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Assessment & Reporting for Wound Care

Assessment & Reporting for Wound Care

Your overall health determines wound healing, so a thorough examination of your health care professional is essential when planning and evaluating treatment.

Patient report
When diagnosing and reporting on a patient, your health care provider will be sure to note the following:

  • Complete medical histories such as diabetes, vascular disease, compromised immune system, connective tissue disorders and allergies
  • Medications
  • Nutritional status
  • Lifestyle, for example, smoking and alcohol habits or mobility impairment
  • Mental problems
  • Health quality

Wound assessment

Determining the underlying cause of an ulcer is an integral part of a wound test and you can treat the wound once it has been discovered. You will also need to check the wound bed and the surrounding skin. After doing these assessments, you can choose the best wound dressing.

Wound report

When diagnosing and reporting a wound, you will want to note the following:

  • Wound location, size and type
  • Features of the wound bed, such as necrotic tissue, granulation tissue and infection
  • Odour and exudate (none, low, medium, high)
  • The condition of the surrounding skin (normal, white, shiny, warm, red, dry, thick, thin)
  • Clinical symptoms of wound infection (delayed cooling, odor, abnormal granulation tissue, increased wound pain and / or excessive exudate)
  • Wound pain (pain area, duration of pain, pain intensity, nociceptive or neuropathic)
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