Wound evaluation is the foundation upon which appropriate wound interventions are based. Evaluation may include specific measurements and tests to assess the wound, periwound skin, limb, or adjacent anatomical regions. Physiological and anatomical systems, general health, functional status, and other factors that affect an individual should also be evaluated. The next step in the evaluation process entails making a judgment about or placing a value on test and measurement data. These clinical judgments drive the plan of care for the patient with a wound. Continuous and timely reevaluation of the individual and his or her wound aids the clinician in monitoring healing. Evaluation of wound and patient responses to treatment allows the clinician to determine treatment effectiveness. If the examination and evaluation reveal negative outcomes, adjustments in the intervention are necessary to augment healing. Consequently, wound evaluation will influence which interventions are chosen to produce or enhance the best outcome for the patient.
Evaluation also serves additional purposes besides directing the decision-making process in wound management. Wound evaluation provides vital information for communication between members of the interdisciplinary wound management team. Communication is essential for ensuring consistency and quality of care provided by the team. The documentation of wound evaluation also plays a role in communication with reimbursement agencies because agencies require this documentation in order to make decisions for payment. Documentation of wound evaluation should include tools, tests, and measures used in the evaluation process. Please see Chapter 33 for more details on documentation and reimbursement. Accurate, valid, reliable, and practical evaluation tools and measures are needed to further the knowledge base regarding all aspects of wound management. Communication, quality patient care, reimbursement, research, and clinical decision making are all factors that will influence selection and utilization of appropriate wound and patient evaluation procedures.
This chapter begins by focusing on aspects of a patient's history that influence evaluation and clinical decision making in wound management. Before considering objective aspects, a review of risk assessment, along with its objective aspects, is appropriate. Knowledge of patient history and possible risk factors for wound development enables clinicians to implement wound prevention tactics. Evaluation of a person with a wound should be based on practical, efficient, reliable, and valid evaluation tools and measures. Also included is a brief discussion of devices, equipment, and other miscellaneous factors to consider when completing a thorough evaluation. Finally, a discussion of wound reevaluation, outcome prediction, and a patient case are presented. Overall, this chapter presents the building blocks needed to lay the solid foundation for a complete wound evaluation, which is the foundation of clinical decision making.
The patient's history, often part of a subjective examination, plays a crucial role in evaluation and subsequent treatment of the patient with a wound. While collecting the history, a clinician simultaneously formulates strategies for essential evaluation. This concurrent decision-making process includes gathering information for determination of the ...