Wound assessment and documentation HOSPITAL mERSING.pptx

WOUND ASSESSMENT
AND DOCUMENTATION
Dr. Khadijah binti Nordin
Coordinator Unit Penjagaan Luka
HEBHK,
CCWC, PGWM(on going)

INTRODUCTION
A structured approach to wound assessment is required to
maintain a good standard of care.
This involves a thorough patient assessment, which should be carried out by skilled and competent practitioners, adhering to local
and national guidelines
Inappropriate or inaccurate assessment can lead to
- delayed wound healing
- pain
- increased risk of infection
- inappropriate use of wound dressings
- a reduction in the quality of life for patients

WHAT IS WOUND
ASSESSMENT?
A holistic assessment to identifythe causative or contributory factors
and to highlightthe factors that could delay wound healing
The World Union of Wound Healing Society (WUWHS) recommended that effective treatment for patients with wounds
should encompass:
1. Determination of the cause of the wound
2. Identification of underlying medical condition
that may contribute to the wound or delay healing
3. Assessment of the status of the wound
4. Development of a management plan

WOUND BASELINE
INFORMATION
•Number of wounds
•Location – can identify/determine cause and act as an
indicator for potential complications
•Cause e.g. trauma, pressure, vascular in insufficiency,
neuropathy, other
•Type/classification – e.g. pressure ulcer, skin tears, burns
etc
•Duration – date of occurrence, length of time,
Acute/Chronic
•Treatment aim – healing, symptom management etc
•Planned reassessment date
Presentation title 5

LOCAL WOUND ASSESSMENT
AND DOCUMENTATION
1. Site/Location
2. Shape
3. Size/Dimension - Length -
Undermining
- Width - Tunneling
- Depth
4. Wound bed – TISSUE, INFECTION, MOISTURE
5. Wound edge
6. Periwound
7. Procedure done
8. Type of dressing product apply
9. Expected wound inspection date

WOUND SIZE /
DIMENSION
Linear measurements measure the greatest
length, width and depth of the wound while
referring to the face of an imaginary clock.
On the feet, the heels are always at 12 o’clock
and the toes are always at 6 o’clock.
Sometimes the length will be smaller than the
width.

WOUND SIZE /
DIMENSION
LENGTH (L)
WIDTH (W)
DEPTH (D)
L(cm) X W(cm) X D(cm)

WOUND SIZE /
DIMENSION
When measuring LENGTH, keep in
mind that:
The head is always at 12 o’clock
The feet are always at 6 o’clock
Your ruler should be placed over the wound on the longest
length using the clock face

WOUND SIZE /
DIMENSION
When measuring WIDTH:
Measure perpendicular to the length , using the widest
width.
Place your ruler over the widest aspect of the wound and
measure from 3 o’clock to 9 o’clock

WOUND SIZE /
DIMENSION
When measuring DEPTH:
Place the cotton-tip applicator into the deepest part of the
wound bed.
Grasp the applicator where it meets the wound margin
and place it against the ruler.
All wounds must have the depth recorded.
For wounds without depth (Stage 1 and Deep Tissue
Injury), record depth as “0cm”.
For wound that are open but appear to have no depth,
record depth as “<0.1cm”wounds

DEEP TISSUE
PRESSURE INJURY
WOUND DEPTH - 0 CM

GRADE 2 PRESSURE
INJURY
WOUND DEPTH < 0.1CM

WOUND SIZE /
DIMENSION
UNDERMINING
TUNNELING

WOUND SIZE /
DIMENSION
UNDERMINING
To measure undermining:
• Check for undermining at each location, or “hour” of the
clock.
• Measure depth by inserting a cotton-tip applicator into
the area of undermining and grasping the applicator
where it meet the wound edge. Then measure against
the ruler, and document the result.
• Using ranges for undermining (eg: underminig of 1.5cm
noted from 12-3 o’clock)

WOUND SIZE /
DIMENSION
TUNNELING
To measure tunneling:
Insert the cotton-tip applicator into the tunnel. Grasp the
apllicator at the wound edge (not the wound bed) and
measure its depth in cm
Document tunneling using the clock as a reference for the
location as well.

T.I.M.E
CONCEPT
All tools developed such as TIME, TOWA, MOIST,
STAR help in making decision making. Author prefer
using TOWA, however our guidelines used TIME as a
standard language. Next slides will incorporate TIME in
TOWA.

TRIANGLE
OF
WOUND
ASSESSMENT
(T.O.W.A)
Wound Bed
Wound Edge Periwound
Tissue type
Exudate
Infection

TISSUE VIABILITY AND ITS SIGNS
Wound bed tissue should be described as either viable or non-viable; with in
detail description listed below;
1. Granulating 2. Epithelializing
3. Sloughy 4. Necrotic
A healthy viable TISSUE will have 4C which are
Consistency, Contractility, Capacity to bleed and Colour
(red).

Black - Necrotic Yellow - Slough
Red - Granulation
Pink - Epitheliazation
WOUND APPEARANCE - THE COLOUR MODEL

WOUND
INFECTION
CONTINUUM
International Wound Infection Institute (IWII) Wound Infection in Clinical Practice. Wounds
International. 2022.

World Union of Wound Healing Societies (WUWHS) Consensus Document. Wound exudate:
effective assessment and management Wounds International, 2019
WOUND EXUDATE
Wound exudate is produced as a natural and
essential part of the healing process (Lloyd Jones,
2014). However, overproduction of wound
exudate, in the wrong place or of the wrong
composition, can adversely affect wound healing
(Moore & Strapp, 2015).
EXUDATE COMPOSITION
Wound exudate is derived from blood and so
contains a wide variety of components (Table 1)
(Trengove et al, 1996; White & Cutting 2006). It
also contains metabolic waste products, micro-
organisms, and can contain wound slough and
devitalised tissue debris (White & Cutting, 2006).

EXUDATE AND ODOUR
Most wounds have a slight odour (Nix, 2016) and some dressings, e.g. hydrocolloids, are associated with a
distinctive odour (WUWHS, 2007).
However, an unpleasant malodour can arise from factors including the presence of necrotic tissue, micro-
organisms, high levels of exudate, poorly vascularised tissue and/ or a sinus/enteric or urinary fistula (WUWHS,
2007; Gethin et al, 2014).
Extremely odorous, purulent exudate can be suggestive of wound infection (Nix, 2016).
Management of malodour can be particularly challenging in patients with malignant wounds (Alexander, 2009;
Thuleau et al, 2018).

TRIANGLE
OF
WOUND
ASSESSMENT
(T.O.W.A)
Wound Bed
Wound Edge
Periwound
Maceration
Dehydration
Undermining
Thickened/rolled edge

TRIANGLE
OF
WOUND
ASSESSMENT
(T.O.W.A)
Wound Bed
Wound Edge
Periwound
Maceration
Excoriation
Dry skin
Hyperkeratosis
Callus
Eczema
Defined as the area of skin extending up to 4cm
beyond the wound
edge, for some wounds damage may extend
outward, whereby any skin under the dressing may be at
risk of breakdown and should be included in any
assessment.

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