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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 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.
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 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.
Other assessment tools may focus on a specific aspect of the patient's care. For example, the Waterlow score and the Braden scale deals with a patient's risk of developing a Pressure ulcer (decubitus ulcer), the Glasgow Coma Scale measures the conscious state of a person, and various pain scales exist to assess the "fifth vital sign".
The nursing documents may contain a number of assessment forms. In an assessment form, a licensed Registered Nurse records the client's information, such as physiological, psychological, sociological, and spiritual status (see Figure 2). The accuracy and completeness of nursing assessment determine the accuracy of care planning in the nursing ...
Wound, ostomy, and continence nursing is a nursing specialty involved with the treatment of patients with acute and chronic wounds, patients with an ostomy (those who have had some kind of bowel or bladder diversion), and patients with incontinence conditions (those with issues of bladder control, bowel control, and associated skin care).