Wound Assessment

Excerpt

Damage or disruption of living tissue's cellular, anatomical, and/or functional integrity defines a wound. Acute and chronic wounds are technically categorized by the time interval from the index injury and, more importantly, by the evidence of physiological impairment. Accordingly, specific treatments, including biofilms, would be planned to address the management of chronic wounds with an impaired physiological outcome. Before treatment, the exact cause, location, and type of wound must be assessed to provide appropriate care. Each clinician will have widely differing and distinct opinions on wound therapy depending on prior experiences. An ostomy nurse will have a completely different approach to wound care than an orthopedic surgeon dealing with an open fracture during a trauma. Both will be far different from a dermatologist who treats burn victims. Nevertheless, each of these healthcare providers is performing wound care. Since non-healing wounds affect millions of people in the United States, impacting a significant percentage of persons 65 years and older, minimizing wound complications is essential in the current healthcare environment.

As non-healing wounds constituted a multi-billion dollar industry of hospital admissions, antibiotics, and local wound care and were called a silent epidemic, this topic will be presented with an emphasis on clinical quality and optimization of patient safety. Moreover, the 0.3 to 0.4 % rate for wound diagnosis has been reported in the general European population. Almost all wounds are colonized with a spectrum of microbes. However, only some of them are considered infected wounds.

Community nurses usually manage patients with chronic wounds. Chronic wounds are identified as wounds persisting for greater than six weeks. Considering the complexity of the patients' health needs and the wound, on the other hand, this is a complicated, perplexing task for the nurse. Accordingly, wound assessment tools are designed to support all qualified nurses in the wound management field in delivering safe and appropriate wound care. The wound assessment tool, TIME, has been recently revised to TIMERS (Tissue, Infection/Inflammation, Moisture, Wound edge, Repair/Regeneration, Social).