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WOUND ASSESSMENT & DOCUMENTATION

Wound Care Training Module

Wound Care Training Module - National Wound Care Committee

Wound Care Training Module

Wound Care Training Module - National Wound Care Committee

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Content

  1. Wound Assessment
  2. Wound Documentation

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WOUND ASSESSMENT

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  • Age (extremes of age )
  • Diseases or co morbidities (e.g. diabetes mellitus , renal impairment )
  • Medication (steroids , chemotherapy )
  • Obesity
  • Nutrition (refer to chapter on nutrition)
  • Impaired blood supply (refer to chapter on arterial and venous ulcers )
  • Lifestyle (smoking, alcohol)

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General assessment:

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to identify and eliminate any underlying causes or contributing factors which may impede the wound healing process; the causes include: �

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WOUND ASSESSMENT

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  • A review of the wound history (How, What, When, Where, Who)
  • Assessment of the physical wound characteristics; 
  • location, size, base/depth
  • presence of pain
  • condition of the wound bed

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Local assessment is an ongoing process and should include:

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*T.I.M.E. - Principles of Wound Bed Assessment and Preparation:

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Clinical Appearance:

Stage 3 pressure ulcer�

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Advancing epidermal margin (epithelialisation)

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WOUND DOCUMENTATION

Aim of Documentation

  • Record the history
  • Identify etiological factors
  • Identify intrinsic and extrinsic factors that may affect wound healing
  • Obtain a baseline for future comparison
  • Provide a legal and organizational record
  • Use in evaluation and planning of wound management
  • Monitor wound progress
  • Communication tool

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Principles of Documentation

  • Timely, Accurate and Objective
  • Concise and Comprehensive
  • Legible writing, Include signature and printed name
  • Use only organizationally approved abbreviations and colloquialisms
  • Regular, Systematic, Standardized, Easily interpreted And Time efficient
  • Used to inform management decisions

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WOUND CHART

Name:

 

Center:

 

IC/ RN:

 

Site:

 

Age:

 

Type:

 

Gender:

 

MALE/ FEMALE

 

Wound Category:

* Refer wound algorithm

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�DATE

SIZE

T – TISSUE

( % of slough/ necrotic tissue)

I- INFECTION

(presence of infection)

M-MOISTURE (presence of exudates)

DRESSING SOLUTION

DRESSING MATERIAL

REMARKS

LENGTH

WIDTH

DEPTH

<25%

>25%

YES

NO

DRY

WET

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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TAKE HOME MESSAGES

  • Wound assessment includes systemic and local assessment.
  • T.I.M.E principle.
  • Wound documentation is essential.

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REFERENCES

  • TIME concept
  • Dr. Gary Sibbald, et al. Preparing the wound bed for healing- debridement, bacterial balance & moisture balance. Ostomy/ wound management, 2000, 46(1)
  • Falanga V. Wound Repair Regen 2000, 8(5):347-52
  • Compendium of wound care dressings in Malaysia-Harikrishna K.R.Nair

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THANK YOU

Wound Care Training Module - National Wound Care Committee