Wound Assessment
The first half of this module looked at the importance of patient assessment in wound management. The rest of this module will concentrate on wound assessment.
Assessment can be defined as information obtained via observation, questioning, physical examination and clinical investigations to establish a baseline for planning intervention (Collins et al., 2002).
Focusing on the whole patient and not just the ‘hole’ in the patient is essential to ensure the underlying cause of the wound is known and that a subsequent treatment plan is optimal for each individual (Hampton & Collins, 2004; Wounds UK, 2018).
An in-depth wound assessment should be used in conjunction with a thorough patient assessment to formulate a holistic plan of care. Inadequate wound assessment can lead to incorrect, inadequate or inappropriate treatment with potentially serious consequences.
A holistic assessment aims to gain an overview of the patient’s medical condition, the cause, duration and status of the wound, together with any factors that may impede healing (Anderson and Hamm, 2012), including: comorbidities, e.g. diabetes, cardiovascular disease, respiratory disease, venous/arterial disease, malignancy.
- Medications, e.g. corticosteroids, anticoagulants, immunosuppressants, chemotherapeutic agents, non-steroidal anti-inflammatory drugs
- Systemic or local infection
- Reduced oxygenation and tissue perfusion
- Increased age
- Pain
- Poor nutrition
- Lifestyle, e.g. alcohol intake, smoking
- Obesity