Wound Assessment

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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:

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Wound Healing

by The WoundSource Editors

There are four stages of wound healing. This systematic process moves in a linear direction. The four stages of wound healing are: hemostasis, inflammation, proliferation, and maturation. It is imperative to remember that wound healing is not linear. It is possible for a patient to move forward or backward through the wound healing phases due to intrinsic and extrinsic forces.

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Nurse with Patient

by WoundSource Editors

Chronic wounds are any types of wounds that have failed to heal in 90 days. Identifying the cause of a chronic wound is most important in the healing process. We as clinicians must help bolster advanced wound care by sharing advances in education in evidence-based treatment, prevention, and wound assessment.1

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Periwound skin

By the WoundSource Editors

The periwound is as important as the wound. As clinicians, we should carefully assess the wound bed, but we need to remember also to assess the periwound and surrounding skin. The periwound should be considered the 4cm of surrounding skin extending from the wound bed. Chronic wounds may manifest any of the following characteristics, depending on wound type: erythema, induration, epibole, ecchymosis, hyperkeratosis, and changes in shape.1,2

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Necrotic Foot

by the Wound Source Editors

Chronic non-healing wounds affect millions of patients each year and contribute significantly to their morbidity and mortality. These wounds have a substantial impact because of their economic burden and the significant effect on the reduction in quality of life, as well as the increased risk of death for those patients affected by them.1 A 2014 study of Medicare data showed that chronic non-healing wounds and associated complications affect nearly 15% or 8.2 million Medicare beneficiaries. The study also estimated the cost to treat these wounds at between $28.1 billion and $31.7 billion annually.2 The highest costs were associated with infected or reopened surgical wounds, and outpatient care had the highest site-of-service costs. In addition to being older, most of these patients have obesity and diabetes. Underlying causes often include diabetic foot ulcers, venous leg ulcers, arterial insufficiency, and pressure ulcers. The list of complications contributing not only to chronicity but also to further deterioration is quite lengthy.

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Clinical Challenges in Diagnosing Infected Wounds

by the WoundSource Editors

Given the impact of infection on delayed wound healing, determining the presence of colonization and infection is imperative to achieving healed outcomes.Chronic wounds are always contaminated, and timely implementation of management and treatment interventions is a key component of the plan of care.

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fistula management

By Holly Hovan MSN, APRN, CWOCN-AP

A fistula is an abnormal opening between two areas that typically shouldn't be connected, or with an epithelialized tract. An example is an opening from the bowel to the abdominal wall, termed enteroatmospheric or enterocutaneous (the terms are sometimes used interchangeably) because this fistula is exposed to the atmosphere, or is open from the abdomen to the skin, and typically needs to be pouched or some type of containment of the effluent.