Assessment is the first part of managing a wound. We believe in a holistic approach, where both the patient and the wound are carefully examined. Afterwards, you’ll be able to decide on the best management.
Wound healing is determined by the general health of your patient, so a comprehensive assessment of your patient is crucial when planning and evaluating management.
When assessing and reporting on the patient, note the following:
- full medical history such as diabetes, vascular diseases, compromised immune system, connective tissue disorders and allergies
- nutritional status
- lifestyle, for example tobacco and alcohol habits or impaired mobility
- psychological problems
- quality of life
Diagnosing the underlying cause of a wound is an essential part of wound assessment – and you can only manage the wound once this has been determined. You’ll also need to assess the wound bed and the surrounding skin. After you’ve made these assessments, you can select the best dressing.
When assessing and reporting on the wound, note the following:
- wound location, size and type
- characteristics of the wound bed, such as necrotic tissue, granulation tissue and infection
- odor and exudate (none, low, moderate, high)
- condition of the surrounding skin (normal, edematous, white, shiny, warm, red, dry, scaling, thin)
- clinical signs of critical colonization or local infection: delayed healing, odor, abnormal granulation tissue, increased wound pain and excessive exudate. (Further details can be found in our pocket guide on managing infected wounds)
- wound pain: location of the pain, pain duration, pain intensity and type of pain, nociceptive or neuropathic pain. (You can find further details in our pocket guide on managing painful wounds).