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05.02 Wound Care – Assessment

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Overview

  1. Purpose
    1. Assessing wound characteristics is the only way to know if healing is occurring

Nursing Points

General

  1. Supplies
    1. Clean gloves
    2. Measuring tape
    3. Cotton-tipped applicators x 2-3

Assessment

  1. Wound bed color
    1. Black – represents full-thickness tissue death
    2. Yellow – represents death of muscle tissue and subcutaneous fat
      1. May be slough
    3. Red  – a red wound bed typically means good vasculature and the wound is healing
      1. Exception – 1st degree burns
    4. Green – gangrenous / infected
  2. Wound edges
    1. Approximated – wound edges touching
      1. May be approximated with staples, suture, or glue
    2. Unapproximated – wound edges aren’t touching
    3. Rolled – the epidermis has rolled under towards the wound bed
  3. Wound bed characteristics
    1. Eschar – black or yellow – may be tough or leathery – reflects necrosis or dead tissue
    2. Granulation  – pink or red and bumpy – means tissue is growing
    3. Moist/dry – depends on drainage, moist is best in open wounds as long as no infection is present.
    4. Tunnelling – there are holes in the wound bed that extend deeper than the main wound
    5. Undermining – the wound bed extends beyond/underneath the wound edges (it is wider than the opening suggests)
  4. Wound drainage
    1. Serous clear yellow
    2. Serosanguineous – yellow/pink-ish
    3. Sanguineous – bloody
    4. Purulent – white/yellow pus

Nursing Concepts

  1. Steps and Nursing Considerations
    1. Review wound care orders
    2. Explain procedure to patient
    3. Perform hand hygiene
    4. Don clean gloves
    5. Raise bed to comfortable working height.
    6. Remove existing dressing and discard in appropriate waste container
    7. Inspect wound:
      1. Wound bed color
      2. Wound edges
      3. Wound bed characteristics
      4. Wound drainage
    8. Measure wound:
      1. Using tape measurer – measure the following:
        1. Length – patient’s head to toe
        2. Width – patient’s side to side
      2. Using a sterile cotton-tipped applicator, determine the depth at the deepest portion
        1. Mark with your finger, then measure with tape
      3. Using a new sterile cotton-tipped applicator for each location – measure depth of any tunnelling or undermining
    9. Discard used supplies
    10. Remove gloves, perform hand hygiene
    11. At this point, you can move on to wound care if applicable – see Wound Care – Dressing Change lesson
    12. Document your findings.

Patient Education

  1. Let the patient know whether their wound seems like it’s healing – compare to previous assessment

Reference Links

Study Tools

Video Transcript

In this video, we’re going to look at the first step when you’re performing wound care, and that is assessing the wound itself.

In order to do that, the first thing you will need to do is remove the existing dressing. This can be done with clean gloves, but if you need to get deep in and remove packing, use sterile forceps or sterile gloves.

Now that the wound is exposed, you’re going to assess it. First you want to look at the color and characteristics of the wound bed – is it red, are there streaks of yellow, is it black or green? Is it moist, is it dry and leathery? Those are all going to tell you a lot about what’s going on.

In this case, the wound bed is red and bumpy, which tells us there’s some granulation tissue – which means it’s beginning to heal.

Now you want to look at drainage and the edges of the wound. In this case, they are unapproximated, but straight. And there is no drainage. Most of the time I look at the old dressing for the drainage characteristics.
Now it’s time to measure the wound. Take your tape measurer and, holding it above the wound, measure from the patient’s head to toe – that’s your length.

Then measure from the patient’s left to right, that’s your width.

Now we want to measure depth, but we don’t want to just stick this tape measurer in the wound. So, instead, we’re going to get this sterile cotton-tipped applicator – stick it down in the wound bed and then mark the depth with your finger.
Now you can measure that on the tape measurer to get the depth.

If you have any tunnelling or undermining, you want to measure each area with a fresh sterile cotton-tipped applicator and document that.

Now that you’ve taken all of your assessment information, you can move on to the dressing change. If you need to, pause to write down your findings so you don’t forget them when you document later.

Make sure you check out the Dressing Change lesson to see how to perform a sterile dressing change.

Now, go out and be your best selves today. And, as always, happy nursing!

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