Nursing Care In Hdu

All Wounds Are Not The Same!

Wound assessment (Subjective)

Remember to ask the client:

Ð'Ñ"Ð"ÐŽ Location

Ð'Ñ"Ð"ÐŽ Timing - Cause/When first appeared

Ð'Ñ"Ð"ÐŽ Size

Ð'Ñ"Ð"ÐŽ Better/Worse - What treatments have worked/what hasnÐ'ÐŽÐ'¦t.

Ð'Ñ"Ð"ÐŽ Changes from initial wound

Ð'Ñ"Ð"ÐŽ Associated Symptoms Ð'ÐŽVitching, pain, redness.

A full ROS will also highlight any other problems that need to be addressed in order to maximise wound healing.

Wound Assessment (Objective)

Crisp and Taylor (2005) use the following headings when attempting to objectively describe a wound:

Skin Integrity:

Ð'Ñ"Ð"ÐŽ Open

Ð'Ñ"Ð"ÐŽ Closed

Ð'Ñ"Ð"ÐŽ Acute

Ð'Ñ"Ð"ÐŽ Chronic

Cause:

Ð'Ñ"Ð"ÐŽ Intentional

Ð'Ñ"Ð"ÐŽ Unintentional

Severity:

Ð'Ñ"Ð"ÐŽ Superficial

Ð'Ñ"Ð"ÐŽ Penetrating

Ð'Ñ"Ð"ÐŽ Perforating

Cleanliness:

Ð'Ñ"Ð"ÐŽ Clean

Ð'Ñ"Ð"ÐŽ Clean-Contaminated

Ð'Ñ"Ð"ÐŽ Contaminated

Ð'Ñ"Ð"ÐŽ Infected

Ð'Ñ"Ð"ÐŽ Colonised

Ð'Ñ"Ð"ÐŽ Another