Wound Diagnostic, Assessments, and Treatments
Assessment is a critical step in wound care because it enables healthcare professionals to establish and implement the appropriate treatment plans, allowing the wound to heal as quickly as possible. Diagnostic assessment is the process that allows the doctor to diagnose the wound, thus administering the proper treatments. Good observation skills and current knowledge are required for an effective wound assessment. In addition, it is important to use the correct terminology in written documentation in order to ensure proper communication between members of the healthcare team.
- General patient health: This includes age, living environment, mental health, nutrition, pre-existing conditions, and history of the wound.
The number of wounds present.
- Location: This should be documented using landmarks and directions such as superior, posterior, medial, etc.
- Dimensions: Measurements should be documented in millimeters or centimeters.
- Pattern: The dispersion of lesions within a particular area should be noted. “Linear” lesions form a straight line pattern. “Satellite” lesions are small peripheral areas that are centered around a larger lesion. “Candidiasis” presents multiple satellite lesions.
- Wound Tissue: A description of tissues found in the wound should be documented. Examples include normal granulation tissue, necrotic tissue, and hypergranulation tissue.
- Drainage: The amount of exudate (drainage) should be documented, along with the color and consistency.
- Odor: Odor in wounds may indicate infection, but it is important to make sure the odor is not coming from wound dressing such as a hydrocolloid.
- Pain: The patient may rate their pain related to the wound using a pain assessment scale designated by their healthcare facility.
- Assessment of the surrounding skin: The surrounding skin should be checked for erythema (redness), excoriation (stripping of the upper layers of the epidermis,) induration (a change in skin texture), and maceration (excess skin moisture resulting in tissues becoming waterlogged).
Once a wound is accurately assessed, it may be classified into one of four main groups:
- Burns, chemical, or thermal injuries
- Chronic Wounds: Wounds such as leg ulcers and pressure ulcers that do not heal within three months.
- Malignant Wounds: These are caused by some type of cancer, such as primary lesions resulting from melanoma.
- Mechanical Wounds: These include surgical and traumatic wounds.
After signs and symptoms are documented in the assessment, primary treatment objectives may be identified including wound cleaning, debridement/desloughing, control of exudate, control of bleeding, and minimization of the effects of infection. Interventions may then take place, including:
- Wound management materials: These include alginates, enzymes, foams, films, hydrocolloids, hydrogels, etc.
- Active wound management materials: These incorporate growth factors that stimulate the healing environment. Examples include epidermal growth factor (EGF) or platelet-derived growth factor (PDGF).
- New technologies: These include hyperbaric oxygen therapy, low level laser therapy, and negative-pressure wound therapy.
Once the primary treatment objective has been achieved, ongoing assessments should be performed in order to identify the next objective and provide evidence of wound healing or deterioration of wound healing. Photographic records aid in this process, as they provide visual evidence of healing. If wounds become fixed in one of the major phases of healing (inflammation, regeneration, or maturation) for more than six weeks, the wound can be considered chronic.