Scottish wound assessment and action guide (SWAAG)

Undertake a person-centred assessment, including aetiology (cause of wound) and understand the intrinsic and extrinsic factors which may impact healing along with full medical history, age and cognitive ability. Consider those who are involved in the wider shared care of the individual and factors which may require further specialist input.

Perform wound assessment at least every 7 days, when the treatment is being changed or if there is any significant change in the wound or the individual.

Using the NHS Scotland Adult Wound Assessment and Healing Chart (SWAHC) or a locally approved version, consider the following in your wound assessment:

• Pre-dressing analgesia.
• Wound dimensions - It’s important not to estimate wound size and use a suitable scale when measuring width, length and depth. (See page 2 in the SWAHC further guidance on how to measure). Wounds may appear deeper once non-viable (slough, necrosis) tissue is debrided.
• Tracking or undermining (utilise clock face method of documenting as seen in the Adult Wound Healing Plan)
• Photography (ensure appropriate local consent when obtaining)
• Tissue type - see below for full guidance on tissue type.
• Wound exudate levels/type. Serous and haemoserous fluid are a normal physiological aspect of wound healing, the components of which support moist wound healing and manage bioburden. Changes in wound exudate (e.g. purulent presentation) with odour may indicate infection, in which case refer to Scottish Ropper Ladder for Infected Wounds / local guidance.
• Skin surrounding wound.
• Signs of infection. Common signs and symptoms of an infection may include increased pain, spreading erythema or increased heat and change in skin tone from the surrounding skin, increased exudate level, malodour, friable tissue and slough. (Consider using the Scottish Ropper Ladder for Infected Wound or local wound infection guidance)
• Treatment objectives.

On initial assessment and whenever the regime is altered, complete/update the wound healing plan (as seen on page 4 of the SWAHC). Detail frequency of dressing changes and document whether the plan has been discussed/agreed with the individual. Within each wound healing plan, consider the following:

Cleansing

If required, gently cleanse the wound to avoid disrupting granulation and/or epithelialisation. Chronic or hard-to-heal wounds with devitalised tissue or suspected biofilm may require mechanical debridement to remove loose devitalised tissue, microorganisms or detritus from the wound bed.

If a biofilm is suspected a surfactant solution should be considered.

Debridement

Always refer to local guidelines/pathways when considering debridement.

Establish if debridement of the wound or wound edges is appropriate. Debridement may not be appropriate where conservative or palliative management of a necrotic wound is required. Do not debride devitalised tissue from wounds which are secondary to peripheral arterial disease (PAD) or diabetic foot ulcers (DFU), without obtaining specialist advice from Vascular/Podiatry. Do not debride devitalised tissue from malignant wounds.

Consider the types of debridement and suitable techniques which can be used such as:

• Mechanical debridement- using debridement pad/cloth to manually remove loose slough and debris from the wound bed. Selection of product as per local formulary.
• Autolytic debridement- using suitable dressing regime to support the body’s natural process in removing devitalised tissue. Consider selecting dressings which maintain a therapeutic moisture balance in the wound to support debridement.
• Larvae - as per local guidelines.
• Sharp - only to be used by appropriately trained professionals who have achieved competency in performing sharp debridement. Utilising suitable tools to remove devitalised tissue.

Other methods of debridement are available for specialist use.

Treatment of the surrounding skin

Consider the wider skin areas. Is a skin barrier required to prevent maceration? Is an emollient required for dry skin and to maintain healthy skin?

Dressings

Following assessment, ensure the chosen dressings align with the treatment objectives.

Be mindful of the action of the dressing and product interactions. Avoid inappropriate multiple layering of dressings.

Consider whether the individual has any allergies, sensitivities or preferences when considering dressing selection.

Primary dressing

Dressing choice must accommodate:

• tissue type
• exudate level
• odour
• bioburden (need for antimicrobial)
• expected wear time
• peri-wound skin
• area to be dressed
• pain at dressing change and individual’s need.

Secondary dressing

Consider need for secondary dressings to secure primary wound dressing and/or manage exudate, reduce risk of contamination or cross infection.

Person-centred goals

Discuss the needs and expectations of the wound management regime with the individual. For example, exudate, odour, pain etc.

“If you didn’t write it down, it didn’t happen!”

Documentation of each episode of care ensures that all practitioners undertaking wound management are aware that wound management has been performed and what products have been applied or removed from the wound.

Utilising a document such as the Wound Dressing Change Log (as found on page 6 of the SWAHC) will also highlight additional information for example, wound photography performed, or swab taken.

Robust documentation is a professional obligation of any clinician managing an individual with a wound and by communicating clearly it preserves safety and ensures effective practice.