WOUND ASSESSMENT I LOCATION II SIZE III TUNNELING

  • Slides: 13
Download presentation
WOUND ASSESSMENT I. LOCATION II. SIZE III. TUNNELING AND UNDERMINING IV. BED V. EDGES

WOUND ASSESSMENT I. LOCATION II. SIZE III. TUNNELING AND UNDERMINING IV. BED V. EDGES VI. DRAINAGE VII. ODOR

Wound LOCATION • Laterality • Specific anatomical location • Body surface (anterior, posterior, etc.

Wound LOCATION • Laterality • Specific anatomical location • Body surface (anterior, posterior, etc. ) Ex. (+) Stage III pressure ulcer on the sacral area (+) Stage II ulcer on the anterior aspect of ® FA

Wound SIZE (LENGTH & WIDTH) Length: 45 cm Width: 15 cm Depth: 10 cm

Wound SIZE (LENGTH & WIDTH) Length: 45 cm Width: 15 cm Depth: 10 cm * Width must be perpendicular Length

Wound SIZE (DEPTH) Deepest portion of the wound

Wound SIZE (DEPTH) Deepest portion of the wound

Wound SIZE • Length x Width = wound surface area (cm 2) • Depth

Wound SIZE • Length x Width = wound surface area (cm 2) • Depth Techniques: 1. Direct measurement 2. Wound Tracing (contact and permanent layer) a. tracing b. Pre measured grid (cm 2)

Wound SIZE DOCUMENTATION: Wound surface area: 45 (cm 2) Wound depth: 12 cm Or

Wound SIZE DOCUMENTATION: Wound surface area: 45 (cm 2) Wound depth: 12 cm Or Wound size: 14 cm x 7 cm Wound depth: 12 cm

TUNNELING Distance from the tip of the probe up to wound edge; locate using

TUNNELING Distance from the tip of the probe up to wound edge; locate using clock terms

UNDERMINING Distance from the tip of the probe up to wound edge; locate using

UNDERMINING Distance from the tip of the probe up to wound edge; locate using clock terms

Wound BED - Take note of granulation and necrotic tissues - amount (%) -

Wound BED - Take note of granulation and necrotic tissues - amount (%) - Sample Documentation: Wound Bed: 50% granulation tissues, 25% slough, 25% eschar APPEARANCE GRANULATION NECROTIC Healthy: beefy red Slough: Tan or yellow Infected or poor Eschar: black circulation: pale color

Wound EDGES Distinctness: define, indistinct borders Thickness: thickened, rolled Attachment to base: attached or

Wound EDGES Distinctness: define, indistinct borders Thickness: thickened, rolled Attachment to base: attached or unattached

Wound DRAINAGE - type, color, amount Type Serous sanguinous Serosanginous purulent *Pseudomonas color Clear

Wound DRAINAGE - type, color, amount Type Serous sanguinous Serosanginous purulent *Pseudomonas color Clear to pale yellow Red, dark brown, Pink to light red, Yellow, green Blue-green Consistency Watery Slightly thickened watery Viscous, creamy Interpretation Normal Infected infected

Wound ODOR - (+) or (-)

Wound ODOR - (+) or (-)

SAMPLE DOCUMENTATION * with attachment of the permanent layer (tracing) Pt’s name: G. G.

SAMPLE DOCUMENTATION * with attachment of the permanent layer (tracing) Pt’s name: G. G. Date: September 9, 2012 Wound location: anterior aspect of (L) lateral malleolus Wound size: 3. 4 x 4. 4 cm, depth: 5 cm Wound bed: 25% granulation tissue, 50% yellow adherent slough, 25% adherent black eschar Tunneling: 6 cm at 3 o’clock Undermining: 4 cm at 5 o’clock to 10 o’clock, Wound edges: distinct, unattached and rolled Wound drainage: copious, purulent Wound odor: (+)