Wound Assessment & Wound Assessment & DocumentationDocumentation

Anita HedzikAnita Hedzik

CDN Ward 5B/C CDN Ward 5B/C

Princess Margaret HospitalPrincess Margaret Hospital

Wound AssessmentWound Assessment

Holistic ApproachHolistic Approach General assessmentGeneral assessment

Determine Type of WoundDetermine Type of Wound AcuteAcute

• TraumaticTraumatic Abrasions, Abrasions,

lacerationslacerations BurnsBurns

• SurgicalSurgical• InfectiveInfective ChronicChronic

• VascularVascular• NeoplasticNeoplastic• MetabolicMetabolic• NeuropathicNeuropathic• Pressure UlcersPressure Ulcers

Acute Traumatic WoundAcute Traumatic Wound

Chronic WoundChronic Wound

Determine Mode of HealingDetermine Mode of Healing

Primary intentionPrimary intention Delayed primary intentionDelayed primary intention Secondary intentionSecondary intention GraftGraft FlapFlap

Determine Mode of HealingDetermine Mode of Healing Primary Intention Primary Intention

(Closure)(Closure)

Determine Mode of HealingDetermine Mode of Healing

Delayed primary Delayed primary intentionintention

Secondary IntentionSecondary Intention

GraftingGrafting

Determine Tissue LossDetermine Tissue Loss

SuperficialSuperficial PartialPartial Deep PartialDeep Partial Full ThicknessFull Thickness

OROR Stages I - IVStages I - IV

SuperficialSuperficial

Partial ThicknessPartial Thickness

Deep Partial ThicknessDeep Partial Thickness

Full ThicknessFull Thickness

Clinical AppearanceClinical Appearance

NecroticNecrotic SloughySloughy GranulatingGranulating EpithelialisingEpithelialising InfectedInfected

Wound LocationWound Location

Wounds in areas of increased Wounds in areas of increased mobility & friction may be slow to mobility & friction may be slow to healheal

Healing promoted in areas with good Healing promoted in areas with good vascularisation vascularisation

Areas at risk of pressure & shearing Areas at risk of pressure & shearing forces will have delayed healingforces will have delayed healing

Wound DimensionsWound Dimensions Allows assessment & evaluation of Allows assessment & evaluation of

healing rate and wound management healing rate and wound management strategiesstrategies

Two dimensional: width & length Two dimensional: width & length (ruler)(ruler)

Three dimensional: measure depth or Three dimensional: measure depth or tracking (use sterile tipped probe)tracking (use sterile tipped probe)

Wound measurement toolWound measurement tool Serial Clinical photographySerial Clinical photography

Wound ExudateWound Exudate

TypeType• serous, haemoserous, serosanguinous, serous, haemoserous, serosanguinous,

purulentpurulent AmountAmount

• major losses can affect fluid & electrolytes, major losses can affect fluid & electrolytes, peri-wound macerationperi-wound maceration

ColourColour• May indicate bacterial load (May indicate bacterial load (PseudamonasPseudamonas))

ConsistencyConsistency OdourOdour

Surrounding SkinSurrounding Skin

Inspect & palpateInspect & palpate Observe for signs of cellulitis, Observe for signs of cellulitis,

oedema, dermatitis, eczema, allergic oedema, dermatitis, eczema, allergic reactions, maceration, foreign bodiesreactions, maceration, foreign bodies

Palpate for warmth, capillary refill, Palpate for warmth, capillary refill, oedemaoedema

Is there evidence of wound healing? Is there evidence of wound healing?

PainPain

Determine cause of painDetermine cause of pain Is pain local or systemic?Is pain local or systemic? Is pain related to wound care Is pain related to wound care

practices?practices? Manage pain appropriatelyManage pain appropriately

Wound InfectionWound Infection

Wounds are classified as: clean, Wounds are classified as: clean, clean contaminated, contaminated, clean contaminated, contaminated, infectedinfected

Microbiological assessmentMicrobiological assessment Assess on an individual basisAssess on an individual basis Ask the patient/parent/staff about Ask the patient/parent/staff about

symptomssymptoms Consider the patient’s general health Consider the patient’s general health

in your assessmentin your assessment

Wound InfectionWound Infection

Psychological ImplicationsPsychological Implications

Self esteem & body imageSelf esteem & body image Alteration in body functionsAlteration in body functions SocializationSocialization Impact on familyImpact on family

Implement Management PlanImplement Management Plan

What is wound care goal?What is wound care goal? What is most important for the What is most important for the

patient?patient? Select appropriate dressing/ Select appropriate dressing/

treatmentstreatments Ensure all treatments/dressings are Ensure all treatments/dressings are

documented accuratelydocumented accurately Evaluate regularlyEvaluate regularly

Documentation - AccountabilityDocumentation - Accountability

ClientClient SelfSelf

Community Community InstitutionInstitution

ProfessionalProfessional

ACCOUNTABILITY

DocumentationDocumentation

ConsistentConsistent

Clear Clear

ConciseConcise

LegibleLegible

AccurateAccurate

Assessment Assessment Wound descriptionWound description

Format:Format:

• Standardised document or chartStandardised document or chart

• Narrative (Descriptive)Narrative (Descriptive)

Wound Assessment ToolWound Assessment Tool

Trial Wound assessment tool Trial Wound assessment tool currently being developed at PMHcurrently being developed at PMH

Narrative (Descriptive) Narrative (Descriptive) DocumentationDocumentation

Wound centrally Wound centrally sloughy with necrotic sloughy with necrotic eschar at medial eschar at medial corner, proximal third corner, proximal third pale with epithelial pale with epithelial buds and distal third buds and distal third granulating ORgranulating OR

20% necrotic, 40% 20% necrotic, 40% slough, 20% slough, 20% granulating & 20% granulating & 20% epithelialisingepithelialising

Documentation in notesDocumentation in notes

Wound 70% pink Wound 70% pink and granulating, and granulating, 30% pale slough.30% pale slough.

OROR Wound pale on left Wound pale on left

arm and left lateral arm and left lateral side of chest, pink side of chest, pink and granulating at and granulating at distal left trunk and distal left trunk and over right side of over right side of chest chest