Wound Care Assessment

Wound Care Assessment

■ Appearance: Color (pink healing; yellow infection; black  necrosis), sloughing, eschar, longitudinal streaking, etc.
■ Size: Measure length, width, and depth in cm.
■ Incisions: Approximated edges, dehiscence, or evisceration.
■ Undermining: Use a sterile, cotton-tipped applicator to gently probe underneath the edges until resistance is met. With a felttipped pen, mark where the applicator can be felt under the skin.
■ Granulation: Bright red, shiny, and granular. Indicates healing.
■ Drainage: Type, (sanguineous, serosanguineous, purulent) amount, color, and consistency.
■ Odor: Foul odor indicates infection.
■ Staging: See Staging Pressure Sores.

Sterile Dressing Change
■ Wash hands, explain procedure, and position and drape Pt.
■ Open sterile gloves on a nearby surface.
■ Using sterile technique open supplies and set up a sterilefield.
■ Instruct Pt not to touch incision/wound or sterile supplies.
■ Don clean (nonsterile) gloves and remove old dressing:
■ Pull tape towards incision, parallel to skin.
■ Be careful not to dislodge any drainage tubes or sutures.
■ Assess condition and appearance of wound. Note drainage on old dressing.
■ Discard gloves and old dressing per Standard Precautions.
■ Wash hands and don sterile gloves.
■ Cleanse wound with prescribed solution:
■ Start from the area of least contamination, cleanse toward the area of most contamination (use separate swab for each stroke).
■ Cleanse around drains using a circular motion working outward.
■ Apply medicated/antiseptic ointments as prescribed.
■ Apply prescribed sterile dressing to the incision or wound:
■ Cut dressings to fit around drain if present (use sterile scissors).
■ Dry dressing: Cover wound with sterile gauze (2 2, 4 4, etc.).
■ Wet-to-dry: Cover or pack wound with saline-moist, sterile gauze, and then cover with dry, sterile gauze (2x2, 4x4, etc.).
■ Wound packing: Soak sterile gauze in prescribed sterile solution and ring out excess. Using sterile forceps, gently pack wound until all wound edges are in contact with the moist gauze, including any undermined areas. Do not over-pack the wound (stop at skin level).
■ Reinforce with a thick cover dressing (ABD or Surgi-Pad®).
■ Secure dressing with tape, rolled gauze, or Montgomery ties.
■ Document: dressing change and assessment findings. Date, time, and initial new dressing.