Wound Assessment and Care Lecture

Introduction

• Identify your agency's approved wound assessment tool.
• Review recommended frequency of wound assessments.
• Perform hand hygiene and ensure patient privacy.
• Introduce yourself and verify patient identity using two identifiers.

Example Introduction

• Nurse: "Hi, my name is Rachel, and I'll be your nurse today. Can you give me your name and birthday?"
• Patient: "Betty Arnett. 10, 15, 55."

Initial Steps

• Review patient's last wound assessment for comparison.
• Ask patient to rate pain on a scale of 0 to 10.
  • Example: Patient rates pain as "About a 2".
• Observe if the patient appears anxious during explanation of procedure.

Preparing for Wound Inspection

• Position patient to comfortably expose only the wound area.
• Fold biohazard bag to form a cuff and place it within reach.
• Apply clean gloves and remove soiled dressing.

Dressing Examination

• Examine the color, consistency, and odor of drainage on the dressing.
• Determine if the dressing is saturated, slightly moist, or dry.
• Dispose of dressing in the biohazard bag and remove gloves.
• Perform hand hygiene and put on new gloves.

Wound Inspection

• Inspect wound location and healing intention (primary vs. secondary).

Primary Intention

• Edges are approximated (sutured, stapled, or taped).
• Check for evidence of infection (erythema, odor, drainage).
• Palpate for a healing ridge (firm tissue beneath the skin).

Secondary Intention

• Occurs in pressure ulcers or contaminated wounds.
• Measure wound dimensions: length, width, and depth using a measuring guide and cotton-tipped applicator.
• Assess for undermining or tunneling using clock face notation.

Specific Assessments

• Identify tissue type and percentage that is intact.
• Note presence of granulation tissue, slough, or necrotic tissue.
• Document color, consistency, odor, and amount of exudate.
• Discuss lifestyle factors (e.g., smoking) affecting healing.

Observations

• Rounded wound edges may indicate delayed healing.
• Epithelialization at edges indicates healing.
• Inspect adjacent skin for clues about healing (color, texture, temperature, integrity).

Final Steps

• Apply dressing as prescribed, noting time, date, and initials.
• Reassess patient's pain level.
  • Example: Patient rates pain as "About a 1" after dressing.
• Clean work area and perform hand hygiene.
• Record findings and compare with earlier assessments for monitoring progress.