Wound care assessment, defined as the documentation of information obtained via observation, questioning, physical examination, and clinical investigations, is a fundamental aspect of wound management. Without wound assessment, it is not possible to gauge healing progress and therefore to determine whether or not a current intervention is effective and should be pursued or modified.
Initial Wound Assessment: Be Thorough
- The first step of better wound care assessment is to always assess a wound thoroughly on initial presentation to provide a baseline against which healing progress can be measured. The wound assessment should include details of the patient history and a full systems review to identify risk factors and underlying disease processes, and determine patient and caregiver educational needs. Wound characteristics that should be documented include wound location and size, and any sign of tunneling or undermining, as well as an assessment of the wound bed, wound edges, wound drainage, periwound and associated skin characteristics, appendages, edema, and temperature.
Assess the Wound Regularly
- The second step of better wound care assessment is to assess the wound on a regular basis in order to determine the effectiveness of current treatment. According to Medicare requirements, measurement of wound healing should be performed at least monthly, although best practice dictates that assessment of wound status should be performed weekly or even more frequently.
Careful & Consistent Tool Selection
- A third and important consideration is the selection of an appropriate tool to perform and document wound assessment. A number of tools for evaluating wounds are in general use, each of which has its own merits and drawbacks. The tool that is used in practice is likely to be determined by the protocol at an individual healthcare facility. In fact, the precise tool that is used probably matters less than the fact that it is used consistently. Assessing the same wound using a different tool at different time-points will lead to confusion and lack of a clear direction.
- Finally, the fourth step of better wound care assessment is to document the findings accurately and fully. An individual wound may be seen by a number of healthcare professionals over the course of weeks and months, and each needs to be able to understand readily the history of the wound and the effect of previous interventions.
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