How do you document wound management?
Documentation for partial- and full-thickness wounds should include length, width, depth, tunneling (if present) color of the wound bed, appearance of the skin around the wound (periwound skin), and the presence of drainage and odor.
How are wounds measured and documented?
The wound is typically measured first by its length, then by width, and finally by depth. The length is always from the patient’s head to the toe. The width is always from the lateral positions on the patient. The depth is usually measured by inserting a q–tip in the deepest part of the wound with the tip of finger.
What is a wound assessment tool?
The Triangle of Wound Assessment is a new tool that extends the current concepts of wound bed preparation and TIME beyond the wound edge5. It divides assessment of the wound into three areas: the wound bed, the wound edge, and the periwound skin.
What are the principles for accurate wound documentation?
A wound assessment must be made and accurately recorded at every dressing change: the size of the wound, its depth, colour and shape, as well as the condition of surrounding skin, should all be docu- mented.
What does wound exudate look like?
Serosanguinous drainage is the most common type of exudate that is seen in wounds. It is thin, pink, and watery in presentation. Purulent drainage is milky, typically thicker in consistency, and can be gray, green, or yellow in appearance. If the fluid becomes very thick, this can be a sign of infection.
When assessing a wound What four things do you observe?
The World Union of Wound Healing Societies [WUWHS] (2007) suggest four categories for assessment when documenting exudate: colour, consistency, odour and amount. It is important for the practitioner to be able to recognise these factors and act accordingly to ensure the optimum wound bed environment for healing.
Why do you do a wound assessment?
The wound assessment helps define the status of the wound and helps identify impediments to the healing process. A clear understanding of the anatomy of the skin is essential for assessing and classifying the wound and defining the level of tissue destruction.
What type of exudate indicates infection?
Exudate viscosity Normal exudate is thin and watery. Thick, sticky exudate indicates high protein levels and can indicate infection. It may also be caused by an enteric fistula, or the presence of necrotic or sloughy tissue.