NHS Scotland wound assessment

Skin and wound care
National Association of Tissue Viability Nurses (NATVNs)

 

Appropriate use 

Social care workers in care homes and care at home services will not carry out full wound assessments. However, this tool will help you to describe a wound to nursing staff and other clinical colleagues so that appropriate action can be taken.

 

General wound assessment chart

This chart is provided by Healthcare Improvement Scotland. The National Association of Tissue Viability Nurse Specialists NATVNS (Scotland) examined this resource in 2019. It is due for review.

 

Visual guide

The visual guide can be accessed here.

This guide presumes that Standard Infection Control Precautions (SICPs) are applied at all times when providing healthcare when there is a risk of exposure to blood, other body fluids, secretions or excretions (except sweat), non-intact skin or mucous membranes.

Step 1

Does the wound need cleansing? 

  • Only cleanse if there is visible debris on the wound bed that needs removed. 
  • Use warm potable tap water or warmed sterile solutions if immunocompromised such as saline 0.9%.
  • PHMB if infected, colonised. 

Step 2

  • Document type of wound, location, duration. Measure wound length, width, depth and undermining and tracking as applicable. 

 

  • Document peri-wound skin condition, pain or any clinical signs of infection. 
  • Do not estimate. 
  • Use a scale such as: 
    • tracing, disposable ruler for length and/or width 
    • wound swab stick, wound probe for depth and/or undermining  
    • wound photography with appropriate consent

 

Step 3

A. What tissue type and levels of exudate does the wound have? 

  • Dressing choice must accommodate tissue type, exudate level, odour, expected wear time, peri-wound skin, area to be dressed, pain at dressing change and patient/client need. 
  • Consider intrinsic and extrinsic factors also – past medical history, age, and cognitive ability.  

 

B. Select secondary dressing if required. 

  • See Step 3A above.

 

Step 4

Document in wound chart

A wound chart must be completed for every patient/client with a wound. 

 

Points to remember: 

  • Know the action and possible side effects of any dressing you apply. 
  • Know how to apply and remove any dressing correctly, eg safe and atraumatic removal of all dressings. 
  • Know how long a dressing can stay in place and indication(s) for dressing change. 
  • Do not mix different primary and secondary types of dressings together, eg hydrogel and hydrofibre. 
  • Select a dressing that is the correct size for the wound. A dressing that is too big or too small can be detrimental to the wound. 
  • Remove old packing from the wound, apply any new packing loosely leaving tail(s) at the entrance and record the number of pieces of packing inserted within the wound care plan. 
  • Use barrier skin preparations as appropriate for any damaged peri-wound skin or if needed as preventative measure. 
  • For chronic or infected wounds refer to  
    • Algorithm for Assessment and Management of Chronic Wounds 
    • Scottish Ropper Ladder for Infected Wounds 
  • If in doubt seek advice from appropriate healthcare professional, ie tissue viability nurse, dermatology nurse, podiatrist. 

 

Copyright information

© Healthcare Improvement Scotland 2021 

Published February 2021 

This document is licensed under the Creative Commons Attribution-Noncommercial-NoDerivatives 4.0 International Licence. This allows for the copy and redistribution of this document as long as Healthcare Improvement Scotland is fully acknowledged and given credit. The material must not be remixed, transformed or built upon in any way. To view a copy of this licence, visit https://creativecommons.org/licenses/by-nc-nd/4.0/ 

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