Patient Assessment

Patient assessment is critical to ensure good wound healing outcomes. A ‘unified patient centred approach’ should be adopted which takes into account the systemic, regional and local factors which may affect wound healing1. It is important to assess the patient and the wound to aid appropriate dressing selection and then accurate treatment interventions can be planned. A multi-disciplinary approach should always be considered1.

Assessment pathway


Assess the Patient
Assess the patient and consider systemic factors which may affect wound healing. These include; co-morbidities / disease processes such as cardiovascular, diabetes, immunosuppressant conditions, carcinomas, psychosocial conditions, medication, age and nutritional status. Any known allergies should be recorded.

Assess the Regional Area
Regional factors to consider include vascular disease, infection and pain.

Assess the Local Wound Area
The local wound bed should be assessed in terms of the type and amount of each respective tissue type present (necrotic, sloughy, granulating) and also the level of pain, infection, exudate and odour present.

Assess the Current Dressing Regime
Assess the current dressing for signs of leakage and strikethrough and assess efficacy in terms of wear time, pain at dressing change and in situ.

At assessment the wound should be measured and the depth of tissue loss expressed as a grade. If the wound is a cavity, then all areas of undermining should be probed, measured and documented. Ideally all wounds should be mapped and photographed. A treatment plan should be selected providing clear rationale for the dressings selected and frequency of dressing changes2

References:

  1. World Union of Wound Healing Societies (WUWHS) Principles of best practice: Wound Exudate and the role of dressings: A consensus document. London MEP Ltd. 2007
  2. Flanagan, M. (1997) A practical framework for wound assessment 2: methods. British Journal of Nursing: 6; 6, 8 - 11

Caveat: The information given is a guide only and should not replace clinical judgement.

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