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Wound assessment should include the following components: Anatomic location. Type of wound (if known) Degree of tissue damage. Wound bed. Wound size. Wound edges and periwound skin. Signs of infection. Pain.
Evaluation Identify the wound location. Determine the cause of the wound: Evaluate for foreign bodies or neoplastic processes. Determine the stage of the wound: Stage I: Superficial, involving only the epidermal layer. Evaluate and measure the depth, length, and width of the wound[51]
HEIDI is a mnemonic for History, Examination, Investigation, Diagnosis Implementation. It can be applied in a clinical setting at the point of care to undertake a holistic assessment of the person with a wound.
The length, width, and depth of the wound are documented. Wound bed: The wound bed is the tissue that makes up the wound. The nurse must take note of the color, texture, and drainage of the wound bed. Wound edges: Wound edges are the borders of the wound.
Wound bed. Healthy granulation tissue is pink in colour and is an indicator of healing. Unhealthy granulation is dark red in colour, often bleeds on contact, and may indicate the presence of wound infection.
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Evaluation Identify the wound location. Determine the cause of the wound: Evaluate for foreign bodies or neoplastic processes. Determine the stage of the wound: Stage I: Superficial, involving only the epidermal layer. Evaluate and measure the depth, length, and width of the wound[51]
It helps you to assess all key areas of the wound and take into account the important factors about the patient and their context that influence a wounds healing process. It also assists you in setting clear management goals and selecting the best treatment.
Overall, documentation should record the following elements5: Wound etiology or cause (pressure, venous, arterial, surgical, etc.) Wound odor (strong, foul, pungent, etc.) Wound location, described with proper anatomical terms. Thickness characteristics for nonpressure wounds.

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