Position document: Advances in wound care: The triangle of wound assessment

Wound assessment is complex and requires a range of clinical skills and knowledge. It has never been more important to challenge current assessment paradigms and extend our understanding of wound assessment beyond the wound edge.

It is vital that wound assessment is comprehensive, systematic and evidence-based. It should provide baseline information against which healthcare practitioners can detail and record the current status of the wound, set realistic treatment goals and monitor progress over time using appropriate interventions.

New treatments for chronic wounds have led to improvements in wound management and in the quality of assistance provided by medical and paramedical staff, but wound monitoring methodologies have not kept pace with this progress.

Therefore, the study of wound healing pathophysiology and the development of new tools for the monitoring of the healing process may represent a possible optimisation of the treatment efficacy for these lesions.

The Triangle of Wound Assessment model enables evaluation of the wound bed, wound edge and periwound skin in the context of holistic patient care. Focusing on the skin beyond the edge to include the periwound skin advances the concept of wound bed preparation (TIME) by facilitating early identification of at-risk patients ensuring that appropriate prevention and treatment strategies are implemented to improve patient outcomes.

An understanding of the factors affecting periwound skin, including maceration, excoriation and increased risk of infection, is fundamental in developing new and better interventions that not only improve clinical decision making but meet the needs of patients living with a wound.

The Triangle of Wound Assessment provides a simple and intuitive framework for the consistent inclusion of periwound skin into wound assessment. This Position Document details how the Triangle of Wound Assessment can be used to assess all wound types and exemplifies how it can be implemented in the management of venous leg ulcers and diabetic foot ulcers. Used effectively, the Triangle of Wound Assessment has the potential to enable healthcare professionals to improve patient outcomes and ensure more appropriate use of healthcare resources.

Supported by an educational grant from Coloplast

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