A nurse’s guide to holistic wound care assessment

Wounds have become a significant public health challenge, consuming a large amount of healthcare resources (Wounds Australia, 2022). They can severely affect people’s quality of life, causing psychological and social distress (Eriksson et al., 2022; Falcone et al., 2021), and may lead to significant periods of lost employment, resulting in financial loss (McCosker et al., 2019).

Many traditional practices relating to wounds have not been based on robust scientific evidence. Every nurse needs to be able to question and challenge wound care practices that are no longer supported by evidence. This can only be achieved if practitioners are well-informed and able to provide the relevant evidence required to support change. The informed wound practitioner’s role is to act as an agent of change.

For nurses to manage wounds effectively, they need to be competent in undertaking holistic and comprehensive wound assessments. This process must incorporate the wound and the person’s medical and social history. A thorough assessment informs decision-making and guides person-centred goal planning.

A holistic approach requires the nurse to consider the cultural, psychological, and socioeconomic aspects of health as well as the physical aspects. Comprehensive history-taking, providing person-centred care, thoroughly examining the wound, initiating appropriate and timely management, follow-up, and investigation are all essential aspects of the nurse’s role in wound care.

Multiple factors can influence the healing process and must be considered in any wound assessment. These factors may be intrinsic, such as age, obesity, oxygen and blood supply (vascular insufficiency), nutritional status, medications, and underlying pathology such as the presence of diabetes or kidney disease (Carville, 2023). Extrinsic factors include mechanical stress, such as shearing, friction, and pressure, and lifestyle factors such as stress, smoking, and alcohol intake (Carville, 2023).

All intrinsic and extrinsic factors need to be identified and appropriately managed for wounds to heal. This is where excellent assessment skills come into play. Wound assessment involves noting identifiable characteristics of a wound to plan treatment strategies and evaluate wound progression. Characteristics that should be identified include the type of wound, measurement of the wound size, tissue type, the amount and type of exudate, and the condition of the surrounding tissue and presence of infection.