Wound assesment

2. WOUNDASSESSMENT
SURGERY WARD STAFF NURSE.
S/N RANJANJ
S/N BOOMIKA.R
S/N KOWSALYA.M
S/N SUBA
S/N MANIKANDAN

3. PRE TEST
1.What is meant by wound ?
A) Tissue damage B) Brokering the continuity of skin
C) Abrasion D) All of the above
• 2.which is the following is the etiological wound?
A) surgical wound B) acute wound
C)penetrating wound D) A and C

4. 3. How many tools used in assessment tools
A) 11 B) 12
C) 13 D) 14
4.which one is the first stage of wound healing
A) inflammatory stage B) Remodelling stage
C) Proliferative stage D) Hemostasis

5. 5. What is meant by necrosis
A) Inflamed skin B) wearing of skin
C) Rough surface D) Death of body tissue
6. What is the meaning of Induration?
A)Unable to pinch the skin B) Tissue firmness
C)Bleeding D)Slough formation

6. 7. How many components present in wound assessment
continum
A) 2 B)3
C) 4 D) 5
8. Which one of the following wound assessment tool used in our
institution?
A) Bates-jensen assessment tool B) Barbara johnson
assessment tool
C) Hierarchy wound assessment D) None of the above

7. INTRODUCTION
•Wound assessment is very important
key to success of wound management
comprehensive holistic assessment is
essential to identify the factors that
will have an impact on wound repair.

9. DEFINITION
•A wound is a break in the continuity
of the tissue of the body either
internal or external.

10. • According to the etiology
• According to the Rank-wakefield classification system
• According to duration of the wound healing
• According to the integrity of the skin
• According to wound depth
• According to morphological characteristics
• According to degree of contamination
• According to severity
TYPES OF WOUND
CLASSIFICATION

11. ACCORDING TO THE ETIOLOGY
•Surgical wounds
•Penetrating wounds
•Blunt wounds
•Burn wounds

12. ACCORDING TO THE DURATION
OF WOUND HEALING
•ACUTE WOUND
•CHRONIC WOUND

13. ACCORDING TO THE WOUND
DEPTH
•SUPERFICIAL WOUND
•PARTIAL THICKNESS WOUND
•FULL THICKNESS WOUND

14. ACCORDING TO
MORPHOLOGICAL
CHARACTERISTICS
•Bruises/Contusion
•Hematoma
•Crush wound
•Abrasions
•Lacrerated wound
•Peneyrated wound
•Perforating wound

15. ACCORDING TO DEGREE OF
CONTAMINATION
•Clean wounds
•Contamination
•Infected

16. ACCORDING TO SEVERITY
•Simple wound
•Complex wound

17. STAGES OF WOUND HEALING
• Hemostasis phase
• Inflammatory phase
• Proliferative phase
• Maturation phase ( Remodelling stage)

19. WOUND ASSESSMENT

20. 1.SIZE
• The wound typically measured first by its lenght, then by
width,and finally by depth.

21. •1=<4square cm
•2=4-<16 square cm
•3=16.1-<36 square cm
•4=36.1-<80 square cm
•5=>80 square cm

22. 2.DEPTH
Measuring the depth (cavity/sinus),length and width of the
wound using a paper tape measure.
Advancing: Edges are pink(Healing is taking place).
Not Advancing:Edges are raised, rolled, red or dusky.

23. •1= Non- Blanchable erythema on
intact skin.
•2= Involving epidermis or dermis.
•3= Full thickness skin loss involving
damage or necrosis of subcutaneous
tissue.
•4= Obscured by necrosis.
•5= Extensive destruction, tissue
necrosis or damage to muscle, bone
or supporting structures.

24. 3.EDGES
• It’srefers to rolled or curled- under closed wound Edges

25. •1= None clearly visible.
•2=Outline clearly visible.
•3=Well defined, not attached to wound base.
•4=Well defined, not attached to wound base, r
under, thickened.
•5=Well defined, fibrotic, scarred or hyperkerato

26. 4.UNDERMINING
• The wound will be measured with a probe in the tunneling or
undermining wound until resistance is met.

27. •1= None present.
•2= Undermining <2 cm in any area.
•3= Undermining 2-4 cm
involving<50% wound margin.
•4= Undermining 2-4 cm
involving>50% wound margin.
•5 = Undermining >4 cm or Tunneling
in any area

28. 5.NECROTIC TISSUE TYPE
• Eschar and Slough.
Eschar present as dry, thick, leathery tissue that is often tan,
brown or black.
Slough is characterized as being yellow, tan, green or brown in
color and maybe moist, loose and stringy in appearance.

29. •1= None visible.
•2= White/ grey.
•3= Yellow slough.
•4= Soft, black eschar.
•5= Hard, black eschar.

30. 6.NECROTIC TISSUE AMOUNT
• Necrotic tissue is a medical condition in which there are dead
cells in your body organ. The death of the cells happens due to
lack of oxygen and interrupted blood supply.

31. •1= None visible.
•2= <25% of wound bed covered.
•3= 25% to 50% of wound covered.
•4= >50% and <75% of wound
covered.
•5= 75% to 100 % of wound
covered.

32. 7.EXUDATE TYPE
• When assessing exudate, fluid consistency such as watery or
varicose.

33. •1= None
•2= Bloody
•3= Serosanguineous
•4= Serous
•5= purulent

34. 8.EXUDATE AMOUNT
• Minimal amount of Exudate on the dressing (exudate covers
less than 25% of the bandage.
• Moderate: 25% to 75% Of bandage.
• Large: more than 75% of the bandage

35. •1= None
•2= scant
•3= Small
•4= Moderate
•5= Large

36. 9.SKIN COLOR SURROUNDING
WOUND

37. •1= pink
•2= Bright Red
•3= White or grey pallor or hypo
pigmented
•4= Dark red or purple
•5= Black or hyper pigmented

38. 10.PERIPHERAL TISSUE EDEMA
• Peripheral edema is an accumulation of fliud in the interstitial
space the occurs as the capillary filtration exceeds the Limits of
lymphatic drainage.

39. •1 = No swelling or edema
•2 = Non pitting edema extends <4 cm
around wound
•3 = Non pitting edema extends> 4 cm
around wound
•4 = Pitting edema extends<4 cm around
wound
•5 = Crepitus and pitting edema extends>
4 cm around wound

40. 11.PERIPHERAL TISSUE
INDURATION
• Induration is abnormal firmness of tissue with margins. Assess
by gently pinching the tissue.
• Induration results in an inability to pinch the tissue.

41. •1 = Non present
•2= Induration,<2 cm around wound
•3 = Induration 2-4 cm extending
<50% around wound
•4 = Induration 2-4 cm
extending>50% around wound
•5 = Induration>4 cm in any area
around wound

42. 12.GRANULATION TISSUE
• Granulating tissue is appears red and moist.

43. •1 = Skin intact or partial thickness wound
•2 = 75% to 100% of wound filled or tissue
overgrowth
•3 = <75% &>25% of wound filled
•4 = Fills <25 % of wound
•5 = No granulation tissue present

44. 13.EPITHELIALIZATION
• Epithelialilization is defined as a process of covering denuded
epithelial surface.

45. •1= 100% wound covered, surface intact
•2 = 75% to <100% Wound covered
•3 = 50 % to <75% wound covered
•4 = 25% to <50% wound covered
•5= <25% wound covered

46. WOUND STATUS CONTINUUM
THERE INCLUDES THE COMPONENTS
OF ;
•Tissue Health
•Wound regeneration
•Wound degeneration
. -By. Bates-
jensen

49. NURSE‘S RESPONSIBILITY
• Identify the wound location
• Determine the cause of the wound.
• Evaluate for foreign bodies or neoplastic process.
• Evaluate and Measure the depth, length, and width of the wound.
• Keep the wound moist.
• Apply topical antibiotics and antiseptic as recommended.
• Apply appropriate wound dressing.
• Remove any dying tissue.

50. TYPES WOUND OF
DRESSING

51. SOLUTION USED FOR DRESSING

52. WOUND PRINCIPAL’S
• Wound assessment
• Wound cleaning
• Timely dressing change
• Selection of appropriate dressing
• Antibiotic use