"Assess the whole person and not just the hole in the person"
(Dr. Gary Sibbald)
What are the goals for this patient?
- healing the wound
- protecting the wound from further breakdown/infection
- 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
- Is the wound wet or dry? (i.e.: how much drainage, if any)
- How deep is the wound?
- What does the wound bed look like? (i.e.: red, yellow black)
- 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:
– 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.