Wound assessment tool chart

To be reviewed in Health Improvement Scotland. Home Patient safety Paediatric wound chart Paediatric wound chart Related pages Tissue viability Tissue viability grading and tools. In the case of lower extremity erythema and edema, especially where it is seen bilaterally, this may simply be vasculitis and not an infection. A simple test is to elevate the leg for three to five minutes.

If the erythema resolves significantly during that period, it is likely that it is vasculitis, not an infection. Imaging in these cases is vital, as the depth and extent of the infection will change the type of treatment. On plain film x-ray, it is possible to see the destruction of bone, which is indicative of osteomyelitis bone infection.

Generally speaking, bone with visible destruction from infection needs to be resected and treated with 6 weeks of antibiotics to clear the infection fully. Other signs to look for are focal areas of decreased density which can indicate an abscess formation that will need to be incised and drained, or soft tissue erythema, which is diffuse areas of decreased density which indicates gas in the tissue and is seen in severe infections including Clostridium perfringens , which is often seen in gas gangrene and is a medical emergency which requires immediate excision and irrigation of infected tissues.

If the infection is suspected, be sure to take deep cultures of the wound as just swabbing the rim will likely culture a wide variety of organisms. If the purulent discharge is present, this is a good source for culture. If sepsis or bacteremia is suspected and the patient is to be given antibiotic therapy, make sure to take the blood cultures before antibiotic therapy is given.

For local treatment of infected wounds, irrigation and debridement are warranted, and if there is a concern for abscess, incision and drainage are necessary to remove any nidus of infection. While there are many factors to consider when approaching a wound, understanding the nature of the wound and underlying factors causing the wound in question will lead to successful evaluation and treatment of the wound.

This review is not exhaustive, but it provides a basic understanding of the common types of wounds, as well as the underlying concerns for each. The takeaway is the need for appropriate assessment of wounds. Too often, wounds are not treated properly because of a lack of understanding of the underlying disease process.

When wounds fail to heal, a thorough assessment is necessary. Most chronic wounds are complex and best managed by an interprofessional team that includes a wound care nurse, general and vascular surgeon, hyperbaric specialist, infectious disease consultant, dietitian, and physical therapist. The key is first to find out the cause of wound breakdown. Without resolving the primary cause, wounds cannot heal. There are hundreds of wound care dressings and solutions, and for the most part, all work in a similar way with the same efficacy.

The second point is to ensure that the wound is clean, has ample blood supply, and is regularly debrided. Other factors that play a role in wound healing include patient nutritional status, comorbidities, state of the immune system, age, degree of ambulation, presence of a foreign body, and infection. It is important to have a team of wound experts regularly assess the wound and the patient in order to heal the wound successfully.

Wound checks are typically once per shift but the clinician may vary this protocol based on concerns raised by the healthcare team. This book is distributed under the terms of the Creative Commons Attribution 4. Turn recording back on. National Center for Biotechnology Information , U. StatPearls [Internet]. Search term. Wound Assessment Sean M. Author Information Authors Sean M.

Affiliations 1 Mclaren Oakland. Continuing Education Activity A wound is damage or disruption of the skin, and, before treatment, the exact cause, location, and type of wound must be assessed to provide appropriate treatment.

Introduction A wound is damage or disruption of the skin and, before treatment, the exact cause, location, and type of wound must be assessed to provide appropriate treatment.

Function Clinicians perform wound assessment as a means for determining the appropriate treatment for an extremely diverse grouping of disease processes. Where: Where on the body is it located? Is it in an area that is difficult to offload or to keep clean?

Is it in an area of high skin tension? Is it near any vital structures such as a major artery? What: What anatomy does it involve? What: What comorbidities or social factors does the patient have which might affect their ability to heal the wound? Figure 7. Left: Digital examination of a wound. Right: Examining a wound with a probe. Table 7 Types of debridement. Sharp —At the bedside using scalpel or curette Surgical —In the operating theatre Autolytic —Facilitation of the body's own mechanism of debridement with appropriate dressings Biological —Larval maggot therapy Enzymatic —Not widely used; pawpaw papaya or banana skin used in developing countries Mechanical —Wet-to-dry dressings not widely used in the UK.

Depth Accurate methods for measuring wound depth are not practical or available in routine clinical practice. Figure 8. Surrounding skin Cellulitis associated with wounds should be treated with systemic antibiotics.

Figure 9. Infection All open wounds are colonised. Table 8 Wound exudate. Pain Pain is a characteristic feature of many healing and non-healing wounds.

Table 9 Clinical features of non-healing wounds. Non-healing wounds Non-healing wounds have traditionally been defined as those that fail to progress through an orderly sequence of repair in a timely fashion. Figure Quality of life Several studies have shown that patients with non-healing wounds have a decreased quality of life. Definitions and guidelines for assessment of wounds and evaluation of healing.

Arch Dermatol ; : Chronic wounds. Clin Plast Surg ; 32 : Text atlas of wound management. London: Martin Dunitz, Support Center Support Center.

External link. Please review our privacy policy. Erythrocyte sedimentation rate; C reactive protein. Non-specific markers of infection and inflammation; useful in diagnosis and monitoring treatment of infectious or inflammatory ulceration.

High urea impairs wound healing. Renal function important when using antibiotics. Markers of autoimmune disease such as rheumatoid factor, antinuclear antibodies, anticardiolipin antibodies, lupus anticoagulant.

Indicative of rheumatoid disease, systemic lupus erythematosus, and other connective tissue disorders. Cryoglobulins, cryofibrinogens, prothrombin time, partial thromboplastin time. Serum protein electrophoresis; Bence-Jones proteins. Not routine; all ulcers colonised not the same as infection ; swab only when clinical signs of infection. Venous, arterial, or pressure ulcer or hydroxyurea induced ulceration. Plantar and lateral aspect of foot and toes.

Basal cell carcinoma; squamous cell carcinoma. Sharp —At the bedside using scalpel or curette. Surgical —In the operating theatre. Autolytic —Facilitation of the body's own mechanism of debridement with appropriate dressings. Skip to main content. The scale is used by health professionals to assess patient's risk for developing a pressure ulcer It measures functional capabilities of the patient that contribute to either higher intensity and duration of pressure or lower tissue tolerance for pressure.

Lower levels of functioning indicate higher levels of risk for pressure ulcer development. Using hands, eyes, ears and a monofilament, clinicians can quickly move through the categories. The tool identifies three 'at risk' categories: a score of indicates 'at risk', a score of indicates 'high risk', and a score of 20 and above indicates very high risk.

Waterlow Scale has demonstrated poor inter-rater reliability, high sensitivity, and low-specificity levels. The descriptors have been modified to reflect the developmental needs of the pediatric population and the unique clinical context for neonates, infants, and children in acute care.

Glamorgan Glamorgan Pressure Injury Risk Assessment The Glamorgan scale is used to help you assess risk of a child developing a pressure ulcer.