Nurses who manage wounds will be interested to access the enclosed article for download titled the Triangle of Wound Assessment. Wound assessment is essential in informing the selection of appropriate therapeutic strategies to achieve clinical goals, e.g. wound healing and improved patient wellbeing.
This article describes a new approach to wound assessment that encourages us to look beyond the wound edge to routinely assess and manage the periwound skin using a new tool. It divides assessment of the wound into three areas: the
wound bed, the wound edge, and the periwound skin. It should be used in the context of a holistic assessment that involves the patient, caregivers and family.
- ”The Triangle of Wound Assessment identifies three different but also interconnected variables to consider.
Wound bed: look for signs of granulation tissue, while seeking to remove dead or devitalised tissue, manage exudate level and reduce the bioburden in the wound.
- Wound edge: lower barriers to wound healing by reducing undermining for dead space, debriding thickened or rolled edges, and improving exudate management to minimise risk of maceration.
- Periwound skin: rehydrate dry skin and avoid exposure to exudate/moisture to minimise the potential for damage.
We appreciate that the next ‘goal’ for the wound will alter depending on the range of variables including the patient’s health status. The tool identifies some of the key goals associated with wounds which in part include the following:
- Protect the granulation /epithelial tissue
- Debride non-viable tissue to reduce infection
- Maintain moisture balance – i.e. rehydrate or reduce the wound exudate levels to create a moist wound environment using an appropriate dressing product
- A key reminder is not to promote moist wound healing where you are dealing with dry gangrene and the objective is to keep the digit/ area dry and not moist
- A strong focus on reducing wound bio-burden and managing infection through the utilisation of topical antimicrobial therapy and the use of antiseptic agents, combined with the use of antibiotic therapy for spreading or systemic wound infections
- Protect the periwound area to reduce the risk of maceration due to excess moisture
- Improve patient wellbeing i.e. reduce pain and wound odour
Its worth a read and I recommend downloading the article for your consideration and reference in the workplace.
The Nursing CPD Institute provides great information and CPD on an array of nursing topics including wound care in a range of easy learning ways including webinars and quizzes on the latest information that Nurses need to know – remember it was created by Australian Nurses for Nurses! https://www.ncpdi.com.au