Assessment


"Assess the whole person and not just the hole in the person"

(Dr. Gary Sibbald)

What are the goals for this patient?

  1. healing the wound
  2. protecting the wound from further breakdown/infection
  3. comfort
  4. decrease in pain during dressing change

What is the patient's prognosis?

What is the patient's quality of life?

Is current pain control adequate?

Pathway to Assessment/Treatment of Pressure Ulcers

Appropriate use of dressings includes matching the dressing function to the wound condition

When choosing the most appropriate dressing for a wound, ask yourself...

  1. Is the wound wet or dry? (i.e.: how much drainage, if any)

  2. How deep is the wound?

  3. What does the wound bed look like? (i.e.: red, yellow black)

  4. Is the wound infected?

Documentation of a Patient with a Wound

Assessing the wound is best accomplished using a standardized assessment tool, such as the Bates-Jensen Wound Assessment Tool, which can be downloaded from their website.

The following components should be included in assessing a patient with a wound:

History
– aids to establish underlying factors and treatment plan
– Medical history – past/present illnesses

allergies
family history
social history
medications – past/current
nutritional status
supportive/positioning devices
footwear
smoking
client knowledge level

Type of Wound

pressure – stage?
venous
arterial
diabetic/neuropathic – remember to examine BOTH feet (visual, neurosensory, vascular/ischemia)
deep tissue
skin tear

Wound Description

type – superficial/deep, acute/chronic
location
size - length x width x depth
shape
color of the wound bed – red, yellow, black
color of periwound skin – inspect for redness
exudate
induration – is the surrounding tissue hard/soft
odor – slight/fills the room
epithelialization
edema
edges – flat, rolled under, loose or tightly rolled
necrotic tissue/eschar
undermining
pain/itchiness
granulation
tunneling – length and direction
sensory – pressure, decreased touch
vascular – pulse, temperature
staging (if pressure ulcer)

* It is important to remember to reassess the wound each time you change the dressing.  Documentation needs to be specific: measure and describe the wound.  Dressing selection/treatment should also be clearly documented.

LHSCHealth Professionals


Please Note

The content and images on the Wound Care Site are intended for Health Professionals and may be disturbing to some.
Last Updated July 20, 2009 | © 2007, LHSC, London Ontario Canada