Sharpen your wound assessment skills?

Learn how impeccable assessment and documentation can help your patient heal.

Accurate assessment holds the key to all aspects of wound care. Besides pointing to the cause and guiding treatment, it serves as a baseline for subsequent assessments. In this article, I'll spell out the components of comprehensive assessment so you can tune in to the processes behind wound formation and help promote healing.

Looking at the big picture

The initial wound assessment takes in the big picture: location, shape, and size.

* Location. This can give you clues to the cause. For example, a trochanteric wound (on the bony prominence at the upper end of the femur) indicates pressure from a side-lying position, and an ischial wound (on the lower portion of the hip bone) indicates pressure from sitting. A sacral wound may be the result of sitting if the patient is elderly or has a weakened musculoskeletal system that causes him to slide down when he sits, applying pressure on his sacrum.

Whenever possible, use anatomic landmarks and language to document the location of a wound. Left trochanter is preferred to left hip, and right medial malleolus is preferred to right inner ankle. A body diagram with separate views of the feet is useful to document wound location.

* Shape. Wound shape also can shed light on the cause. A triangular sacral or coccygeal wound could be due to shearing and pressure forces caused by movement in bed. A linear wound on the posterior midthigh of someone who uses a wheelchair could be caused by pressure from the edge of the seat.

* Size. Measure the length, width, and depth of your patients wound in centimeters. If possible, the same nurse should measure the wound and the patient should be in the same position for each subsequent assessment.

Length is the largest area from a head-to-toe perspective; width, the largest area from a side-to-side perspective. When a wound has an irregular shape, a tracing is useful to document size. Use manufactured tracing sheets or a sheet of plastic wrap folded in half. Place it against the wound and trace around the perimeter. Remove the sheet, cut it along the fold, and place the half that touched the wound in a biohazard container. The part with the tracing is clean and can be included in the medical record.

If you photograph a wound, be sure to have written consent and adhere to your facility's policies and procedures. Use wound film with size markings included or place a ruler in the photograph for perspective.

To measure wound depth, moisten a sterile, cotton-- tipped applicator with 0.9% sodium chloride solution. (Don't use a dry one, which could injure newly formed granulation tissue.) Place the applicator tip in the deepest aspect of the wound and measure the distance to the skin level. If the depth is uneven, measure several areas; document the range and which part of the wound is the deepest.

Visit www.woundassessment.co.uk for an accurate and intuitive measurement solution.