Assessing the Wound (Nursing)

00:04 So let's take a look at some characteristics in regards to wound assessment.

00:09 So there are six things on this slide.

00:11 And this is important about how we assess and also how we document, and we'll discuss this further.

00:17 So of course, when we talk about wound care, we got to know where it is right? So, what's the location when we assess that wound and what type? There's lots of different types.

00:27 This could be incision, it could be a laceration or abrasion.

00:32 It's important to know the type of wound on assessment because that will affect to how it heals.

00:38 Next, we got to think about the type of wound tissue when we're talking about wound assessment.

00:43 And believe it or not measuring the wounds really important.

00:47 That's how we progress if the wounds getting bigger or worse, or if it's getting better.

00:53 This next word is called exudate.

00:55 You may have never heard of that.

00:57 But what we're talking about is assessing the drainage of the wound.

01:00 That drainage actually tells us some really key things in the healing process.

01:05 And there's that allude again, or that word again, peri-wound, this is the tissue around the wound.

01:11 And again, this is important to assess, that's going to help keep the integrity of the healing of the surrounding skin.

01:18 We just talked about the six different categories in regards to wound assessment.

01:22 And I'll take you through each one of these.

01:25 The first one is location.

01:27 This is really important that we're specific about where that wound is.

01:31 So here's a really poor example about describing wound location.

01:36 "Client has a wound on their leg." Well, that's not very helpful as it.

01:40 It could be anterior, posterior, we don't know if it's on the upper thigh.

01:44 This is not a great example about a description on where it's located.

01:48 So let's take a look at this other slide.

01:50 This is much better on a description such as, "Client has a wound on their right distal medial upper leg." That's much more specific than the previous example.

02:03 So now let's take a look at the different types of wounds.

02:06 This is going to actually be really important because it's going to determine how we treat it.

02:11 So this first slide and the example you see here is normal skin integrity.

02:15 That's what we want to see that epidermis is intact.

02:18 This is before we get into these wounds.

02:21 So let's take a look at the next kind.

02:23 This is an incision wound.

02:25 So this is usually a clean approximated edges.

02:28 And this is typically post surgery.

02:31 So this could be on a patient's hip or their knee or their back, for example.

02:36 The next kind of wound is more of the tearing of the skin called a laceration wound.

02:42 This could be from some sort of trauma, for example.

02:45 Now the next wound that I think about is what we call an abrasion.

02:49 This is something that takes me back for when I was a kid and I fell off my bike and I scraped up my elbows really bad.

02:56 This is more of an abrasion type wound.

02:59 Now the next half, we're going to talk about some other types of wounds.

03:02 And one of those is a puncture wound.

03:05 This may be not as common but what this makes me think of is maybe if you work in an ER and you see someone with a knife wound for example, that's a great example of a puncture wound.

03:16 Now a pressure wound is something that you will see most commonly, this is really common occurrence that can happen with the patients in mobile and bed, in the varying degrees of pressure wound can go from pretty mild to pretty severe.

03:31 Now the next two wounds are a little bit different.

03:34 So this is called a contusion and usually the skins intact.

03:37 Think of this as more like a bruise.

03:40 And lastly, when we're talking about types of wound, you may hear the word hematoma.

03:45 Now what this means there's a pocket of blood, for example, caused by some sort of bleeding or some sort of trauma.

03:52 Now let's take a look at different types of wound tissue.

03:55 So this one is what we see here in this lovely slide is called granulation tissue.

04:00 Believe it or not, it may look a little bit bad, but this is actually a good thing.

04:05 See how this wound bed is red.

04:07 This is all nice new tissue that's healing.

04:10 So this is a positive here.

04:12 You may also see this different type of wound tissue called slough.

04:17 Now this is due to the inflammatory process.

04:19 And this typically means there's some dead cells in here, there's some debris.

04:24 See how it's kind of yellowish and you don't see all the nice red, that's typically something that we may have to remove in regards to wound healing.

04:33 And lastly, you see, this is called eschar.

04:36 This may look pretty crazy to you, but this means that there's dead tissue within the wound.

04:42 So think about it this way.

04:44 You see on this image, the black is actually sitting inside the wound that's called eschar.

04:50 Now I want you to think about the difference between eschar and like a scab that you get.

04:55 What the difference is a scab actually sets on top of the wound or eschar is inside the wound.

05:01 So we're talking about a major wound, eschar may be noted.

05:06 Now, here's the problem with eschar.

05:08 You may not be able to see everything underneath and what's going on with that wound.

05:13 So sometimes we may have to remove this for healing.

05:17 Also, before we leave this slide, I want to go back really quickly to granulation tissue.

05:23 Here's the thing to know when you're a nurse in regards to wound healing.

05:27 Believe it or not, we actually want to see that red, that ooze, a little bit of bleeding tissue.

05:33 Again, nice pink or nice red tissue, as you see in the granulation slide, that is a positive thing for wound healing.

05:41 That means bloods coming to the surface, and we're oxygenating that tissue, which is important for wound healing.

05:48 Now, let's talk about measuring the wound for assessment.

05:52 This may seem like an odd thing to you, but we do this because this will help us track the wounds.

05:58 So one thing to note is if you're in a acute care facility, there is something we call the wound care team.

06:05 And thank goodness for this team.

06:08 They're advanced certified nurses that are diligent in wound care assessment.

06:13 And sometimes as a bedside nurse, you may do wound measurement.

06:17 But a lot of the times, the wound care team, if it's a complex wound, it will track that wound.

06:22 And they do that by measurement.

06:25 So let me show you how we do measurement here.

06:27 So we usually do by three different things such as width, as you see here.

06:32 We'll do the full length of it and also the depth.

06:36 So know this is kind of tricky.

06:39 So you see that we typically take like a cotton tip applicator, we will put it to the deepest part of the wound standing up, we're going to take that cotton tip applicator and compare it to a measuring tape and see how deep that wound.

06:52 Believe it or not, guys, these can get really deep.

06:55 But again, using these measurements of width, length and depth, this is really helpful to track the progress of that wound.

07:03 And as you see on this slide, many times we'll use a sterile, by keyword, sterile cotton tip applicator for measurement and also a measuring tape.

07:14 Now let's take a moment and we you heard this funny word before, but this is called exudate.

07:19 This is actually really important in regards to assessment of a wound and what you should expect as a nurse.

07:25 So see all these progression of colors, we'll talk about these.

07:30 So exudate, the fluid produced by a wound again, as it heals.

07:34 Again, guys, this is normal, this is what we should see is going from that clear all the way to kind of that yellowish at the end, we'll talk about this again more in depth.

07:44 So we're talking about exudate.

07:47 This is actually really important to kind of know your exudate here.

07:51 And we classify by 4 different categories.

07:54 How much exudate or otherwise known as drainers there is? What color is it? What consistency it is and the odor? So let's talk about the amount.

08:04 So this is important in documentation and assessment.

08:08 It can go if you look at this category from basically not much at all, all the way down the copious, that seems like an odd word.

08:16 But we're talking about copious it's not just a little bit, it's a lot of extra fluid and probably more than is normally expected for a wound.

08:25 So copious drainage is not always a positive thing.

08:29 So again, it goes from none all the way down to copious.

08:33 Next we'll look at the color of the wound.

08:36 These names are very hard to spell I know as a nursing student, but get familiar with these because this is how we document the color of the drainage.

08:44 It should go by serous to sanguineous so bloody, serosanguineous where you get a little bit of clear fluid, a little bit of blood.

08:53 And then purulent could be a negative sign.

08:56 Purulent drainage could be discolored, it could be signs of infection.

09:00 So why it's important to get familiar with the color of your drainage.

09:05 And next consistency.

09:07 This may kind of sound a little gross, but your exudate should be fairly thin.

09:12 Sometimes they can get really thick, or even what we call tenacious if they're signs and symptoms of infection.

09:19 And next is odor.

09:21 So know that there's sometimes an odor with a wound and sometimes there's not.

09:25 Now if there's a foul odor, again, that could be signs of infections that we need to report.

09:31 Now the next few slides we're going to discuss each one of these options and show you more examples.

09:37 So let's take a look at that exudate amount again.

09:40 So you see here this is called scant.

09:43 So meaning there is a tiny amount as you see on this gauze pad.

09:47 Typically this is nothing for us to worry about as a nurse.

09:50 Something we'll keep an eye and to see if it gets any worse when we're looking at a wound dressing.

09:55 We look at this next one is about moderate drainage.

09:59 And this next slide is more large.

10:00 So this gives you a great comparison on the image.

10:04 So here is that copious.

10:06 Now I want you to compare the copious to the large.

10:09 If you have copious exudate, what that typically means, it's saturating through the bandage so much that we're going to have to change that out frequently.

10:19 This could be a problem when we're talking about an incision wound, we may need to report that to the physician.

10:26 So now let's talk about color.

10:29 Colors important here.

10:31 So initially, anytime that you have a wound, you start out with serous exudate or serous drainage.

10:36 This is like a light yellowish to clear and this is to be expected.

10:41 Now eventually, that's going to turn to the sanguineous, meaning this is more bloody drainage, and that's perfectly fine as well.

10:48 Now, with more wound healing, we'll have serosanguineous.

10:52 As you can see, it's kind of a mix between serous and the bloody, why we call it serosanguineous here.

10:58 So it's more of like a light red, kind of pink or watery here.

11:02 And next we have purulent drainage.

11:05 This can be thick in consistency, it could be anywhere from like yellow to tan to green to brown.

11:12 We want to watch this purulent drainage because of it's really dark brown, or maybe really green or really wide even.

11:21 This could be an issue with our incision or our wound.

11:26 Now let's go on to consistency and odor.

11:29 So consistency, like we talked about a bit can be thick, it can be thin or tenacious.

11:34 And sometimes again, that wound may have an odor.

11:38 And if it does, we need to monitor this because that could mean there's a complication occurring.

11:44 Now we talked about the peri-wound, if you remember earlier in the presentation.

11:49 This is the part around the wound the skin surrounding it.

11:53 So we need to see, is this red, warm? Is it super swollen? Is it starting to break down around there? If it is, we need to protect this skin integrity, and the peri-wound skin is important to assess.

12:07 Now let's take a look at these bullets here.

12:10 This is some abnormal other key points to know about your wound assessment.

12:14 And if you see any of these things, this could be a particular issue.

12:19 So if there's pain or swelling that's different from when you first assess that wound.

12:24 If that's getting increasingly different, that could be a problem.

12:28 Sometimes with wound assessment, maybe a patient has a wound on their arm.

12:34 If it's getting excessively stiff, that could be an issue.

12:38 And we already talked about that drainage, that's really important to note.

12:42 If it's pussy or if it has an odor, that's definitely abnormal, and we need to report it to the physician.

12:49 Now these last points as well are also abnormal.

12:52 So let's make sure we pay attention to these.

12:55 There's a lot of redness around the wound.

12:58 If your patient spiking a fever, if the wounds not healing, meaning those edges aren't closing in as we're going through that healing process.

13:07 That could be a problem, if it's gaping open, that's not a good sign.

13:11 And lastly, if there's any, here's my wound and it's streaking around it.

13:16 Also a very bad sign and we want to report all of these pieces to the physician.