All Wounds Are Not The Same! Wound assessment (Subjective) Remember to ask the client: f’a Locationf’a Timing – Cause/When first appeared’a Size f’a Better/Worse – What treatments have worked / what hasn! |t. f’a Changes from initial wound’a Associated Symptoms! V itching, pain, redness. A full ROS will also highlight any other problems that need to be addressed in order to maximis e wound healing. Wound Assessment (Objective) Crisp and Taylor (2005) use the following headings when attempting to objectively describe a wound: Skin Integrity: f’a Openf’a Closedf’a Acutef’a Chronic Cause: f’a Intentionalf’a Unintentional Severity: f’a Superficialf’a Penetratingf’a Perforating Cleanliness: f’a Cleanf’a Clean-Contaminatedf’a Contaminatedf’a Infectedf’a Colonisedf’a Another way to classify wounds is by the colour, which identifies the healing phase.
A wound may be a mixture of colours: f’a Black – necrotic / dead tissue’a Yellow! V fibrous exudate f’a Red! V granulation tissue’a Pink -epithelialisationODHB (Otago District Health Board) use this classification system to assess wounds, and have adopted a wound assessment tool as part of their co-ordinated care pathways. (see attached form as an example) When cleaning the wound, the 2 most common methods involve: a) irrigation with warmed 0. 9% Normal Saline b) using a gauze soaked with 0. 9 % normal saline to wipe the wound. (Remember 1 gauze = 1 wipe! ) What method (a or b) would you use to cleanse wounds #1 to #5? References Crisp, J & Taylor, C. (2005).
Potter & Perry! |s Fundamentals of Nursing. (2 nd ed) Elsevier: Australia. Wound care made incredibly easy (2003). LWW. PhilidelphiaODHB co-ordinated care pathway assessment tool (2003), MIDAS doc 23648.