Inside My Wound Care ToolboxEmpty heading

To begin a thorough wound assessment, I take a comprehensive history, not just of the wound itself, but of the patient’s overall health, medications, and lifestyle. I use the following tools:

a) The TIME Framework

The TIME Framework³ helps guide initial assessment with baseline observations:

• Tissue: Is it viable or necrotic?
• Infection/Inflammation: Are there signs present?
• Moisture: Is the balance helping or hindering healing?
• Edge: What’s happening at the wound margins?

b) The MEASURE Framework

I also follow the MEASURE Framework⁴ for documentation and ongoing review:

• Measure: Length, width, depth, and area of wound
• Exudate: Quantity and quality
• Appearance: Wound bed tissue characteristics
• Suffering: Pain level and type
• Undermining: Any hidden tracts?
• Re-evaluate: Reassess regularly
• Edge: Look at the periwound skin

These frameworks keep our assessments consistent, evidence-based, and easy to communicate to colleagues.

Why identifying aetiology comes first

You can’t treat what you don’t understand.

Determining the aetiology of a wound is crucial. In community settings, this can be challenging due to limited access to testing, the availability of supportive health care professionals to advocate for the client or patient, and the willingness required to pursue a clear diagnosis. In fact, a large percentage of the population may even slip between the proverbial “cracks” because aetiology has not been determined.

What I always consider

I take time to understand the client or patient’s context. Here are key factors I assess:

• Have they had analgesia? I often call 45 minutes ahead so they can pre-medicate
• Did the wound occur in traumatic circumstances?
• Are there signs of infection?
• Any history of previous wounds and/or obstructions/delays to healing?
• Mobility issues?
• Access to specialist care?
• Nutritional concerns?
• Funding arrangements?
• Staff distance to attend to dressing?

Explaining dressing choices to patients

One of the most overlooked but essential parts of wound care is patient education. Even if it is temporary dressing, I always explain what I’m applying and why.

Even if the client doesn’t fully understand, when they feel involved, they’re far more likely to engage with the healing process.

Involving the right people

These are some of the specialist clinicians I commonly involve early in the process:

• Wound Clinical Nurse Consultants (CNCs)
• Local wound clinics
• Immunologists
• Vascular or infectious disease specialists
• Dermatologists and podiatrists
• Physiotherapists and occupational therapists
• Psychologists, especially in trauma-related wounds

Why reassessment if non-negotiable

Just because a treatment protocol worked last week doesn’t mean it’s right this week.

Evaluation and re-evaluation is extremely important as this will direct whether treatment protocols are working and when changes in dressing regimes need to occur.

Final thoughts

Our nurse’s toolbox is limitless.

Not all wounds will heal. Some “wounds can linger for weeks, months or even years without improvement…” and “over time they can lead to serious complications including infection, amputation or perhaps even death”⁴

That’s the reality we face. As clinicians we need to ensure that we offer the most appropriate, least painful, cost-effective, and dignified dressing for the wound in consultation, with everyone involved in the care, especially the client or patient.