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WOUND ASSESSMENT. Chapter 31. Lesley Wayne. Introduction. This presentation explores the history, ‘red flags’ and examinations pertaining to wound assessment. It builds on the material found in the printed text. Part 1 – A Wound Assessment Tool Part 2 – Taking a History
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WOUND ASSESSMENT Chapter 31 Lesley Wayne
Introduction • This presentation explores the history, ‘red flags’ and examinations pertaining to wound assessment. It builds on the material found in the printed text. • Part 1 – A Wound Assessment Tool • Part 2 – Taking a History • Part 3 – Examination Techniques • Part 4 – Key Points and Examples
Wound Assessment Tool On the following screen you will find a sample wound assessment tool.
Wound Assessment History • Which is the patient’s dominant hand? • This may affect your management (e.g. raised index for referral to a hand surgeon). • What is the patient’s tetanus status? • You may need to boost a patient’s immune status. • Does the patient have any known allergies? • Allergic responses to medications or dressings may affect your management. • Is there any relevant past medical history? • Underlying medical conditions may impede wound healing (e.g. diabetes, cancer, peripheral vascular disease).
Is the patient taking any medications (including ‘over the counter medicines’ and recreational drugs)? • Some medications will affect wound healing (e.g. steroids, Chemotherapy). Patients injecting non prescribed drugs may be at higher risk of infections, such as HIV, hepatitis C. • What is the patient’s social history (e.g. occupation, leisure activities, smoking , alcohol consumption)? • Occupation and leisure activities may affect management, and smoking and alcohol consumption may affect wound healing.
SPECIFIC QUESTIONS RELATED TO THE INJURY • How did the injury happen? (e.g. using machine tool? knife?) What happened (i.e. exact mechanism?) • Answers to these questions will indicate any possible damage to underlying structures. • Where did the injury happen? • You need to assess whether the environment was clean or dirty. • Why did the injury happen? • Was this a pure accident or was the patient unwell prior to injuring themselves? • When did the injury happen? • The time the injury occurred may affect your management of the wounds (e.g. wounds that have not been cleaned for over 6hrs are considered tetanus prone)
Examination Technique • Control bleeding and remember pain relief • LOOK • For bruising, swelling, erythema, apparent deformity. • Identify the type of wound (e.g. cut, puncture wound, and amputation injury). • Measure the wound accurately to include the length, depth and breadth. • Note direction and shape of wound (e.g. transverse, oblique, longitudinal, stellate (star like), etc.). • Note any skin loss and the viability of the surrounding tissue. • Note whether the wound is clean or dirty. Check for foreign bodies. • Contaminants will impair healing and require removal. • Visualise the base of wound in order to exclude involvement of underlying structures (e.g. tendons, nerves, joints and fractures).
FEEL • Probe wound with gloved finger and/or probe if indicated, to determine the extent of wound. • Palpate for bony tenderness where indicated. • Assess neurovascular function distal to wound. Sensory deficit may indicate nerve damage and require further assessment. Any circulatory deficit will need attention in order to preserve and restore healthy tissue. • Remember to assess circulation distal to wound when examining injuries to limbs. • MOVE (LIMBS) • Assess motor function. • Assess tendon function, where applicable. Delay in identifying tendon injury may result in permanent loss of function.
Key Points • Remember to: • Look to see whether there is any bone exposed. • Palpate for bony tenderness. • Assess tendon function and look to see whether tendons are exposed. • For wounds over joints, check whether joint capsule has been breached and x-ray to check for air in joint. • Check movement of limb. • Assess neurovascular status.
Examples • AMPUTATION: FINGER TIPS • Substantial loss to the pulp may require referral to a specialist medical practitioner for review
WOUND TO PROXIMAL LOWER LEG • Initial inspection of this wound appears to show a deep but innocuous injury. • Closer inspection however reveals a more serious injury. The wound is a deep subcutaneous wound which involves the patella tendon.
WOUND TO DISTAL LOWER LEG • There is an obvious underlying fracture to this wound, which may impede the neurovascular function. This injury needs immediate and continued assessment of the sensation and circulation distal to the wound. • Urgent referral to a medical practitioner is required.
