Assess

AHS’ Formulary is in the process of developing a full set of recommendations for an initial wound assessment that will align current guidelines, standards and best practices with the treatment recommendations in AHS’ Treatment and Documentation protocols.

AHS 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.

Please note that the descriptions below are abridged. Complete content is available in AHS’ Wound Treatment Guidelines.

Once an initial assessment has been completed follow-up assessments should, at a minimum, be performed weekly, with special attention paid to some of 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 AHS for the specific purpose of defining Diabetic wounds
• Slough: Slough is soft, moist, devitalized (dead) tissue. It is usually adherent 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: AHS uses this descriptor primarily for purposes of choosing an appropriate dressing for the wound.