The fundamentals of wound assessment.
Although many questions related to the process of wound assessment remain unanswered, clinicians agree on one issue: it is better to regularly assess using the same, possibly less-than-perfect tool, than to not assess at all. This article discusses the fundamentals of wound assessment, beginning with defining "assessment." The rationale for wound assessment is based on the goal of care and patient care plan. Frequency depends on the rationale for a particular patient and may, therefore, change over time. Assessing the wound involves a number of steps, beginning with choosing reliable and valid wound assessment methods, which often include: measuring wound area/size and depth, assessing the wound edges, aspect of the wound bed and surrounding skin, as well as the amount and type of exudate and odor. Consistent documentation of all findings is crucial. Wound assessments provide the foundation for the plan of care and are the only way to determine its effectiveness.
van Rijswijk
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D000465:Algorithms; D003663:Decision Trees; D006801:Humans; D009730:Nursing Assessment / Q000379:methods*; D010347:Patient Care Planning; D014947:Wounds and Injuries / Q000145:classification* / Q000451:nursing* / Q000473:pathology