Nurses need to assess the patient holistically when devising an effective treatment plan. Assessment tools help with accurate monitoring of the wound’s progress
This article is the second in a series designed to enhance nurses’ knowledge of wound management. It highlights the importance of assessing patients holistically, and provides an overview of the key factors that should be considered when assessing a wound. A well-designed template enables nurses to carry out a comprehensive assessment that ensures accurate documentation to monitor wound healing.
Citation: Brown A (2015) Wound management 2: The principles of holistic wound assessment. Nursing Times; 111: 46, 14-16.
Author: Annemarie Brown is lecturer at the University of Essex, Southend.
Whether acute or chronic, wounds are the result of some kind of trauma, infection or disease; when assessing them it is important to see wounds in relation to the patient. When conducting a wound assessment, nurses should assess the patient systematically and holistically, rather than focusing only on the wound (Brown and Flanagan, 2013; Eagle, 2009). Apart from the patient’s medical history, there are other factors that affect the wound and its ability to heal. Taking time to assess these will help ensure all the information needed to formulate a treatment plan is gathered. Table 1 (see PDF) outlines patient factors that can interfere with the healing process.
Wound assessment tools
There are several wound assessment tools that will help nurses to assess a wound and develop a care plan in a concise, systematic way (Brown and Flanagan, 2013). Examples include:
- TIME, developed by Smith and Nephew;
- National Wound Assessment Tool (Fletcher, 2010);
- Applied Wound Management (Gray et al, 2006).
The content of these are all very similar in that they use prompts to document wound characteristics, as itemised in Table 2 (see PDF). Local tools are also available.
One of the key priorities when assessing a patient with a wound is pain. Many patients with wounds experience pain, which must be assessed and managed appropriately before focusing on the wound itself.
Developing a treatment plan
After completing the wound assessment, the next step is to develop a treatment plan based on the findings. Asking the following questions can help to formulate the treatment plan:
- At what stage in the healing process is this wound? This will help with choosing the most appropriate dressing or treatment.
- What do I want this wound to do next? This will help prioritise the most immediate short-term treatment aim.
- How can I achieve this objective? Consider the aetiology of the wound. For example, if it is a pressure ulcer, it will need pressure relief; if it is a venous leg ulcer, compression therapy will treat the underlying cause (Greatrex-White and Moxey, 2013).
Changes in the wound bed
As a wound heals its appearance will change and it is important to be able to determine normal progression that shows the wound is healing nicely and there is no infection. The phase of healing and/or the presence of infection determines subsequent treatment.
If the initial treatment aim was to debride slough or necrotic tissue, once this has occurred, the wound will initially appear larger; this should be explained to the patient, who may need reassurance that it is not getting worse.
Wound infection results in delayed healing, can be difficult to treat and may cause distress to the patient (Edwards-Jones and Flanagan, 2013). Signs of infection are different in chronic and acute wounds (Box 1). A change or increase in pain together with two other signs is highly indicative of wound infection (World Union of Wound Healing Societies, 2008).
The infection in Fig 1 (see PDF) is signalled by localised swelling and the red colour of the skin. The skin would probably feel hot to the touch and very painful to the patient.
Box 1. Signs of infection
Acute wounds (surgical/trauma/burns)
- New or increasing pain
- Local warmth
- Raised temperature (may be 7-10 days post-surgery)
- Abscess formation
- Abnormal odour
- Delayed healing
Chronic wounds (diabetic foot/leg ulcers/pressure ulcers)
- New, increasing or altered pain
- Delayed healing
- Oedema to wound edges
- Granulation tissue bleeds easily
- Increased exudate/purulent discharge
- Discoloured wound bed; abnormal or change in odour
- Stalled healing
Source: adapted from World Union of Wound Healing Societies (2008)
Assessment should not be a one-off process as the condition of the wound will constantly change. To establish that the treatment is effective, nurses should assess the wound frequently. A healing wound has been defined as “a reduction of 20-40% in wound area after 2-4 weeks of treatment (Kantor and Margolis, 2000); it is therefore recommended that wounds are remeasured and reviewed weekly or at each dressing change according to the wound type and care setting.
Referral to specialist services should be considered if, after re-assessment, there is no evidence of healing after four weeks.
Accurate and regular wound assessment is necessary to ensure the correct treatment can be carried out as soon as possible. Using a wound assessment form can ensure all relevant information is collected and recorded accurately; this information forms part of the patient’s documentation. Keeping comprehensive records also ensures good communication between healthcare providers and enables the wound to be monitored for healing or for the development of complications.
- Assessment should include observing the whole patient, not just the wound
- Wound assessment forms are useful tools for accurately documenting the condition of a wound
- Assessing the wound bed enables nurses to plan treatment options
- A wound should be measured at least weekly – or more frequently if the appearance of the wound changes – so its progress can be monitored
- The underlying cause of the wound informs the treatment plan
Also in this series
- Wound management 1: Phases of the wound healing process
- Wound management 3: Assessing and treating wound pain
- Wound management 4: Accurate documentation and wound measurement
- Wound management 5: Selecting wound dressings for optimum healing
- Wound management 6: How to address wound healing complications
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