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Wound assessment and documentation vitally important

Timely identification, assessment and documentation of a wound is essential in improving patient outcomes.  A wound assessment detailing the characteristics, size, type, and location of a wound play a very important role in wound care.  Determining appropriate interventions, wound treatment goals, and a plan help slow the progression of the wound and improve the odds of healing a wound without complication.

Mary Brennan (2019), a Certified Wound Ostomy and Nurse (CWON) detailed seven key steps in a wound assessment which include:

  1. health history
  2. location and type of wound
  3. dimensions
  4. tissue type
  5. odor
  6. drainage
  7. peri wound skin

Health history is the first step, it is important to determine what kind of comorbidities or risk factors a patient may have, this could include, but is not limited to: diabetes and peripheral vascular disease, poor nutritional status and limited mobility.  The type of medications a patient takes plays a role as well, an example is a patient on a steroid medication, they may experience delayed wound healing.  Lastly, it is important to determine if a patient has had wounds in the past or currently suffers from acute or chronic wounds.

Location, type of wound, dimensions, tissue type, odor, drainage and peri wound skin are all important parts of the wound assessment as these are the key factors in determining a wound treatment plan.  A treatment plan can include things such as what type of wound care products and dressings will be used, the frequency of the dressing changes and if any type of specialists may be needed for implementing advanced wound care.

If a wound assessment is not accurately documented it can lead to a delay in treatment, deterioration of the wound and ultimately a more difficult healing process.  Patients with deteriorating wounds can experience longer stays in hospital, more complications, such as infection and may require invasive treatment such as complex wound care, and surgical intervention.

To read more about the steps in wound assessment and to read a case study please see below.

Reference

Brennan, Mary (2019). Wound assessments: a step-by-step process. Nursing, 49(8), 62-64.

https://journals.lww.com/nursing/Fulltext/2019/08000/Wound_assessment__A_step_by_step_process.16.aspx