Wounds are common presentations in a healthcare setting. As nurses, your response and management directly impact the patient’s recovery time and life, in general. Mismanagement of such could lead to the worsening of the patient’s condition and may even lead to mortality.
Since each wound is unique, it also requires different assessment and care relative to its characteristics. This post will help you assess wounds properly!
A thorough examination of a patient’s entire body precedes a wound assessment. Every seven days, all wounds must be examined, measured, and effectively documented. More details are always preferable when it comes to documenting a wound assessment. The following are some of the most important components to include in your documentation:
-Location: To clearly identify the wound’s location, use the relevant anatomical terms.
-Type of wound: Surgical wounds, burns, and pressure injuries are all examples of wounds that can be analyzed and documented. Acute and chronic wounds are both possible.
-Measurement: The wound’s size should be measured in centimeters and recorded as length times width times depth on the wound care treatment chart. Any digging or undermining must also be documented by nurses, including the location and depth.
-Wound bed: It’s critical to keep track of tissue type (slough, eschar, epithelium, granulation, and so on), color, and adhesion level in percentages.
-Wound Edges: Determine whether the edges of a wound are defined or undefined, attached or detached, rolled under, macerated, fibrotic, or calloused.
-Drainage: In a wound care assessment, the amount and type of drainage must be noted.
-Odor: Wounds can have a variety of odors such as strong, foul, pungent, fecal, musty, or sweet.
-Pain: Pain: A detailed wound assessment notes the location and degree of a patient’s pain, as well as any patterns or variations in pain type.
-Infection: Infections are common in wounds, causing the healing process to be greatly slowed.
-Response to Care/Treatment Plan: It’s critical to keep track of whether the wound has improved and any signs of healing.