Wound Care

242 Nurse to Nurse
client and caregiver are educated about handwashing
for all care providers before wound evaluation or
treatment. The client and caregiver are expected to
observe and request when necessary for care
providers to perform handwashing before wound
evaluation or treatment is performed.
• Subsequent encounters:
— Evaluate client and caregiver adherence with homework
— Evaluate wound including measurements, description of
periwound area, evidence of necrotic tissue, wound
bioburden
— Continue with education and homework at each
encounter*
CHRONIC WOUND HEALING
Determination of amount of skin damage (Table 9–1).
• No reverse order staging once the ulcer is staged, it is always
that stage. Be sure to indicate healing.
• Staging is NOT possible in the presence of slough, tissue necrosis,
or eschar that hampers proper visualization of the wound
bed and the wound should ONLY be thoroughly described by
the health-care practitioner in these circumstances.
Nursing Alert
Staging of wounds is for use in pressure ulcers ONLY.
WOUND ASSESSMENT
The wound assessment is the written record, photograph, picture,
drawing, and diagram of the progress of the wound and
all the observations about that wound, data collection, and
evaluation over time.