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Wound bed, wound edge and periwound skin should be examined before the initial treatment plan is devised. It should also be re-assessed at each visit or each dressing change. For wound bed, the following parameters are assessed: Tissue type; presence and percentage of non-viable tissue covering the wound bed; Level of exudate; Presence of infection
The periwound (also peri-wound) is tissue surrounding a wound. Periwound area is traditionally limited to 4 cm outside the wound's edge but can extend beyond this limit if outward damage to the skin is present. Periwound assessment is an important step of wound assessment before wound treatment is prescribed. [1]
Periwound skin damage caused by excessive amounts of exudate and other bodily fluids can perpetuate the non-healing status of chronic wounds. Maceration, excoriation, dry (fragile) skin, hyperkeratosis, callus and eczema are frequent problems [17] that interfere with the integrity of periwound skin. They can create a gateway for infection as ...
The Abbreviated Injury Scale (AIS) is an anatomically based consensus-derived global severity scoring system that classifies each injury in every body region according to its relative severity on a six-point ordinal scale: Minor; Moderate; Serious; Severe; Critical; Maximal (currently untreatable).
The Braden Scale for Predicting Pressure Ulcer Risk, is a tool that was developed in 1987 by Barbara Braden and Nancy Bergstrom. [1] The purpose of the scale is to help health professionals, especially nurses, assess a patient's risk of developing a pressure ulcer .
The International Red Cross wound classification system is a system whereby certain features of a wound are scored: the size of the skin wound(s); whether there is a cavity, fracture or vital structure injured; the presence or absence of metallic foreign bodies.
Glasgow Coma Scale (also named GCS) is designed to provide the status for the central nervous system. It is often used as part of other scoring systems. FOUR score - 17-point scale for the assessment of level of consciousness. Aims to have higher sensitivity and specificity then GCS, applicable in intubated patients. CMM - Cancer Mortality ...
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