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J Wound Care. 2018 Nov 2;27(11):790-796. doi: 10.12968/jowc.2018.27.11.790.

Preliminary experience of an expert panel using Triangle Wound Assessment for the evaluation of chronic wounds.

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Diabetic Foot Unit. Universidad Complutense de Madrid. Madrid, Spain.
Dermatology Department. Hospital Infanta Leonor. Madrid. Spain.
Wound Care Unit. Hospital Lucus Augusti. Lugo.
Domiciliary Hospitalization. Hospital Universitario de Cruces. Bilbao. Spain.
Wound Care Unit. Hospital Infanta Leonor. Madrid. Spain.
Nurse; General Surgery Department. Hospital Comarcal de Alcañiz. Teruel. Spain.
Wound Care Unit. Hospital Universitari Germans Trias I Pujol. Badalona. Barcelona. Spain.
Centro Polivalente de Recursos para Personas Mayores El Cristo. Oviedo. Spain.



Wound assessment is an essential part of wound management and has traditionally focused on the wound bed. The Triangle of Wound Assessment (Triangle) is a new assessment tool that includes a holistic evaluation of the patient with a wound. The aim of this pilot study was to describe the use of the Triangle in our clinical practice in Spain.


Prospective, consecutive patients, male and female, over 18 years old, with wounds of any aetiology and duration, who attended the centres involved in the study, were recruited between May and June 2017. The TWA was used during the first presentation, to assess the wound bed, edge and periwound skin. The study's expert panel met to discuss the results collected by the assessment, as well as the advantages and disadvantages of the system.


We recruited 90 patients. Non-viable tissue (necrotic/sloughy) was recorded in 57.8% of the patients, elevated exudate (medium/high) in 52.2%. Approximately 25% of the patients had signs or symptoms of local infection. Maceration was the most prevalent issue recorded on the wound edge and periwound skin assessment, affecting 31.1% and 30.0% of the patients, respectively. The presence of hyperkeratosis was high for the study population as the main aeitologies of the wounds identified here were DFU.


The implementation of Triangle Wound Assessment could help in the holistic approach to patient care by focusing on more than local wound care, identifying barriers to achieving wound healing and evaluating wound response and patient compliance.


chronic wounds; triangle wounds assessment; wound assessments

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