In a patient who is healthy and without underlying disease, healing usually occurs without complex topical treatments. A chronic wound does not proceed through the phases of wound healing in an orderly or timely fashion. If a wound has not shown evidence of healing or has not healed within four weeks, it may be a chronic wound. Wound Assessment Wound assessment is a complex process that involves a thorough examination of the entire wound. Nurses visually assess wounds and document their findings to monitor and evaluate the progress of wound healing.
Documentation needs to address the following eight areas.
Describe the anatomic location of the wound to ensure accurate documentation and communication to other members of the healthcare team. Measure the length, width, and depth of the wound in centimeters for consistency in documentation. When measuring the depth of a wound, gently insert a sterile cotton-tipped applicator into the deepest part. Measure from the tip of the applicator to skin level. Both conditions result in dead space, open areas beneath the skin that can lead to further tissue destruction and infection.