Assessment

Advanced Healing Institute (AHI) has developed recommendations for an initial wound assessment that aligns current guidelines, standards, and best practices with the treatment recommendations in the Institute’s Treatment and Documentation protocols.

AHI always recommends that practitioners follow appropriate facility guidelines for content and timing of wound assessments as well as all applicable state and federal laws and regulations.




The following is a summary of the Advanced Healing Institute Wound Treatment Guidelines. Upon completion of an initial wound assessment, follow-up assessments should be performed weekly (at minimum) with special attention the following characteristics:

  • Signs of Significant Infection: Signs of significant infection include a patient who may be septic (falling blood pressure, tachycardia, fever), or have rapidly progressing areas of cellulitis (pain, redness, warmth, and swelling progressing away from the wound and into intact tissue), or purulent drainage from the wound site (thick yellow or greenish drainage accompanying cellulitis).
  • Presence of Eschar: Eschar is dry dead tissue covering the surface of the wound. It is typically brown, red or black in color depending on the amount of blood or necrosis involved in the wound progression. Eschar is typically firm, or hard to the touch. Note that soft devitalized tissue is called slough (which is not a form of eschar and is evaluated in a subsequent portion of the wound assessment).
  • Wound Stage, Type, or Category: Wound staging is the appropriate way to describe a pressure ulcer (stages I-IV, Unstageable, and suspected Deep Tissue Injury), while wound type is used for venous and arterial wounds (partial thickness or full thickness). Wound category is a ranking system developed by Advanced Healing Institute for defining diabetic wounds.
  • Slough: Slough is soft, moist, devitalized (dead) tissue. It usually adheres to the base of the wound. Slough may or may not be indicative of infectious processes at the wound site.
  • Presence of moisture or drainage: AHI uses this descriptor primarily for purposes of choosing an appropriate dressing for the wound.
 
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