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CHAPTER 32 Skin Integrity & Wound Healing
Physical Examination: Wound Assessment All Wounds Assess all wounds for the following: Location Describe the location of the wound in anatomical terms. For example, you would describe an incision from cardiac surgery as a midsternal incision extending from the manubrium to the xiphoid process. Size ➤ Measure the length and width of the wound in centimeters. ➤ To measure wound depth, gently insert a sterile cotton- tipped applicator into the deepest part of the wound. Measure the applicator from the skin level to the tip. ➤ If possible, use photo documentation, indicating the dimensions on the photo.This is especially useful in the case of a wound with an irregular border. Appearance Your description of the appearance of the wound should be detailed.You must describe the following: ➤ Type of wound (open or closed) ➤ If the wound is sutured, examine the closure.Are the wound edges approximated? Is there tension on any aspect of the wound? Are the stitches intact? ➤ The color of the wound. Redness and inflammation for the first 2 to 3 days is normal, but erythema or swelling beyond that time may indicate infection. ➤ Condition of the wound bed (in an open wound). A beefy red, moist appearance is evidence of healing.A pale color or dry texture indicates a delay in healing. ➤ Examine for necrosis, slough, and eschar. Examine for a tunnel or sinus tract in the wound bed; if there is one, inspect and probe it for depth and characteristics. ➤ The skin surrounding the wound. Observe for skin discoloration, hematoma, or additional injury to the surrounding tissue. Observe for maceration, tunnelling, crepitus, blistering, or erythema. Examine the edges of the wound for epithelial tissue and contraction. Look for undermining beneath the wound margins. Drainage ➤ Presence of drainage or exudate. Describe the color, consistency, amount, and odor. ➤ Assess the quantity of wound drainage by weighing dressings before they are applied and again when they have
been removed.The change in weight reflects the amount of drainage that they have absorbed. ➤ If a drain is present, measure the amount of fluid in the collection container. ➤ Odor may indicate fistula formation or contamination with bacteria. If a new odor develops, assess carefully for presence of a fistula. Patient Responses Ask your patients about pain, discomfort, or itching related to the wound or wound care. Assessing an Untreated Wound Your assessment should determine what, if any, additional professional support is necessary.Assess the following same aspects as for treated wounds: location, size, appearance, description of drainage, condition of wound margins, condition of surrounding skin, and effect of the wound on the patient. In addition, assess the following: ➤ Bleeding. If bleeding is profuse, apply direct pressure to the site. If bleeding continues after you apply pressure for 5 minutes or if blood is spurting from the wound, call the physician immediately. ➤ Severity of the wound. A gaping wound or a deep wound with fat, fascia, or muscle exposed will need additional care. ➤ Last tetanus immunization. Immunization should be given if (1) the last immunization was 10 years ago or longer, (2) the wound is contaminated with dirt or debris and the tetanus injection was given more than 5 years ago, or (3) it is uncertain when the patient last received an immunization. ➤ Whether the wound was caused by a bite. Determine whether the wound was caused by any type of bite, animal or human.A deep bite wound usually requires additional observation and/or antibiotics. ➤ Pain. Assess for pain.Any wound causing severe pain requires a comprehensive evaluation. ➤ Numbness or loss of movement. If any deficit is detected, the patient will need immediate evaluation. ➤ Presence of chronic medical conditions. Examples include diabetes, malnutrition, immunocompromise, a bleeding disorder. Patients with conditions that affect wound healing will need ongoing evaluation.
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