Wound assessment and treatment

An initial and accurate assessment of a wound is essential in order to establish a baseline, as well as ensure correct and realistic planning of wound healing. The initial assessment should include history taking, physical examination, observation and clinical investigations (Wilson, 2012).

Hess (2019) stated that holistic assessment is vital towards wound healing, as effective wound assessment requires consideration of a broad range of factors.

As part of a holistic wound assessment, healthcare professionals should record the complete medical history (cardiac, renal, endocrine and vascular systems) and medication history of the patient, to understand which underlying factors may affect wound healing (Wilson, 2013).

The healthcare professional must adhere to local policies and assessment tools when assessing patients. Tools such as the Waterlow score for risk assessment, Purpose T and Braden scale can be used to assess patients with pressure ulcers.

Wound assessment is required to identify the underlying cause of both the wound and delayed healing. The clinician must conduct both a local and systemic assessment, as it is very common for wounds to have more than one underlying cause.

Atkin et al (2019) proposed five essential components of effective wound care:

Wound healing is most likely to occur when effective care is continued throughout the patient’s transitions between healthcare professionals and care settings. During these transitions, it is necessary to define the

Healthcare professionals should photograph (if possible) and document their assessment on the patient’s file with the patient’s consent.

Wound assessment involves the 10 following steps:

1. Holistic patient assessment – includes past medical history, medication, physical, psychological, spiritual and social needs. Identify underlying pathophysiological causes, risk factors and wound location.
2. Wound assessment – use aSSKINg if the patient has a pressure ulcer, and TIMERS for other wounds (leg ulcers, surgical, traumatic). Must include measurement (length, width, depth, undermining and tunnelling), wound bed assessment (epithelialisation, granulation, slough, necrosis), exudate type and level, pain and malodour.
3. Identify and manage the underlying problem.
4. Decide realistic outcome, such as wound healing or conservative management, and establish a management plan.
5. Implement wound care in accordance with local policy and/or wound formulary.
6. Follow up, reassessment and measurement.
7. Change care plan and refer, if required, to specialists or a multidisciplinary team.
8. Provide education to the patient, family and carers.
9. Transfer care, if needed, to appropriate team to prevent recurrence.
10. Document outcomes and actions at each point

The main risk associated with wound assessment and treatment relates to misdiagnosis of wound type. Misdiagnosis of a wound (eg leg ulcer, pressure ulcer, traumatic wound, moisture lesion) can lead to a delay in wound healing and/or deterioration of the wound (Hess, 2019). Healthcare professionals should closely adhere to appropriate wound assessment frameworks (eg TIMERS, aSSKINg) to reduce the risk of misdiagnosing a wound.

Wound healing is a natural physiological reaction to tissue injury, which is a complex process involving cellular and biochemical reactions (Hess, 2019).

Wound bed preparation requires healthcare professionals to holistically assess the wound, as well as identify and address the underlying cause. Wound bed preparation incorporates cleansing and debridement to increase the effectiveness of treatment (Ousey and Schofield, 2021).

Cleansing is the effective elimination of loose debris, exudate, bacteria and remainders of previous dressings (Barrett et al, 2022). Cleansing of the wound bed as well as the periwound skin is essential.

Wound debridement removes non-viable tissue, such as necrosis and slough. The most used debridement is autolytic, sharp, larvae therapy and surgical debridement.

Infection prevention helps to overcome delays in healing. All chronic wounds contain bacteria, but not all are infected. Identifying signs and symptoms of infection is a clinical skill, which can be supported by laboratory findings when necessary.

Atkin L, Bućko Z, Conde Montero E, et al. Implementing TIMERS: the race against hard-to-heal wounds. J Wound Care. 2019;23(Sup3a):S1-S50. https://doi.org/10.12968/jowc.2019.28.Sup3a.S1

Atkin L, Tettelbach W. TIMERS: expanding wound care beyond the focus of the wound. Br J Nurs. 2019;28(20):S34-S37. https://doi.org/10.12968/bjon.2019.28.20.S34

Barret S, Dowsett C, Ousey K, et al. Wound preparation by cleansing and debridement using Alprep® Pad. 2022. https://www.wounds-uk.com/resources/details/wound-preparation-by-cleansing-and-debridement-using-alprep-pad (accessed 22 May 2023)

Britto EJ, Nezwek TA, Popowicz P, Robins M. Wound Dressings. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022.

Dowsett C, Newton H. Wound bed preparation: TIME in practice. 2005. https://www.woundsinternational.com/uploads/resources/content_9029.pdf (accessed 22 May 2023)

Hess CT. Misdiagnosis of Wounds. Advances in Skin & Wound Care. 2019;32(3):144. https://doi.org/10.1097/01.ASW.0000553590.13071.99

McCoulough S. NHS improvement guidelines update to the SSKIN model called aSSKINg. Why the update and what does it mean to your organisation? 2020. https://oska.uk.com/nhs-improvement-guidelines-update-to-the-sskin-model-called-assking-why-the-update-and-what-does-it-mean-to-your-organisation/ (accessed 22 May 2023)

National Institute for Health and Care Excellence. Wound