Think like a Surveyor, Act Like a Home Care Wound Nurse

Keep the Horse Before the Cart and the Wound Assessment Before the Dressing

I am approaching my 27th year in wound care and my second year in home health. Throughout my career, I have always believed and taught that wound assessment is the key to choosing the right advanced wound care product at the right time for the right wound.

When a patient with a wound is admitted to home care, I often see orders that read, “Assess and advise, clean and dress with gauze [or any of the 400+ products on the market today] or notify the WOCN [wound care nurse] to assess and advise [or treat per protocol].” So does “assess and advise” mean “tell me what dressing to order”?

If the first task of nursing is to assess the patient, should that include their wound(s), too? Nurses frequently think the first step in wound care is to decide, “What dressing am I going to use?”—when, in fact, the dressing selection should be made after the wound is cleansed and assessed.

Advanced wound care dressings (not active interventions like negative-pressure wound therapy, or NPWT) are designed to absorb exudate in a draining wound or add moisture to hydrate a dry wound. They also fill and cover the wound until the body can fill and close the wound with tissue. The only way to choose the correct interventions (e.g., dressings) is to first:

  • Assess the wound to determine the measurements for choosing the correct dressing size and filler and for comparing measurements to assess for wound closure.

  • Assess the amount and type of exudate/drainage and the type to determine if the wound needs absorption or hydration.

  • Assess the tunneling/undermining to choose a dressing that can be used to fill the tunnel/undermining.

  • Assess the tissue type (e.g., slough, eschar, granulation) to determine if debridement is needed—and if so, which type.

  • Assessing the wound’s location and type (e.g., pressure, venous or arterial ulcer, surgical, trauma or other), which will add information necessary for choosing other interventions such as a pressure redistributing surface, compression, antibiotic therapy, etc.

Do you provide advanced wound care…if so, where? What are your thoughts about wound assessment and dressing selection?

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