Acute wound assessment

Acute wounds are wounds which are expected to progress through the normal stages of healing and are not associated with features of chronicity such as a prolonged inflammation in the wound tissues and delayed healing (Rucigaj, 2022). Initially, traumatic wounds are considered acute although they may become chronic due to numerous factors including the aetiology (cause) of the wound, patient co-morbidities and the quality of initial wound management (Guo and DiPietro 2010).

Acute wounds may include wounds with varying aetiologies such as:

• Surgical wounds
• Penetrating trauma
• Lacerations
• Abrasions
• Blast injury
• Burns

These different aetiologies require different approaches to treatment, and it is therefore essential that the aetiology is determined during the initial wound assessment and documented clearly. By undertaking an effective wound assessment, appropriate management plans can be developed and evaluated.

The first part of a wound assessment is obtaining a robust history of the wound. Examples of questions which could be asked during this process may include:

1. How and when was the wound created? (may help determine aetiology)
2. What co-morbidities does the patient have? (identifies factors affecting healing)
3. How does the wound affect the patient e.g. pain/mobility/movement? (identifies key nursing issues to be addressed as part of the management plan)

Other things to consider when assessing an acute wound include:

1. What anatomy is affected (this may impact on treatment options and warrant referral to other relevant professionals e.g. medical/ surgical teams)
2. Is the wound life threatening?
3. Where on the body is the wound? (this may have implications for longer term management e.g. scar contraction over a joint may limit movement)

The following equipment is required to carry out a wound assessment:

• Sterile dressing pack and spare sterile gloves (dressing pack should include sterile drape, gallipot, sterile gloves, swabs and measuring tape)
• Rubbish bag
• Personal protective equipment (apron and gloves)
• Dressings
• Cleansing solution, potable tap water is acceptable (Cornish and Douglas 2016)
• Wound probe
• Forceps
• Wound swab and sample pot
• Adhesive remover (if necessary)
• Dressing trolley (if available)
• Detergent and antiseptic cleansing wipes to prepare dressing trolley (if necessary)
• Digital device (this could be a camera or smart phone) for imaging and potentially other assessment functions such as tissue type analysis or documentation (if available)

* Please note that in community settings a dressing trolley may not be available. Aim to use a horizontal surface where your dressing pack can be opened easily with a low risk of contamination by household objects, pets or people.

1. Obtain a thorough history of the wound
2. Obtain consent to assess the wound
3. Wash hands
4. Don personal protective equipment
5. Clean dressing trolley using detergent wipe, followed by an antiseptic wipe e.g. alcohol or chlorhexidine to disinfect the trolley surface.
6. Remove gloves and wash hands
7. Open the dressing pack using an antiseptic non-touch technique.
8. Don non-sterile gloves
9. Remove any dressings in situ
10. Doff non-sterile gloves and don sterile gloves
11. Cleanse the wound using potable water and gauze. Remove any overt debris in the wound using forceps
12. Examine the wound considering the acronym TIMERS (Table 1)
13. Obtain a photograph of the wound (with consent)
14. Inform patient of the outcome of the assessment and the rationale for the proposed treatment plan, discuss this with the patient and include them in decision making ensuring they are informed of the current evidence related to any treatment options you propose
15. Document the outcome of the assessment

When assessing the wound, it is important to consider factors which may be detrimental to healing. These may include:

• Excessive amounts of time without a dressing in place or using excessive cold cleansing fluids may cause cooling of the wound tissues which may delay healing (Wynn, 2021)
• Pain may be caused if highly adherent dressings are removed without using an adhesive remover or the wound tissues are handled aggressively (Gardner et al, 2017)
• Poor documentation of the wound tissues, dimensions and lack of imaging may impede evaluation of the efficacy of management plans. This may lead to both delayed wound healing, potentially increase the risk of infection and increase the costs of wound care (Greatrex-White and Moxey, 2013)

Effective wound assessment requires a good understanding of the pathophysiology of healing and the factors which may impact healing. In cases where there is uncertainty over the aetiology of a wound or the cause(s) of delayed healing, specialist advice should always be sought.

Any nurse undertaking wound assessment should ensure they consider local policies and procedures. Ensure any digital devices used during the wound assessment process and for documentation have been approved for use by your employer to ensure compliance with data security protocols. Patients should be well informed about the assessment of their wounds and treatment plans. In some cases, patients may want photos of their wounds taken on their own devices to allow them to track healing themselves and this should be facilitated where possible.

References

Atkin L, Bućko Z, Montero EC et al. Implementing TIMERS: the race against hard-to-heal wounds. J Wound Care. 2019; 3(Sup3a): S1-S50. https://doi.org/10.12968/jowc.2019.28.Sup3a.S1

Cornish L, Douglas H. Cleansing of acute traumatic wounds: tap water or normal saline? Wounds UK. 2016; 12(4), 30-35.

Gardner SE, Abbott LI, Fiala CA et al. Factors associated with high pain intensity during wound care procedures: A model. Wound Repair and Regen. 2017; 25(4), 558-563. https://doi.org/10.1111/wrr.12553

Greatrex-White S, Moxey H. Wound assessment tools and nurses' needs: an evaluation study. Int Wound J. 2015;12(3), 293-301. https://doi.org/10.1111/iwj.12100

Guo S, DiPietro LA. Factors Affecting Wound Healing. J Dent Res. 2010; 89(3), 219-229. https://doi.org/10.1177/0022034509359125

International Wound Infection Institute (IWII). Wound infection in clinical practice. 2016. https://www.woundsinternational.com/resources/details/iwii-wound-infection-clinical-practice (accessed 19 January 2022).

Ručigaj TP. Skin Wound Healing. In, B. Smoller & N. Bagherani (Eds.). Atlas of Dermatology, Dermatopathology and Venereology: Cutaneous Anatomy, Biology and Inherited Disorders and General Dermatologic Concepts, pp. 227-236.