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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?
- healing the wound
- protecting the wound from further breakdown/infection
- comfort
- 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...
- 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:
History
– aids to establish underlying factors and treatment plan
– Medical history – past/present illnesses
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allergies |
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family history |
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social history |
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medications – past/current |
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nutritional status |
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supportive/positioning devices |
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footwear |
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smoking |
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client knowledge level |
Type of Wound
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pressure – stage? |
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venous |
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arterial |
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diabetic/neuropathic – remember to examine BOTH feet (visual, neurosensory, vascular/ischemia) |
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deep tissue |
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skin tear |
Wound Description
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type – superficial/deep, acute/chronic |
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location |
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size - length x width x depth |
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shape |
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color of the wound bed – red, yellow, black |
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color of periwound skin – inspect for redness |
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exudate |
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induration – is the surrounding tissue hard/soft |
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odor – slight/fills the room |
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epithelialization |
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edema |
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edges – flat, rolled under, loose or tightly rolled |
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necrotic tissue/eschar |
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undermining |
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pain/itchiness |
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granulation |
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tunneling – length and direction |
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sensory – pressure, decreased touch |
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vascular – pulse, temperature |
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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.
