Criteria to be assessed for the assessment of a wound
Wound identification is an important part of wound care, providing the basis for caregivers to develop an appropriate wound care plan.
Wound assessment is the assessment of wound condition such as type, location, size of wound, degree of exudation, fluid nature, skin around the wound, pain condition, ..
1. Determine the type and location of the wound
Each type of wound will have different care, so it is necessary to determine what type of wound is being cared for, chronic or acute, surgical or non-surgical, open or closed,… Not only Therefore, determining the location of the wound is also very important in care. Wounds in places prone to infection such as the perianal area, or in places that are easy to press, require a more meticulous and special care plan.
2. Wound size
Wound size judgments are judgments about the length, width, and depth of the wound, as well as the volume of the wound.
The length of the wound is calculated as the maximum length measured in the head-to-toe direction and the width is calculated as the maximum distance measured in the direction perpendicular to the length. The researchers showed that, if the width is not measured perpendicular to the maximum length, the wound area can be estimated to be more than 70% in some wounds.
Wound depth is measured from the deepest point of the wound to the surface of the skin and is usually measured with a damp cotton swab.
The volume of the wound is usually measured only for research purposes, in practice, the volume of the wound is rarely measured in clinical practice.
3. Wound shape
Determine whether the wound shape is round, elliptical, triangular, butterfly, or no specific shape. Determining the shape of the wound not only helps the caregiver choose the right dressing for the wound, but also helps to find the cause of the wound.
4. Wound fluid
When assessing wound fluid, it is necessary to identify the characteristics: fluid volume (more, less or moderate), fluid nature (clear, clean, serum, bloody, or pus,…) and odor. of fluid (odorless, odorless, strong-smelling,…).
The assessment of wound fluid status is very important in wound assessment, it is the basis for determining whether the wound is progressing in the direction of better or worse, as well as the basis for caregivers to choose the right type of treatment. the appropriate dressing for each wound as well as determine the time it is necessary to change the dressing. For example, for wounds with a lot of fluid, the choice of alginate or hydrofiber dressings will be better than hydrocolloid dressings and vice versa.
5. Skin around the wound
Assess the color, moisture, temperature, and integrity of the skin around the wound. This assessment provides data for evaluating the effectiveness of treatment and care. Besides, it is also the basis for caregivers to choose the appropriate use of the tape, for example, whether to use tape or not.
6. Pain condition
Pain is considered the fifth vital sign besides pulse, temperature, blood pressure and respiratory rate. Assessing the pain status of the wound helps caregivers identify the effectiveness of treatment and care methods. If the patient does not feel pain, pain is less or the pain decreases over time, it means that the healing process is going well and vice versa.