NUR 113: PROCEDURAL GUIDELINE 38-1

1. NUR 113: PROCEDURAL GUIDELINE 38-1 Performing a wound assessment

2. PERFORMING A WOUND ASSESSMENT - Intro • Wound assessment provides the baseline for planning and evaluating the wound care plan. • Normal wound healing occurs in an organized fashion, and evaluating the wound status provides an ongoing assessment of wound healing and helps to determine wound treatments. • The frequency of wound assessment depends on the patient’s overall condition, policy of the health care setting, type of dressing used, and overall patient’s goals. • Routine wound assessments provides valuable information regarding the status of the wound. • For example, is the wound healing progressing as expected, or is it delayed? Is there new drainage?

3. PERFORMING A WOUND ASSESSMENT – INTRO – CONT’D • Wound size may increase in a wound with necrotic tissue. Removal of the necrotic tissue may result in a larger wound and is an expected finding. • Obtain the health care provider’s order as indicated for consultations such as a wound, ostomy, and continence (WOC) nurse or clinical nurse specialist (CNS) to discuss findings. • If there is an increase in the amount and consistency of the drainage and if there is new presence of odor, these factors may indicate a wound infection; and a wound culture is often necessary to support appropriate antibiotics.

4. PERFORMING A WOUND ASSESSMENT – INTRO – CONT’D • The following parameters are included in a wound assessment: • Location: Note the anatomic position of the wound on the body. • Type of wound: If possible, note the etiology of the wound (i.e., surgical, pressure, trauma). • Extent of tissue involvement: Full-thickness wound involves both of the dermis and the epidermis. • Partial thickness: wound involves only the epidermal layer. • If it is a pressure ulcer, use the staging system of the European Pressure Ulcer Advisory Panel and the National Pressure Ulcer Advisory Panel.

5. Performing a Wound Assessment • Type and percentage of tissue in wound base: Describe the type of tissue (i.e., granulation, slough, eschar) and the approximate amount. • Wound size: Follow agency policy to measure wound dimensions, which includes width, length, and depth. • Wound exudate: Describe the amount, color and consistency. Serous drainage is clear like plasma; sanguineous or bright red drainage indicates fresh bleeding; sero-sanguineous drainage is pink; and purulent drainage is thick and yellow, place green, or white. • Presence of odor: Note the presence or absence of odor, which may indicate infection. • Peri-wound area: Assess the color, temperature, and integrity of the skin. • Pain: Use a validated pain assessment scale to evaluate pain.

6. HERE IS A PICTURE OF PRESSURE ULCERS

7. PROCEDURAL STEPS • 1. Determine agency-approved wound assessment tool and review the frequency of assessment. Examine the last wound assessment to use as comparison for this assessment. • 2. Assess comfort level or pain on a scale of 0 to 10 and identify symptoms of anxiety. • 3. Explain procedure of wound assessment to patient. • 4. Close room door or bed curtains and position patient. • A. Position comfortably to permit observation of wound in well-lighted room. • B. Expose only the wound

8. PROCEDURAL STEPS – CONT’D • 5. Perform hand hygiene and form a cuff on waterproof biohazard bag and place near the bed. • 6. Apply clean gloves and remove soiled dressing. • 7. Examine dressings for quality of drainage (color, consistency), presence or absence of odor, and quantity of drainage (note if dressings were saturated, slightly moist, or had no drainage). Discard dressings in waterproof biohazard bag. Discard gloves. • 8. Perform hand hygiene and apply clean gloves. • 9. Inspect wound and determine type of wound healing (e.g., primary or secondary intention). A partial-thickness wound heals by re-epitheliazation, whereas a full-thickness wound heals by the creation of scar tissue and will take longer to heal.

9. PROCEDURAL STEPS – CONT’D • 10. Use agency-approved assessment tool and assess the following: • A. Wound healing by primary intention (surgical wound): • 1. Assess anatomic location of wound on body. • 2. Note if incisional wound margins are approximated or closed together. The wound edges should be together with no gaps. • 3. Observe for presence of drainage. A closed incision should not have any drainage. • 4. Look for evidence of infection (presence of erythema, odor, or wound drainage). • 5. Lightly palpate along incision to feel a healing ridge. The ridge will appear as an accumulation of new tissue presenting as firmness beneath the skin, extending to about 1 cm (1/2 inch) on each side of the wound between 5 and 9 days after wounding. This is an expected positive sign.

10. PROCEDURAL STEPS – CONT’D • B. Wound healing by secondary intention (e.g., pressure ulcer or contaminated surgical or traumatic wound). • 1. Assess anatomic location of the wound • 2. Assess wound dimensions. Measure size of wound (including length, width, and depth) using a centimeter measuring guide. Measure length by placing a ruler over wound at the point of greatest length (or head to foot). Measure width from side to side. Measure depth by inserting cotton-tipped applicator in area of greatest depth and placing a mark on applicator at the skin level. Discard measuring guide and cotton-tipped applicator in a biohazard bag.

11. PROCEDURAL STEPS – CONT’D • 3. Assess for undermining. Use cotton-tipped applicator to gently probe wound edge. Measure depth and note location using the face of a clock as a guide. The 12 o’clock position (top of wound) would be head of patient, and the 6 o’clock position would be the bottom of the wound toward the patient’s feet. Document the number of centimeters that area extends from the wounds edge (e.g., underneath intact skin). • 4. Assess extent of tissue loss. If wound is a pressure ulcer, determine the deepest viable tissue layer in wound bed. If necrotic tissue does not allow visualization of base of the wound, the stage cannot be determined. • 5. Notice tissue type, including percentage of tissue intact and presence of granulation, slough, and necrotic tissue.

12. PROCEDURAL STEPS – CONT’D • 6. Notice presence of exudate: Amount, color, consistency and odor. Indicate amount of exudate by using part of dressing saturated or in terms of quantity (e.g., scant, moderate or copious). • 7. Note if any wound edges are rounded toward wound bed; this may be an indication of delayed wound healing. Describe presence of epithelialization at wound edges (if present) because this indicates movement toward healing. • 8. Inspect peri-wound skin: Include color, texture, temperature, and description of integrity (e.g., open macerated areas). Peri-wound assessment gives clues about the effectiveness of the wound treatment and possible wound extension.

13. PROCEDURAL STEPS – CONT’D • 11. Reapply dressing per order. Place time, date, and initials on new dressing. • 12. Reassess patient’s pain and level of comfort, including pain at wound site, using a scale of 0 to 10, after dressing is applied. • 13. Discard biohazard bag, soiled supplies, and gloves per agency policy; perform hand hygiene. • 14. Record wound assessment findings and compare assessment with previous wound assessments to monitor wound healing. • Clinical Decision Point: Compare the wound assessment to previous assessment, determine progress toward healing. If there is no movement toward healing or if you notice deterioration, consider a wound care consultation. Lack of wound healing is often related to infection. Notify health care provider and WOC nurse or team.

14. END OF SKILL • This is the end of the skill • Your book has provided a video for you and the link is provided below: • http://booksite.Elsevier.com/Perry-Potter/ClinicalSkills/video45.php • Elsevier: Perry-Potter: Clinical Nursing Skills and Techniques, 8e-PG 38.1: Performing a Wound Assessment • WATCH THE VIDEO!