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To evaluate wound progression and check for infections, you should conduct a basic assessment at every dressing change, using an assessment tool, such as the Triangle of Wound Assessment.
The condition of both the wound and patient should match the goals and objectives identified in your care plan.
You should conduct a full holistic and wound re-assessment every 4 weeks in the community or general practice setting or 2 weeks for the acute setting – including measuring the wound depth, length and width – to monitor healing progression, overall patient wellness and care plan concordance.
Examples of wound progression
Healthy wound edge
Healthy periwound skin
Granulating wound bed
Day 0:
Wound depth 9mm and width 40mm.
Day 40:
Wound depth 2mm and width 25mm.
When you re-assess it is important to determine:6
- If the current dressing regime met clinical and patient objectives.
Remember: The condition of a previous dressing can indicate if a change is needed in regards to dressing type or frequency of dressing changes. - If the care plan needs to be changed.
Remember: To follow your local guidance in relation to referral to a specialist such as the Tissue Viability Team if the wound is deteriorating. - If the patient needs to be referred to a specialist.
Remember: A deterioration in the wound or the patient’s overall wellbeing should trigger automatic referral to a wound care specialist. - If further diagnostics are required
- M.R. Liberato de Moura, C. Dowsett. Advancing practice in holistic wound management: a consensus-based call to action. Wounds International 2020;11(4)
- Price P, Krasner DL. Health-related quality of life and chronic wounds: evidence and implications for practice. In: Krasner DL, Rodeheaver, GT, Sibbald RG, Woo KY, eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. Vol 1. 5th ed. Malvern, PA: HMP Communications; 2012
- Strohal, R., Apelqvist, J., Dissemond, J. et al. EWMA Document: Debridement. J Wound Care. 2013; 22 (Suppl. 1): S1–S52.
- Dowsett C et al. Triangle of wound assessment. Made easy. Wounds International, May 2015
- Dowsett et al. (2020). Closing the gap between the evidence and clinical practice – a consensus report on exudate management (11(3))
- Wounds UK. (2018). Best Practice Statement Improving holistic assessment of chronic wounds. London: Wounds UK.
Also in this section
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WoundTheme
Developing a care plan
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WoundTheme
What is the Triangle of Wound Assessment?
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WoundTheme