Directions Ask students to work in pairs. Have students complete the table relating to wound assessment that follows. A student handout for this activity is included at the end of the document. Tips After students complete the table, these ideas should be reviewed with the entire class. It may be wise to review this table more than once to reinforce the many findings for wound assessment. This table can also serve as an excellent review for exams. The table provides sample assessment and descriptions. Assessment Expected Assessment and Description Location Use anatomical terms to describe location (distal, proximal, lateral, etc.). Size
Measurement of length and width in centimeters. Measure depth by inserting a sterile cotton tip, then measure the depth in centimeters from the deepest area to the skin level. Photos are helpful for comparison. Describe type of wound and its color, whether it is sutured, the condition of the wound bed (examine for necrosis, slough, eschar, granulation, nongranulation, or epithelial tissue), and evaluate the surrounding tissue. If drainage is present, describe it and assess quantity and color. Note whether there is an odor.
Appearance
Drainage
Patient responses
Note whether there is pain, itching, or discomfort.
Goals The purpose of this activity is to help students become familiar with the complexities of wound assessment. Online Application • During a live Web class using Zoom or other Web conferencing program, provide students with the Expected Assessment and Description and have them type in the course chat what they think the assessment is that is being described. R ELATED C LINICAL J UDGMENT A SSIGNMENT To help students build clinical judgment skills and prepare for the Next Generation NCLEX ® for this topic, the following is available to assign:
• Clinical Judgment assignment: Skin Integrity & Wound Healing
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