cellular level, and it is one of the wound components that guide our topical treatments. As mentioned in prior blogs, a dry cell is a dead cell, but a wound with too much moisture will also have delayed healing. Additionally, infection, poor nutrition, impaired mobility, impaired sensory perception, and even malignancy in the wound can impair the healing process.
In acute wounds, drainage typically decreases over several days while the wound heals, whereas in chronic wounds, a large amount of drainage is suggestive of prolonged inflammation with failure to move into the proliferative phase of wound healing. An increase in drainage with malodor can be an indication of infection and should be treated appropriately based on the overall picture and goals of wound care.
There are many different types, consistencies, colors, and characteristics of wound drainage. In this blog, we discuss the most common types and what they could mean.

Holly Hovan's picture
Wound Drainage

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

Wound assessment is one of the initial steps in determining the plan of care, changes in treatment, and the choice of key players in wound management. However, wound assessment needs to be accurately understood and documented by frontline staff to paint a true picture of what is happening with the wound.

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

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

As wound care professionals, the Braden Scale for Predicting Pressure Sore Risk® is near and dear to our hearts. With that in mind, our evidence-based tool needs to be used correctly 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 Braden Scale use may contribute to a multitude of different scores. The resident behaves differently on different shifts, for example, being asleep on the night shift but up and about on days. What is the correct way to score these patients? I believe that a less frequent Braden Scale assessment yields more accurate results. However, we should still complete a Braden Scale on admission, during transfer, when receiving, and most importantly, with any change in condition.

Diane Krasner's picture
wound care documentation

By Diane L. Krasner, PhD, RN, FAAN

Scope of Practice and Standards of Practice guide nurses and other members of the interprofessional wound care team in caring for patients with wounds. Documentation in the medical record is a key aspect of the standard of practice and serves to record the care delivered to the patient or resident. Your documentation should follow your facility guideline for documentation. Accurate documentation helps to improve patient safety, outcomes, and quality of care.

This WoundSource Trending Topic blog considers general wound documentation dos and don'ts and presents 10 tips for success. Good, better, and best documentation examples are included for each tip.

Susan Cleveland's picture

By Susan Cleveland, BSN, RN, WCC, CDP

The subject of my previous blog on skin assessment was interview; here in part 2, we will look at the elements of observation. Interviewing clients and significant others can provide the clinician with valuable information related to the client’s knowledge of their situation and a historic review of skin issues or potential events. However, observation is also necessary in a comprehensive skin assessment.

Holly Hovan's picture

Holly Hovan MSN, APRN, RN-BC, CWOCN-AP

Identifying wound etiology before initiating topical treatment is important. Additionally, correctly documenting wound etiology is significant in health care settings for many reasons. Accurate documentation and appropriate topical treatment are two critical components of a strong wound treatment plan and program. Bedside staff members should be comfortable with describing wounds, tissue types, and differentiating wound etiologies. Training should be provided by the certified wound care clinician, along with follow-up (chart reviews and documentation checks, one-on-one education as needed, and routine competency or education days). Additionally, the wound care clinician should be able to develop an appropriate treatment plan based on wound etiology, by involving additional disciplines as needed to best treat the whole patient.

WoundSource Practice Accelerator's picture

Aseptic: Aseptic surgical procedures are those that aim at eliminating the risk of transmission of all harmful microorganisms. Aseptic practices can prevent the cross-contamination of pathogens.

Bioburden: The number of microorganisms within a wound is referred to as bioburden. Bioburden management is crucial in post-operative care to prevent infection.

Cellular/tissue-based products: These are products, commonly derived from cadavers or other human and other animal cells, that can aid in closing dehisced surgical wounds by providing a substitute for the skin to act as a barrier while healing.

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