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Wound assessment, evaluation and documentation

The aim is prevent pressure sore, skin infection and monitor the wound condition. Health workers should regularly inspect the skin condition for high-risk residents (frail, immobile, incontinent and/or bed-ridden). Observation can be done during bathing, diaper changing, position turning and wound care by Community Nursing Service. Special attention should be paid to the prominent bony areas. If the skin is red or a blister is seen, do more frequent turning and give appropriate wound care. For wound assessment, the aspects to pay attention include the cause of the injury, medical history, wound location, wound condition (color, size, depth, secretion and infection), pain intensity and the patient's nutritional status. It is recommended to assess, evaluate and document weekly or every 2 weeks. If wound infection is observed, medical treatment should be sought as soon as possible.