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An application of Triangle of Wound Assessment (TOWA) for pressure injury
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Journal of Nursing & Care

ISSN: 2167-1168

Open Access

An application of Triangle of Wound Assessment (TOWA) for pressure injury


23rd World Nurse Practitioner Conference

September 28-29, 2017 Dubai, UAE

Ping-Ru-Wu

Cathay General Hospital, Taiwan

Posters & Accepted Abstracts: J Nurs Care

Abstract :

Introduction: This article is about the application of TOWA to a long-term bedridden, 74-year-old female. She was hospitalized for pneumonia and pressure injury at the right heel was found on January 13, 2016. This wound has been persistent delay healing for 4 months. A consultation visit with wound nurse was on May 20, 2016. Purpose: The aim of this study is to monitor wound progress with TOWA to improve the quality of wound care and act as a selection option for wound treatment. Methods: (1) Wound Bed Evaluation: The size of wound was recorded as 5 cm long, 6 cm wide and 1 cm deep at the right heel; tissue type was 90% of granulation tissue and 10% of slough; exudate was slightly turbid; Wound Culture: Staphylococcus aureus. (2) Evaluation of Wound Edge: The wound edge was 0.5 cm maceration with a tunneling wound of 1 cm deep at the direction of 11 O├ó┬?┬?clock. (3) Evaluation of Periwound Skin: 2 cm surrounding the wound. (4) Management Plan for Wound Bed: With hydrogel for wound bed and foam dressing at outside to control exudate and protect granulation and epithelial tissue with skin barrier to protect skin. Result: Wound Bed Evaluation: The size of wound was recorded as 0.5 cm long, 1 cm wide and 1 cm deep at the right heel; tissue type was 100% of granulation tissue; exudate was slightly watery. The indication of wound edge and periwound skin was intact. Management: With alginate dressing to promote the release of growth factors and foam dressing at outside to control exudate. Implications for Practice: With a periodical re-evaluation of wound healing to determine the effectiveness of wound cares, the TOWA is of great help in solving problems during wound healing.

Biography :

Ping-Ru-Wu is a RN of Division of General Surgery in Cathay General Hospital, Taipei, Taiwan.

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