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"Assess the whole person and not just the hole in the person"
(Dr. Gary Sibbald)
What are the goals for this patient?
What is the patient's prognosis?
What is the patient's quality of life?
Is current pain control adequate?
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:
– aids to establish underlying factors and treatment plan
– Medical history – past/present illnesses
|medications – past/current|
|client knowledge level|
Type of Wound
|pressure – stage?|
|diabetic/neuropathic – remember to examine BOTH feet (visual, neurosensory, vascular/ischemia)|
|type – superficial/deep, acute/chronic|
|size - length x width x depth|
|color of the wound bed – red, yellow, black|
|color of periwound skin – inspect for redness|
|induration – is the surrounding tissue hard/soft|
|odor – slight/fills the room|
|edges – flat, rolled under, loose or tightly rolled|
|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.
|The content and images on the Wound Care Site are intended for Health Professionals and may be disturbing to some.|