The assessment of wounds
ASSESSMENT OF A PERSON WITH A WOUND
Wounds continue to present a global challenge, growing in quantity and impact, especially within ageing populations. The number of non-healing/ chronic wounds continues to rise (1,2). The Burden of Wounds Study (3) highlights that many patients with chronic/ non healing wounds had received poor assessments and inaccurate diagnosis. Wounds that are not effectively managed can lead to delayed healing, complications, decreased quality of life and an inevitable increase in healthcare costs (1,4).
There are a variety of wound assessment tools available to support healthcare professionals, but not all incorporate an assessment of the person as well as the wound – a holistic evaluation.
This type of assessment takes into consideration the individual's overall health, including general, social, and emotional health, to identify factors that may delay healing, both intrinsic and extrinsic (4,5). The holistic approach can also be used to ascertain the individual’s wound experience and their goals relating to the wound healing management plan (4).
Subsequent assessment looks at the wound or wounds present. The results of this process combined with the individual health information is required for a successful resolution and to promote uncomplicated wound healing. A full holistic assessment provides valuable background to enable informed decisions about an individual and their wound.
WOUND BASELINE INFORMATION
This information is key to esuring the effects of the treatment chosen can be reviewed effectively (6).
For example, the location and type of wound can determine which type of specialist to involve, such as Tissue Viability, Diabetic Foot, Vascular etc (4).
WOUND ASESSMENT
It is important to establish a baseline for the wound incorporating the factors shown.
The method for measurement needs to be consistent to assist with accuracy when monitoring wound progression. (7)
The tissue type within the wound can indicate the stage of wound healing and input into type of treatment and dressings selected (5).
The peri wound and surrounding skin findings contribute to a comprehensive wound assessment.?
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WOUND SYMPTOMS
For many people living with a wound, the symptoms can cause the most distress, affecting their quality of life (7). Pain can be overlooked, but if not addressed, can lead to non-concordance.
The risk and presence of infection can significantly delay wound healing and further investigation may be required (2). ?
On reviewing wound fluid/exudate, levels and consistency should be recorded.
A comprehensive holistic wound assessment provides a solid foundation to implement an effective wound healing management plan. (1)
To learn more about wound assessment, wound care education and dressing selections contact us at [email protected].
References
1. World Union of Wound Healing Societies (2020) Strategies to reduce practice variation in wound assessment and management: The T.I.M.E. Clinical Decision Support Tool. London: Wounds International. Available at: www.woundsinternational.com
2. Atkin L, Bu?ko Z, Conde Montero E, Cutting K, Moffatt C, Probst A, Romanelli M, Schultz GS, Tettelbach W. Implementing TIMERS: the race against hard-to-heal wounds. J Wound Care 2019; 28(3 Suppl 3): S1–S49
3.Guest JF, Ayoub N, McIlwraith T et al. Health economic burden that wounds impose on the National Health Service in the UK. BMJ Open 2015; 5: e009283
4. Sarah C.Hunt, Sanjay.Azad. ABCDEFGHI Systematic Approach to Wound Assessment and Management. Clinical Management Extra. Advances in skin & wound care. July 2022. www.aswcjournal.com
5. Wounds UK. Best Practice Statement: Improving holistic assessment of chronic wounds. London: Wounds UK, 2018. www.wounds-uk.com
6. Scott-Thomas J, Hayes C, Ling J et al (2017) A practice guide to systematic wound assessment to meet the 2017–19 CQUIN target. J Community Nurs 31(5) 30–4
7. Dowsett C, Protz K, Drouard M, Harding KG (2015) Triangle of wound assessment Made Easy. London: Wounds International