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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.