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Wound Assessment & Wound Assessment & DocumentationDocumentation
Anita HedzikAnita Hedzik
CDN Ward 5B/C CDN Ward 5B/C
Princess Margaret HospitalPrincess Margaret Hospital
Wound AssessmentWound Assessment
Holistic ApproachHolistic Approach General assessmentGeneral assessment
Determine Type of WoundDetermine Type of Wound AcuteAcute
• TraumaticTraumatic Abrasions, Abrasions,
lacerationslacerations BurnsBurns
• SurgicalSurgical• InfectiveInfective ChronicChronic
• VascularVascular• NeoplasticNeoplastic• MetabolicMetabolic• NeuropathicNeuropathic• Pressure UlcersPressure Ulcers
Acute Traumatic WoundAcute Traumatic Wound
Chronic WoundChronic Wound
Determine Mode of HealingDetermine Mode of Healing
Primary intentionPrimary intention Delayed primary intentionDelayed primary intention Secondary intentionSecondary intention GraftGraft FlapFlap
Determine Mode of HealingDetermine Mode of Healing Primary Intention Primary Intention
(Closure)(Closure)
Determine Mode of HealingDetermine Mode of Healing
Delayed primary Delayed primary intentionintention
Secondary IntentionSecondary Intention
GraftingGrafting
Determine Tissue LossDetermine Tissue Loss
SuperficialSuperficial PartialPartial Deep PartialDeep Partial Full ThicknessFull Thickness
OROR Stages I - IVStages I - IV
SuperficialSuperficial
Partial ThicknessPartial Thickness
Deep Partial ThicknessDeep Partial Thickness
Full ThicknessFull Thickness
Clinical AppearanceClinical Appearance
NecroticNecrotic SloughySloughy GranulatingGranulating EpithelialisingEpithelialising InfectedInfected
Wound LocationWound Location
Wounds in areas of increased Wounds in areas of increased mobility & friction may be slow to mobility & friction may be slow to healheal
Healing promoted in areas with good Healing promoted in areas with good vascularisation vascularisation
Areas at risk of pressure & shearing Areas at risk of pressure & shearing forces will have delayed healingforces will have delayed healing
Wound DimensionsWound Dimensions Allows assessment & evaluation of Allows assessment & evaluation of
healing rate and wound management healing rate and wound management strategiesstrategies
Two dimensional: width & length Two dimensional: width & length (ruler)(ruler)
Three dimensional: measure depth or Three dimensional: measure depth or tracking (use sterile tipped probe)tracking (use sterile tipped probe)
Wound measurement toolWound measurement tool Serial Clinical photographySerial Clinical photography
Wound ExudateWound Exudate
TypeType• serous, haemoserous, serosanguinous, serous, haemoserous, serosanguinous,
purulentpurulent AmountAmount
• major losses can affect fluid & electrolytes, major losses can affect fluid & electrolytes, peri-wound macerationperi-wound maceration
ColourColour• May indicate bacterial load (May indicate bacterial load (PseudamonasPseudamonas))
ConsistencyConsistency OdourOdour
Surrounding SkinSurrounding Skin
Inspect & palpateInspect & palpate Observe for signs of cellulitis, Observe for signs of cellulitis,
oedema, dermatitis, eczema, allergic oedema, dermatitis, eczema, allergic reactions, maceration, foreign bodiesreactions, maceration, foreign bodies
Palpate for warmth, capillary refill, Palpate for warmth, capillary refill, oedemaoedema
Is there evidence of wound healing? Is there evidence of wound healing?
PainPain
Determine cause of painDetermine cause of pain Is pain local or systemic?Is pain local or systemic? Is pain related to wound care Is pain related to wound care
practices?practices? Manage pain appropriatelyManage pain appropriately
Wound InfectionWound Infection
Wounds are classified as: clean, Wounds are classified as: clean, clean contaminated, contaminated, clean contaminated, contaminated, infectedinfected
Microbiological assessmentMicrobiological assessment Assess on an individual basisAssess on an individual basis Ask the patient/parent/staff about Ask the patient/parent/staff about
symptomssymptoms Consider the patient’s general health Consider the patient’s general health
in your assessmentin your assessment
Wound InfectionWound Infection
Psychological ImplicationsPsychological Implications
Self esteem & body imageSelf esteem & body image Alteration in body functionsAlteration in body functions SocializationSocialization Impact on familyImpact on family
Implement Management PlanImplement Management Plan
What is wound care goal?What is wound care goal? What is most important for the What is most important for the
patient?patient? Select appropriate dressing/ Select appropriate dressing/
treatmentstreatments Ensure all treatments/dressings are Ensure all treatments/dressings are
documented accuratelydocumented accurately Evaluate regularlyEvaluate regularly
Documentation - AccountabilityDocumentation - Accountability
ClientClient SelfSelf
Community Community InstitutionInstitution
ProfessionalProfessional
ACCOUNTABILITY
DocumentationDocumentation
ConsistentConsistent
Clear Clear
ConciseConcise
LegibleLegible
AccurateAccurate
Assessment Assessment Wound descriptionWound description
Format:Format:
• Standardised document or chartStandardised document or chart
• Narrative (Descriptive)Narrative (Descriptive)
Wound Assessment ToolWound Assessment Tool
Trial Wound assessment tool Trial Wound assessment tool currently being developed at PMHcurrently being developed at PMH
Narrative (Descriptive) Narrative (Descriptive) DocumentationDocumentation
Wound centrally Wound centrally sloughy with necrotic sloughy with necrotic eschar at medial eschar at medial corner, proximal third corner, proximal third pale with epithelial pale with epithelial buds and distal third buds and distal third granulating ORgranulating OR
20% necrotic, 40% 20% necrotic, 40% slough, 20% slough, 20% granulating & 20% granulating & 20% epithelialisingepithelialising
Documentation in notesDocumentation in notes
Wound 70% pink Wound 70% pink and granulating, and granulating, 30% pale slough.30% pale slough.
OROR Wound pale on left Wound pale on left
arm and left lateral arm and left lateral side of chest, pink side of chest, pink and granulating at and granulating at distal left trunk and distal left trunk and over right side of over right side of chest chest
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