Transcription of Wound Assessment
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Wound Assessment
Kim Kaim 8/19/2016 Page 1 of 31 Wound Assessment Kim Kaim RN BNursing MWoundC Assessment .. 2 History .. 2 Examination .. 3 Measure the Wound .. 4 Wound Location .. 6 Using TIME to assess the Wound .. 7 T is for TISSUE .. 7 I is for INFECTION / INFLAMMATION .. 10 M is for MOISTURE .. 13 E is for EDGES .. 15 Investigation .. 16 Diagnosis .. 16 Implementation .. 17 Collaboration .. 18 Assessment tools used in Wound management .. 18 The digital age .. 21 Appendix A Student Assessment Tool .. 22 Appendix B STAR Skin Tear Classification .. 24 Appendix C Pressure Injury Classifications.
wound with 12 o’clock being at the head. Therefore, in the picture on the right you would describe the undermining as being Xcm extending from 6 O’clock to 9 O’clock. Wound Location The location of the wound will also impact on determining a diagnosis and contribute to the plan(3). Below is a table showing
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