Before assessing a wound, identify your agency's approved wound assessment tool and review the recommended frequency of assessment. Perform hand hygiene and ensure privacy. Introduce yourself to the patient and identify her using two identifiers. Hi my name is Rachel and I'll be your nurse today.
Can you give me your name and your birthday? Betty Arnett. 10, 15, 55. Okay, I'm going to look at your wound today. Review the patient's last wound assessment and use it for comparison as you proceed with this one.
Ask the patient to rate her pain on a scale of 0 to 10. Ms. Arnett, before we get started on your dressing change, what would you rate your pain? 0 being none, 10 being the worst? About a 2. Note whether she appears anxious as you explain the wound assessment procedure to her.
Position the patient comfortably so that the wound is clearly visible. To preserve her modesty, expose only the area of the wound. Fold the top of a waterproof biohazard bag to form a cuff and place the bag within your reach.
Okay, good. Apply clean gloves and remove the soiled dressing. Examine the color and consistency of the drainage on the dressing and note whether it has any odor. Is the dressing saturated, slightly moist, or dry?
After you've inspected it, dispose of the dressing in the biohazard bag. Then remove and discard your gloves and note your findings. Perform hand hygiene and put on a new pair of clean gloves.
Okay, I'm going to get a closer look at your wound. Now inspect the wound. Where is it located? Is it healing by primary or secondary intention?
When healing occurs by primary intention, the edges of the wound are pulled together and approximated with sutures, staples, or strips of adhesive tape. Gradual formation of scar tissue allows the wound to close slowly. Note whether the margins of your patient's wound are approximated or close together. Ideally, there should be no gap between the edges of the wound.
Look for evidence of infection, such as erythema, odor, or wound drainage. A closed incision should have no drainage. Lightly palpate along the incision to feel for a healing ridge. Such a ridge presents as firm tissue beneath the skin, extending one half inch on each side of the wound. It appears five to nine days after surgery.
Pressure ulcers and contaminated surgical or traumatic wounds heal by secondary intention. In this process, granulation tissue forms and the wound edges contract, healing quickly but leaving behind a more obvious scar. To assess such a wound, begin by noting its anatomic location.
Using a centimeter measuring guide, note the wound's length, width, and depth. Measure its length at the longest point of the wound. Measure its width from side to side.
Gauge the depth of the wound by inserting a cotton-tipped applicator into its deepest part. Mark the applicator at the level of the skin. Then discard the applicator and measuring guide in the biohazard bag.
To assess for undermining or tunneling, use a cotton-tipped applicator to gently probe beneath the edges of the wound. Indicate the location of the undermining, if any, using a clock face with the patient's head representing the 12 o'clock position and her feet marking 6 o'clock. Document how many centimeters the undermining extends beneath intact skin.
If the wound is a pressure ulcer, assess the extent of tissue loss by determining the deepest viable tissue layer in the wound bed. Necrotic tissue may prevent you from seeing the base of the wound. Identify the tissue type, noting what percentage is intact. Note also whether granulation tissue, slough, or necrotic tissue is present. Indicate the color, consistency, odor, and amount of exudate.
Express the amount in terms of how much of the dressing is saturated, such as one-third, or simply describe its quantity using terms such as scant, moderate, or copious. Do you smoke? Occasionally.
Smoking does delay the wound healing. Well that gives me good reason to stop then, doesn't it? Yes.
If the wound edges are rounded toward the wound bed, this may indicate delayed healing. Evidence of epithelialization at the wound edges, on the other hand, indicates wound healing. Complete your assessment by inspecting the skin adjacent to the wound. It offers clues to how well the wound is healing. Take note of its color, texture, temperature, and integrity.
When your assessment is complete, apply the dressing as prescribed. Write the time and date on the new dressing and initial it. Check the patient's pain level again. How's your pain score from 0 to 10?
About a 1. About a 1? Good. Clean up your work area and perform hand hygiene. As part of your follow-up care, record your wound assessment findings and compare them with earlier findings to monitor healing.