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 .. 26 References .. 29 Kim Kaim 8/19/2016 Page 2 of 31 Assessment Years ago, cleverer people than I could see patterns emerging where if certain things were done there would be better Wound healing outcomes.
quick method and works best with regularly shaped, small to medium sized wounds like the one in the photo on the right(3, 4). Multiply length x width to convert to an area measurement. In irregularly shaped wounds, it is more accurate to trace the wound onto acetate and measure the area by placing the tracing on grid
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