The correct assessment of a wound is a crucial component of nursing practice, especially when dealing with chronic or complex wounds. Proper wound assessment provides valuable information that helps determine the most appropriate treatment and predict healing time. Wound assessment should be an ongoing process, as wound characteristics can change over time, influencing the choice of treatment.
Wound Location and Size
Wound location is important as it can affect dressing choice and treatment plan. For example, wounds in pressure areas such as the sacrum may require a pressure relief dressing. Wound size (width, length, and depth) should be measured and documented to assess healing progression. Wound measurement is also helpful in determining the size of dressing needed.
Wound Stage
Wound classification is based on depth and type of exposed tissue. Pressure ulcers, for example, are categorized into four stages, with stage I being redness of intact skin and stage IV involving full-thickness skin loss with exposed muscle, bone, or tendon. Wound grading helps guide treatment and predict healing time.
Wound Exudate
Wound exudate, or drainage, can vary in amount, color, consistency, and odor. The amount of exudate can be described as none, minimal, moderate or large. The color can be clear, yellow, green or brown. The consistency can be thin, thick or purulent. Odor can be described as none, weak, moderate or strong. Assessment of wound exudate may indicate the presence of infection or necrosis.
Wound Tissue Condition
Wound tissue assessment involves identifying the type of tissue present at the base of the wound (eg, granulation tissue, necrotic tissue, or slough) and assessing the condition of the skin surrounding the wound. The presence of granulation tissue (red and lumpy) is a sign of healing. Necrotic (dead) tissue can be yellow, gray, green or black and may need to be removed to promote healing. The skin surrounding the wound should also be evaluated for signs of maceration, erythema, edema, or infection.
Signs of Infection
Signs of wound infection may include increased pain, heat or redness around the wound, purulent drainage, fever, or a foul odor. The presence of any of these signs requires immediate intervention to prevent progression of the infection.
In summary, wound assessment is a detailed, ongoing process that provides valuable information for treatment and prediction of healing time. Accurate and complete documentation of the wound assessment is essential for tracking healing progress and for effective communication among healthcare team members.
