WOUND HISTORY

It is important to determine how long the wound has been present, and any factors that may have contributed to the wounds development, e.g. surgery, trauma, poor seating, inadequate pressure care, infection or general poor health (Eagle, 2009). Failure to identify accurately and correct causation factors results in failure to heal due to a persistent ‘cycle of injury’. For example a patient with a pressure ulcer must be placed on an appropriate pressure redistribution surface and a turning schedule. Major clues as to aetiologic factors include location, wound contours, depth and patient history.

Look at the Wound

A large amount of information can be gained from looking at a wound and speaking to the patient.

Type of Wound

Wounds can be acute or chronic, and heal by either primary or secondary intention. Acute wounds result from surgery or trauma, and usually have a relatively short, uneventful healing time.

Chronic wounds are those such as leg ulcers, pressure ulcers, diabetic foot ulcers and malignant wounds. They tend to have longer healing times, are prone to infection, and may have increased levels of exudate due to prolonged inflammation (Eagle, 2009). Is the wound healing by primary intention? (see module 2). There is often minimal tissue loss and the healing process is short.

Is the wound healing by secondary intention? (see module 2). Usually an open wound where the wound edges cannot be easily brought together.

Cause

An experienced practitioner will be able to determine the cause of a wound by its appearance and position. For example if a wound is caused by pressure, the cause will influence the healing process if not removed. The history of the wound is also useful to determine the cause.

Clinicians should consider if the wound is acute or chronic and if it is caused by pressure, infection, trauma, surgery, vascular insufficiency, neuropathy or an underlying condition. If the patient has more than one wound, each of the wounds should be assessed individually and documented.

It is important not to forget to assess the skin surrounding a wound as this may also hold vital clues as to the aetiology of a wound. It is also important to try and understand the cause of each wound, so that the cause of the wound can be treated, as well as the wound itself.

Site

As stated above, the position of a wound can help determine its cause and also act as an indicator of potential complications, such as the risk of contamination in the sacral region. The site of a wound will also help determine the most appropriate dressing or treatment choice.

Size and Depth

It is important to measure the size and depth of the wound so that the progress of the wound can be measured over time.

The results documented in the patient’s notes at each dressing change.

There are many different methods of measuring wounds. To measure the wound size, a photograph is sometimes taken or a picture is drawn, and measurements made with a ruler.

Visual documentation of the wound is useful and can be achieved through tracing or photographing the wound. If photographing the wound, ensure local guidance is adhered to and the patient’s permission is documented prior to the image being taken.

To measure depth, a probe is sometimes inserted into the wound and then measured. It is often difficult to measure depth as small sinuses may be hidden by wound debris. Measuring depth can present a problem in cavity wounds as often the cavity will extend to deep tissues underneath healthy tissue. Clinicians often map the extent of the cavity onto the healthy skin, this helps to map the progress of wound healing and also ensures that the wound is dressed effectively.

However, the three dimensional structure of a wound and the natural curvature of the body as well as the way in which the individual practitioner uses the measurement tool, especially in defining the wound boundary, will affect the accuracy of these measurements (Khoo, 2016). The usefulness of measuring the depth of a wound has been questioned as it is quite difficult to obtain an accurate measurement (Benbow, 2005; Khoo 2016).

The size and depth of a wound will have an effect on the length of time a wound will take to heal (Wound Source, 2012).