Treating any wound, it is necessary to conduct a corresponding comprehensive and systematic assessment of the wound. Recording after the wound assessment can effectively intervene in the treatment of wounds at different stages. Of course, wound assessment is a dynamic process, so it is convenient for us to constantly adjust the treatment plan. Proper wound management begins with a thorough assessment and documentation, the results of which inform patient care options. Next, please follow me to understand what are the elements of the wound record.
First, understand the basic situation of the patient's wound:
Wound allergy history, skin sensitivity,pact on health
To classify wounds:
According to the wound healing time, it can be divided into memory wounds and chronic wounds.
Acute wound: It occurs suddenly and lasts for a short time. This type of wound generally recovers well, and the healing process has a regular pattern.
Chronic wounds: long-term wounds that recur repeatedly, the healing process is irregular, and the healing recovery process is very slow.
Wound color classification:
Red wound: It means healthy blood flow and granulation tissue, usually a wound that is healing properly.
Yellow wound Indicates slough, exudate, and infection within the wound.
Black Wound: Necrotic tissue lacking blood supply in the wound, usually forming a scab.
Mixed wound: There are various colors mentioned above in the wound, and the fraction can be used to describe how much surface area the wound occupies.
Classification of Wound Staging:
The first stage wound: the epidermis is intact, and there are erythema marks that will not turn white when pressed.
The second stage wound: the epidermis or dermis is partially damaged, the dermis has not yet penetrated, the bottom of the wound is moist and red, painful, no necrotic tissue, surface broken skin, blisters or small shallow pits appear.
Stage III wound: The epidermis and dermis are completely damaged, involving the subcutaneous tissue, with deep pits and no pain at the base of the wound. Fascia and muscle layers are not affected. Visible necrotic tissue, dead space, exudate, or infection.
Stage IV Wound: Extensive destruction, penetrating subcutaneous fat to fascia, muscle, or bone, may have necrotic tissue, burrowing depth, fistula, exudate, or infection. The base of the wound is not painful.
When the wound has yellow carrion and black necrosis, it is necessary to debride the wound to see clearly which stage the wound is in.
Evaluation of Wound Exudate:
Wound exudate can be clear, bloody, greenish-yellow pus, and smelly. It is also necessary to record the change of wound exudate: a small amount < 5ml, a medium amount of 5-10ml, and a large amount > 10ml/24h.
Record wound assessment parameters:
1. Number and type of wounds
2. Wound site
3. Wound size (measurement of area and depth)
4. Whether there is a sinus tract in the wound
5. Characterization of wound edges/margins
Record wound symptoms:
1. Wound pain (presence, severity, and frequency)
2. Exudate volume consistency (small-large), type (serous, bloody, serous, or purulent), and color
3. Presence of odor (strong, unpleasant, pungent)
4. Signs of systemic or local infection.
Through the dynamic assessment of the wound, the corresponding treatment plan can be found more effective in treatment.
Comprehensive record analysis can more accurately judge which type of wound dressing to use, which can make the wound heal faster and reduce the pain of the patient.
While many factors need to be considered when approaching a wound, understanding the nature and underlying factors of a strengthening-related wound will lead to successful evaluation and treatment.
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Editor: kiki Jia
Date: March 9, 2023