05.02 Wound Care – Assessment

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Pressure Ulcer Staging (Cheat Sheet)
Pressure Ulcer Staging (Image)
Common Pressure Ulcer Sites (Image)
Stage Four Pressure Ulcer (Image)
Wound Vac Therapy (Image)
Diabetic Foot Ulcer (Image)
Hydrogel Dressing (Image)
Rolled Gauze (Image)
Hydrocolloid Dressing (Image)
Types of Dressings (Image)
Types of Wound Healing (Picmonic)

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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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