Wound Assessment and the RN
June 6th, 2012
By Jennifer Olin, BSN, RN
Caring for patient’s wounds is a large part of many nurses’ jobs. If you are a flight or emergency
Wound Assessment and the RN
June 6th, 2012
By Jennifer Olin, BSN, RN
Caring for patient’s wounds is a large part of many nurses’ jobs. If you are a flight or emergency room (ER) nurse you see fresh trauma wounds; if you work on a floor in a hospital you may well be in charge of taking care of surgical wounds. Knowing how to assess a wound is key to taking care of your patient.
Nurses commonly assess both “untreated” and “treated” wounds. “Untreated” wounds are those found at the scene of an accident or in the Emergency Department. Assessing in the field or the ER starts with basic emergency care, in other words, your A-B-Cs. Once you have determined the victim has a clear airway, is breathing adequately and has a pulse then you look at the wound.
Assessing Untreated Wounds
- Check the size and severity of the wound. If you are in the field arrange for transport, if you are in an ED arrange for a physician.
- Inspect for bleeding. How much blood depends on the wound type and location. Penetrating wounds may cause internal bleeding.
- Look for foreign bodies such as soil, broken glass, shreds of cloth or other substances.
- If the wound is contaminated with foreign material, determine when the client last had a tetanus shot.
- Assess for associated injuries such as fractures, internal bleeding, spinal cord injuries, or head trauma.
Guidelines For Care of the Untreated Wound
- Control severe bleeding by applying direct pressure over the wound and elevating if it is on an extremity.
- Prevent infection by cleaning or flushing abrasions or lacerations with water and covering the wound with a clean or sterile dressing, if possible. When applying a dressing, wrap the wound tightly enough to apply pressure and approximate the wound edges, if possible. If bleeding saturates the first dressing, apply a second layer without removing the original dressing. Removing it may disturb clots that have already formed and increase bleeding.
- Apply ice to the wound to reduce swelling and pain.
- If bleeding is severe or internal bleeding is suspected assess the patient for signs of shock.
Assessing Treated Wounds
“Treated” wounds are usually assessed to determine the progress of healing. They may be inspected during a dressing change, however if the wound itself cannot be directly inspected, the dressing is inspected and other data, such as pain, assessed.
These days many “treated” wounds are covered with a transparent occlusive dressing that permits observation of the wound with complete exposure. You will be assessing using the following guidelines:
- Appearance – Inspect color of wound and surrounding area and approximation of wound edges.
- Size – Note size and location of dehiscence, if present. For wounds healing by “secondary intention” measure the length, width, and depth in centimeters.
- Drainage – Observe location, color, consistency, odor, and degree of saturation of dressings. Note number of gauzes saturated or diameter of drainage on gauze.
- Swelling – Wearing sterile gloves, palpate wound edges for tension and tautness of tissues. A small to moderate amount of swelling is normal in the early stages of healing.
- Pain – Expect severe to moderate postoperative pain for three to five days; persistent severe pain or sudden onset of pain may indicate hemorrhaging or infection.
- Drains or Tubes – Inspect drain security and placement, amount and characteristics of drainage. Make sure drainage apparatus is working, if present.
Surgical wounds follow a standard sequence when healing. The nurse can expect:
- There should be an absence of bleeding and the appearance of a clot binding the wound edges. The wound edges are well approximated and bound by fibrin in the clot within the first few hours after a surgical closure.
- There should only be inflammation at the wound edges for the first one-to-three days.
- As granulation tissue starts to bridge the wound there should be a reduction in inflammation as the clot diminishes. The wound should be closed with seven-to-10 days. Increases in inflammation, fever, and drainage likely indicate an infection of the wound site. The wound edges will appear brightly inflamed and swollen.
- Collagen synthesis starts four days after injury and continues for six months or longer, forming the scar.
- Scar size will lessen over a period of months or year. An increase in scar size indicates keloid (irregularly shaped scars that progressively enlarge) formation.
Wound Care Nursing
A whole specialty in nursing has grown up around wound care and management. Wound care nurses work with a patient's medical team to monitor a variety of wounds and their healing process. They also care directly for the patient, promoting healthy and rapid healing of a wide variety of wounds. The minimum qualification for work in this nursing specialty is a nursing certification but most wound care nurses pursue additional board certification from a professional organization such 