Accurate wound assessment is a critical component of effective wound management. A skilled nurse who can accurately assess a wound, plays a vital role in determining the appropriate management of a wound to promote healing and avoid secondary complications.
The use of wound assessment tools, such as flowcharts and measuring tools are helpful in performing accurate and comprehensive assessments. Flowcharts allow for the comparison of a wound status from one dressing change to the next. This streamlines and standardizes the evaluation process, allowing for accurate recognition and intervention for wounds that have reached a plateau or deteriorated.
Factors to include in a comprehensive assessment differ for wounds that are healing by primary intention (cleanly incised surgical incisions) and wounds that are healing by secondary intention, which include open wounds like pressure ulcers.
For wounds healing by primary intention, key assessment factors include the approximation of wound margins (the edges of the wound fit together snugly), drainage (a closed incision should not have any drainage), evidence of infection and the presence of a palpable healing ridge along the incision by the fifth postoperative day. This confirms that granulation tissue is forming, which is necessary for wound healing.
For open wounds healing by secondary intention, key assessment factors include the location, dimension and depth of tunneling, the appearance of the wound base and the status of surrounding tissue. The approximation of the wound edges are an important factor to evaluate as well.
Begin the assessment by documenting the anatomic location of the wound, using landmarks to define the position. Once the location is defined, both the size and depth of the wound must be assessed. The size of a wound can be calculated by multiplying the point of the greatest length by the point of greatest width by the point of greatest depth (in centimeters). When using this technique, greatest depth is measured by placing a cotton-tipped applicator into the wound at the deepest point, marking the applicator at the skin level, then comparing the applicator to a ruler. To assess for tunneled areas, use a moistened cotton-tipped applicator to probe the wound periphery, and document the location and depth of these tunneled areas. The position of the tunneled area is described according to a clock face location, in which the patient's head represents noon. This documentation is important as this data provides the basis for selection of topical therapy and determination of healing progress.
Continue the wound assessment by describing the condition, color and temperature. Use correct terminology to describe your findings, such as ecchymosed (bruised), erythematous (red), indurated (firm), edematous (swollen).
Wound edges must also be carefully defined. Wound edges can be described as diffuse, well defined or rolled. The pattern or distribution refers to the location of the lesions within a certain area. Arrangement refers to the position of nearby lesions. The arrangement of lesions can assist in confirming a diagnosis.
Next, describe the types of tissue found in the wound. Normal granulation tissue has a beefy, red, shiny and textured appearance that bleeds easily. Necrotic tissue is usually gray and soft and is called slough. Black-gray, hard leathery tissue is referred to as eschar.
Note the amount, color and consistency of wound drainage (exudate).
Drainage can be serous (clear), serosanguinous (blood-tinged) or sanguinous (bloody). Drainage from heavily colonized wound may have a tan or milky appearance.
Odor in wounds is a significant diagnostic tool. Blue-green drainage combined with a musty odor usually indicates presence of Pseudomonas in the wound.
Accurate wound assessment is a critical component of effective wound management, and requires solid observational skills, knowledge and judgment. Without correct assessment of the wound and skin, proper diagnosis and treatment cannot occur.