982 CHAPTER 38 Wound Care and Irrigations

Wound assessment provides the baseline for planning and evalu-ating the wound care plan. Normal wound healing occurs in an organized fashion, and evaluating the wound status provides an ongoing assessment of wound healing and aids in determining wound treatments. The frequency of the wound assessment de-pends on the patient’s overall condition, the policy of the health care setting, type of dressings used, and the overall patient goals (Nix, 2007). There are a variety of wound assessment tools; use will depend upon the facility’s policy.

Routine wound assessments provides valuable information re-garding the status of the wound. For example, is wound healing progressing as expected, or is it delayed; is there new drainage? Sometimes a wound increases in size. This often occurs in a wound with necrotic tissue. Removal of the necrotic tissue may result in a larger wound. This is not a negative fi nding. Obtain physician’s order, (when needed) for consultations, such as a wound, ostomy and continence nurse or clinical nurse specialist (CNS) to discuss fi ndings. If there is an increase in the amount

PROCEDURAL GUIDELINE 38-1 Performing a Wound AssessmentIntermediate / Wound and Pressure Ulcer Care /

Assessing WoundsWound Care Module / Lesson 1NSO

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983 CHAPTER 38 Wound Care and Irrigations

and consistency of the drainage and if there is new presence of odor, these factors may indicate a wound infection, and a wound culture is often necessary to support appropriate antibiotics.

The following parameters are included in a wound assessment:• Location: Note the anatomical position of the wound on the

body.• Type of wound: If possible, note the etiology of the wound—

surgical, pressure, trauma.• Extent of tissue involvement: Full-thickness wound involves

both the dermis and epidermis. Partial-thickness wound in-volves only the epidermal layer. If it is a pressure ulcer, use the staging system of the National Pressure Ulcer Advisory Panel (NPUAP) (see Chapter 18).

• Type and percentage of tissue in wound base: Describe the type of tissue—granulation, slough, eschar—and the approximate amount.

• Wound size: Determine facility policy on how to measure dimensions, which will include width and length and, in some cases, depth.

• Wound exudate: Describe the amount, color, and consistency.• Presence of odor: Note the presence or absence of odor.• Periwound area: Assess the color, temperature, and integrity of

the skin.

Delegation ConsiderationsThe skill of wound assessment cannot be delegated to nursing assis-tive personnel (NAP). It is the nurse’s responsibility to assess and document wound characteristics. The nurse directs the NAP by:• Instructing the NAP to report drainage from the wound that

is present on sheets or as strike through from the dressing.• Discussing the importance of reporting the presence of odor in

the area of the wound.

Equipment❑ Protective equipment: clean gloves, gown, and goggles if

splash/spray risk exists❑ Agency tool to document assessment: measuring guide❑ Cotton-tipped applicator❑ Dressing supplies❑ Disposable garbage bag

Procedural Steps 1 Determine the facility’s approved assessment tool, and review

the frequency of wound assessment. Examine the last wound assessment to use as comparison for this wound assessment.

2 Assess comfort level or pain on a scale of 0 to 10, and identify symptoms of anxiety.

3 Explain procedure of wound assessment to patient. 4 Close room door or bed curtains, and position patient.

a Position comfortably to permit observation of wound in a well-lighted room.

b Expose wound only. 5 Perform hand hygiene, and form a cuff on waterproof biohaz-

ard bag and place near bed. 6 Apply clean gloves, and remove soiled dressings. 7 Examine dressings for quality of drainage (color, consistency),

presence or absence of odor, and quantity of drainage (note if dressings were saturated, slightly moist, or had no drainage). Discard dressings in waterproof bag. Discard gloves.

8 Perform hand hygiene, and apply glean gloves 9 Use the agency-approved assessment tool, and assess the fol-

lowing features: a The anatomical location of the wound on the body. b Extent of tissue loss: Determine if the wound is full or

partial thickness. A partial-thickness wound heals by reepithelialization, whereas a full-thickness wound heals by the creation of scar tissue and will take longer to heal (Doughty and Sparks-Defriese, 2007).

c The type and the percentage of tissue, noting granulation tissue, slough tissue, and/or eschar.

d Size of wound in centimeters: Measure length, width, and depth (Nix, 2007) (see illustration).(1) Insert a cotton-tipped applicator into the deepest

section of the wound to measure depth. Discard applicator in biohazard bag.

e Presence of exudate from wound (amount, color, and consistency). Indicate amount of exudate by using part of dressing saturated or in terms of quantity (e.g., scant, moderate, copious). Expect amount to decrease as healing takes place. Serous drainage is clear like plasma; sanguin-eous or bright-red drainage indicates fresh bleeding; sero-sanguineous drainage is pink; purulent drainage is thick and yellow, pale green, or white.

f Odor: State whether or not there is odor. A change in wound odor may indicate the presence of a wound infec-tion (Stotts, 2007).

g Periwound skin integrity: Include color, texture, tempera-ture, and a description of any areas that are open, stripped, or have a rash. Periwound assessment gives clues on the effectiveness of the wound treatment, as well as possible wound extension (Nix, 2007).

10 Reassess patient’s pain and level of comfort. 11 Reapply dressings as per order. 12 Discard biohazard bag, soiled supplies, and gloves as per

agency policy; perform hand hygiene. 13 Record wound assessment fi ndings, and compare assessment

with previous wound assessments to monitor wound healing.

Critical Decision Point Once you compare the wound assessment to previous assessment, determine progress toward healing. If there is no movement toward healing, or if you notice deterioration, consider a wound care consultation. Lack of wound healing is often related to infection. Notify physician and wound care nurse or team.

PROCEDURAL GUIDELINE 38-1 Performing a Wound Assessment —cont’d

STEP 9d Measuring wound length and width.

Length

Width

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RESEARCH REFERENCES

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Moscati RM and others. A multicenter comparison of tap water versus sterile saline for wound irrigation, Acad Emerg Med 14:404, 2007.

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