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Wound assessment is a component of wound management.As far as may be practical, the assessment is to be accomplished before prescribing any treatment plan. The objective is to collect information about the patient and about the wound, that may be relevant to planning and implementing the treatment.
The Lund and Browder chart is a tool useful in the management of burns for estimating the total body surface area affected. It was created by Dr. Charles Lund, Senior Surgeon at Boston City Hospital , and Dr. Newton Browder, based on their experiences in treating over 300 burn victims injured at the Cocoanut Grove fire in Boston in 1942.
The International Red Cross wound classification system is a system whereby certain features of a wound are scored: the size of the skin wound(s); whether there is a cavity, fracture or vital structure injured; the presence or absence of metallic foreign bodies. A numerical value is given to each feature (E, X, C, F, V, and M).
This parameter measures a patient's ability to detect and respond to discomfort or pain that is related to pressure on parts of their body. The ability to sense pain itself plays into this category, as does the level of consciousness of a patient and therefore their ability to cognitively react to pressure-related discomfort.
Total body surface area (TBSA) is an assessment of injury to or disease of the skin, such as burns or psoriasis. In adults, the Wallace rule of nines can be used to determine the total percentage of area burned for each major section of the body.
The following areas are assessed for each patient and assigned a point value. Build/weight for height; Skin type/visual risk areas; Sex and age; Malnutrition Screening Tool
The Abbreviated Injury Scale (AIS) is an anatomically based consensus-derived global severity scoring system that classifies each injury in every body region according to its relative severity on a six-point ordinal scale:
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.