Assessment tool for wound

For example, skin tears are often painful because the nerve endings are exposed in the dermal layer, whereas patients with severe diabetic ulcers on their feet may experience little or no pain because of existing neuropathic damage. Skip to content Wounds should be assessed and documented at every dressing change.

Wound assessment should include the following components: Anatomic location Type of wound if known Degree of tissue damage Wound bed Wound size Wound edges and periwound skin Signs of infection Pain [1] These components are further discussed in the following sections.

Anatomic Location and Type of Wound The location of the wound should be documented clearly using correct anatomical terms and numbering. Figure Wound Base Assess the color of the wound base. Type and Amount of Exudate The color, consistency, and amount of exudate drainage should be assessed and documented at every dressing change.

Use the following descriptions to select the appropriate terms: [3] No exudate: The wound base is dry. Scant amount of exudate: The wound is moist but no measurable amount of exudate appears on the dressing. Sanguineous : Sanguineous exudate is fresh bleeding. It can be tan, yellow, green, or brown. It is never considered normal in a wound bed, and new purulent drainage should always be reported to the health care provider. Pain The intensity of pain that a patient is experiencing with a wound should be assessed and documented.

Wound care Nursing, 49 Exudate amounts. Wound undermining. Wound drainage that is fresh bleeding. Wound drainage that is clear, thin, watery plasma. Wound exudate contains serous drainage with small amounts of blood present.

Wound exudate that is thick and opaque and can be tan, yellow, green, or brown in color. The skin around the outer edges of a wound. Based on the above, the question asked was: Do selected WATs meet the needs of nurses in carrying out best practice wound assessment?

Criteria selection for the optimal WAT The criteria against which the WATs were evaluated were developed from the international literature on wound assessment. Criteria for inclusion in the optimal WAT were identified as follows: Details and characteristics of the wound —In order to achieve holistic wound management, it is important for nurses to have access to basic background information on the wound, including details of site, duration, and if known aetiology WAT selection The WATs to be evaluated were selected from tools readily available for nurses to use in their practice.

Search strategy The search terms used were Wound assessment tool. Wound assessment chart. Wound assessment form. Wound assessment scale. Wound scoring. Wound assessment. Table 1 Criteria for inclusion and exclusion of WATs.

Inclusion criteria Exclusion criteria Tools for adults' wounds Tools for children's wounds Generic tools and tools for common wounds including leg ulcers, pressure ulcers, general surgical wounds, traumatic wounds Tools for specialised wounds e. Open in a separate window. Table 2 WATs included in the evaluation.

Wound Assessment Tool Schulz et al. Audit tool development In order to assess the quality of the selected WATs, an audit tool was needed. Figure 1. Figure 2. Discussion The results of the action evaluation provide a measure of how well the included WATs performed against criteria of the optimal WAT.

Conclusions and recommendations We have shown that there are WATs in existence which meet many of the needs of nurses in carrying out wound assessment and that no tool has been identified which meets all the requirements of nurses. References 1. Wound care: a collaborative practice manual for physical therapists and nurses. Gaithersburg, MD: Aspen Publishers, Fletcher J. Wound assessment and the TIME framework.

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From novice to expert: excellence and power in clinical nursing practice. New Jersey: Prentice Hall, Flanagan M. A practical framework for wound assessment 2: methods. Br J Nurs ; 6 :6— An overview of techniques used to measure wound area and volume.

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Assessing nurses' knowledge of wound management. J Wound Care ; 9 — Assessment of wound healing: validity, reliability, and sensitivity of available instruments. Wound Pract Res ; 17 — Kelly M. Qualitative evaluation research. Qualitative research practice. London: Sage, — McKie L. Engagement and evaluation in qualitative inquiry. In: May T, editor. Qualitative research in action. Ovretreit J.

Abingdon: Radcliffe Medical Press, Oldfield A. Assessing the: open surgical wound. Wound Essent ; 5 — Davidson M. Sharpen your wound assessment skills: learn how impeccable assessment and documentation can help your patient heal. Hosp Nurs ; 32 hn1—32hn4. Nazarko L. Wound care part two: carrying out a thorough assessment. Nurs Residential Care ; 7 — Dowsett C. Using the TIME framework in wound bed preparation. Measuring wounds. Nursing ; 37 — Eagle M. Wound assessment: the patient and the wound.

Wound Essent ; 4 — An overview of wound healing and exudates management. Young T. Wound assessment and documentation. Pract Nurs ; 8 — Assessment of wound pain: overview and a new initiative. Patel S. Understanding wound infection and colonisation. Wound Essent ; 2 — Record keeping: guidance for nurses and midwives. London: Nursing and Midwifery Council, Maylor ME. J Clin Nurs ; 12 — Baranoski S, Ayello EA. Typically this scale is used for newborn to age 3.

Whenever feasible, behavioral measurement of pain should be used in conjunction with self-report. When self-report is not possible, interpretation of pain behaviors and decisions regarding treatment of pain require careful consideration of the context in which the pain behaviors are observed. Pain Behavior-Presence: six pain behaviors with graphic illustrations are presented pain words, pain faces, pain noises, bracing, rubbing, restlessness and the rater marks those observed.

Pain Behavior-Intensity: the rater evaluates the intensity of each pain behavior on a 6-point Likert scale from 0 to 5.

Pain Intensity: the rater assesses the highest pain intensity observed in the patient on an point numerical rating scale. Total pain scores range from The Wound-QoL can be used in clinical and observational studies and in daily practice. This tool has good sensitivity and specificity to predict adverse outcomes.

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