1. Wound Assessment: Part 1
Dot Weir, RN, CWON, CWS

2. Objectives
To describe the rationale for accurate wound assessment and documentation.
To recall the most common elements of a wound assessment.
To identify important aspects of soft tissue, wound characteristics and underlying structures.

3. Wound Assessment Keypoints
Foundation for developing goals and plan of care
Ultimate driver of treatment decisions (wounds are dynamic / may change often)
Evaluation of progress towards meeting goals of care (change from previous assessments)
Important to have common language to facilitate consistent documentation
van Rijswijk, L, Eisenberg, M. (2014) Wound assessment and documentation.
In: Krasner, D.L. (Ed). Chronic Wound Care: The Essentials. Malvern, PA., HMP Communications

4. Wound Assessment Frequency and Documentation
Complete assessment generally performed weekly
- Evaluation of wound status : every dressing change
- Observe for significant changes both positive and negative that may require treatment change
Document per facility / agency protocol

5. Elements of the Wound Assessment
Wound Etiology
- Location
Measurements
- Surface area
- Depth
- Undermining, tracts & tunneling
Exudate
- Color
- Character
Tissue Type
- Eschar
- Slough
- Granulation tissue
- Epithelium
Wound Edges & Surrounding Skin
Structure
- Bone
- Tendon

6. Location Important to document correct anatomical location
Left trochanter and left iliac crest versus left hip.
Important to document correct anatomical location
Use descriptors such as proximal/distal, anterior/posterior, superior/inferior with multiple wounds
Left scapula versus left shoulder

7. Wound Etiology Diagnosis established by health care provider
- Accurate diagnosis critical to guide treatment and goals of care (e.g. topical versus medical or combination of both)
- Lower extremity wounds frequently have mixed etiology
- Skin cancers may appear as small open area that fails to heal
If wound is not progressing as expected with current management, look further/revisit treatment plan

8. Common Wound Etiologies
Diabetic foot ulcer
Surgical
Peripheral Arterial Disease
Misc. Atypical Wounds
Skin Cancer
Burn
Trauma
Pressure Ulcer
Venous Ulcer

9. Wound Measurements
Initial wound measurements critical as baseline to assess healing progress
Length multiplied by the width will provide approximate (though usually overstated) surface area
Length X Width X Depth can be calculated to provide approximate volume (using electronic medical records)

10. Wound Measurements – Length and Width
Measure longest length of the wound and widest then perpendicular line to that for width

11. Wound Measurements – Depth
Insert cotton end of sterile applicator into deepest part of wound at 90° angle to skin
Grasp applicator at skin level, remove and measure using disposable measuring guide.

12. Undermining and Tracts
Undermining is an area or space parallel to the skin
Tracts (also called sinus tracts or tunneling) are narrow areas that extend beyond the depth or edge of the wound
Important to assess, measure and document to guide treatment related to dressings and packing and to establish a baseline to assess healing

13. Undermining, Tracts and Depth Measurements: Document Using a “Clock” Method
“Undermining 5 cm from 12 to 3 o’clock”

14. Drainage or Exudate: Amount
Assessing amount is inexact unless dressings are weighed which is only done in clinical trials
Assess to the extent possible knowing when the last dressing was changed
Examples of estimating amount:
Changed 1 week ago = Small
Changed 2 days ago = Moderate
Changed 1 hour ago = Large

15. Drainage or Exudate: Color
Describe what you see
Impacted by previous treatments, bacteria
Common colors: Red, yellow, pink, tan, green

16. Drainage or Exudate: Character
Common terms:
- Serous: clear light yellow
- Serosanguinous: clear pink/yellow
- Sanguineous: red/bloody
- Purulent: Usually white/tan, may be tinged with other colors, opaque, cloudy
Use caution using the term purulent! Exudate may be byproduct of treatment: Autolysis, enzymatic debridement, cellular tissue products that have biodegraded, silver nitrate or other silver products

17. Exudate Character: Examples
Serosanguinous
Predominately serous
Sanguineous

18. Exudate Character: Examples
Tan Purulent
Green Purulent
Previous treatment residue; enzymatic ointment in use, expected outcome.

19. Exudate Character: Previous Treatment Residue

20. Tissue Types Eschar: Dark in color, may be dry or moist
Slough: Necrotic tissue at some level of liquefying, may be dry or moist
Granulation: Wound in process of healing, tissue pink or red, granular in appearance
Clean non-granular: Wound bed pink or red but no evidence of healing
Hyper-granulation tissue: Tissue growth above the level of the skin

21. Eschar
Dry Eschar
Soft Eschar
© Dot Weir - Used with permission

22. Mixed Slough and Eschar
Moist / Loose
Dense / Adherent
Mixed Slough and Eschar

23. Granulation Tissue
Pink, Non-Granular
Red, Granular

24. Hyper-granulation Tissue

25. Epithelium Migration of cells from the edge of the wound to resurface
May be evident, or may be thin layer which gives surface of wound a matte appearance
May originate in center of wound from structures such as hair follicles

26. Wound Edges and Surrounding Skin
Assessing edges provides evidence of:
Trauma: Callous, tearing
Inadequate wound surface: Cells thickened at edge
Epibole: Rolled edges, migration of cells down the wound edge closing them in

27. Callous/Rolled Edges

28. Epibole/Rolled Edges

29. Thickened

30. Surrounding Skin Identify Potential Issues Maceration
Erythema (Infection?)
Rash
Reaction to treatment
Fungal growth
Excoriation
Itching

31. Maceration

32. Erythema

33. Rash
Reaction to Treatment
Fungal Infection

34. Excoriation

35. Structures
Recognizing visible or palpable deep structures such as bone, tendon or fascia is critical
Potential for migrating infection or osteomyelitis
Need to maintain moisture to prevent drying

36. Bone
White, firm, shiny, either visually present in the wound, noted when cleansing or felt when gently probing deeper wound

37. Fascia
Dense fibrous connective tissue that surrounds the muscles, bones, nerves and blood vessels

38. Tendon
Cords of tough, fibrous connective tissue; glistening white in color

39. Summary
Accurate assessment is foundation for developing plan and goals of care
Accurate assessment guides wound treatment decisions
Accurate assessment and documentation is foundation for evaluating progress towards meeting goals of care (change from previous assessments)

40. References
Van Rijswijk L, Eisenberg M. Wound assessment and documentation. In: Krasner DL, ed. Chronic Wound Care: The Essentials. Malvern, PA: HMP Communications; 2014:29-46.
Baranoski S, Ayello E, Langemo D. Wound Assessment. In: Baranoski S, Ayello E. (eds) Wound Care Essentials, Practice Principles. Philadelphia, PA: Wolters Kluwer; 2016:
Livingston M, Wolvos T. Wound Assessment. In: Scottsdale Wound Management Guide. Malvern, PA: HMP Communications; 2015: 1-8.

41. Key Nursing Concepts Assessment Caring Communication Ethics
Evidence-based practice
Infection
Infection Control
Pain
Patient Education
Prevention
Self Care Deficit
Safety
Tissue Integrity

42. Key Nursing Diagnoses Potential for Alteration in Skin Integrity
Tissue Integrity
Impaired Skin Integrity
Impaired Tissue Integrity
Oral Mucous Membranes, Altered
Knowledge Deficit r/t
Self Care Deficit r/t

43. Key Nursing Practice Issues
Registered Nurses (RN) assess wounds; Licensed Practice Nurses monitor wounds per state nurse practice acts
Physicians diagnose wound etiology; some Advance Practice Nurses diagnose wound etiology per state nurse practice acts
Accurate wound assessment and documentation is foundation for evaluating attainment of progress towards goal of care

44. Websites for Further Information on Wounds
- Association for the Advancement of Wound Care
- Canadian Association for Wound Care
- National Pressure Ulcer Advisory Panel
- World Union of Wound Healing Societies
- Wound Ostomy Continence Nurses Society