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Wound assessment

A step-by-step process

Brennan, Mary R. MBA, RN, CWON

doi: 10.1097/01.NURSE.0000559936.42877.4a
Department: WOUND & SKIN CARE
Free

Step-by-step wound assessment

Mary R. Brennan is an assistant director of wound and ostomy care at North Shore University Hospital in Manhasset, N.Y.

The author has disclosed no financial relationships related to this article.

ACCURATE identification and documentation of wound characteristics, along with appropriate interventions, are vitally important in improving patient outcomes and reducing costs of care.1 Wound assessment documentation must be as accurate and timely as possible because it defines the care provided and characterizes the improvement or deterioration of the wound.

Documenting the required criteria to properly describe wounds (both acute and chronic) and pressure injuries can be daunting for nurses, resulting in a less than complete assessment.2 This article provides a guide for nurses on how to properly perform a clinical wound assessment.

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Seven key steps

While many facilities require a skin check daily or on each shift, weekly wound assessments help clinicians determine if a treatment regimen is appropriate and is contributing to healing. The following is a step-by-step process for completing a wound assessment.

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Step 1: Health history

Keep the patient's clinical status in mind when performing a wound assessment.2 Review the patient's health history, including comorbidities such as diabetes and peripheral arterial disease, prior treatments, and nutritional status. Perform medication reconciliation, including over-the-counter medications, and herbal and dietary supplements. Understanding and evaluating the patient's health history helps determine the path to appropriate preventive interventions or a treatment plan. For example, explore how well patients with diabetes are managing their disease to help identify patients who need further diabetes education. What has their diet been in the past few weeks? Do they take their medications as prescribed? Maintaining optimal A1C levels is important for proper wound healing.

If a wound is present, how long has it been present and what care has been provided for the wound? How has the patient responded to any prior treatments? Has the patient and/or family noticed any unusual odor or drainage from the wound? Has the patient experienced new pain onset from the wound, or has the wound increased recently in size? If the patient reports pain, determine whether it occurs only with activity such as walking or running or during rest, and ask what measures, if any, relieve the pain. Determine if the patient is experiencing edema or decreased sensation in the lower extremities.

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Step 2: Location and type of wound

Location may be challenging at times to discern. Confusion may occur when a patient has multiple wounds and the next caregiver struggles to identify which location is wound number three versus number two, especially if they are in close proximity. Using a visual aid, such as a body diagram, that provides a clear definition of all key anatomic locations (including bony prominences, soft tissue areas, and body folds) may be helpful to accurately communicate wound location. Using standard clinical terms such as distal and proximal enhances clarity.3 Numbering each wound along with the location can help ensure each wound is documented consistently and accurately.

After identifying the location, consider the type of wound. For example, is the injury over a pressure point?4 A pressure injury should be staged according to the National Pressure Ulcer Advisory Panel staging system.5 However, if the patient has several superficial open wounds across a buttock and is incontinent, this may indicate incontinence-associated dermatitis rather than a cluster of Stage 2 pressure injuries.

If the wound is on the leg or toes, assess and grade lower extremity pulses and assess for signs and symptoms of vascular compromise (such as pallor, pain, paresthesia, paralysis, pulselessness, and poikilothermia).

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Step 3: Dimensions

Nurses may be uncertain how to measure a wound that is shaped irregularly. Many facilities will outline in their policies how to measure a wound because trending wound measurements is critical to monitor healing. All staff need to follow the same procedure of wound measurement to ensure accuracy.

If two wounds are present, does intact tissue separate them? If so, each wound should be assessed separately. Over time, however, intact skin separating the wounds may break down. If that happens, consider the wound to be one wound and measure it as such. Clearly document this change in the wound's characteristics and the reason for the decrease in the number of wounds documented.

Measurement is crucial in assessing a wound. If the wound is healing, the wound depth will decrease first. The length and width may then decrease. Remeasure the wound whenever a debridement is done.6,7 A wound that increases in length, width, or depth would be a concern if this change was not related to the debridement.

The presence of undermining and sinus tracts is important to document as accurately as possible. Usage of a clock face may be employed to identify where the undermining or tunneling is located within the wound and how extensive the tract and/or the undermined area may be. (See How to measure undermining andtunneling.)

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Step 4: Tissue type

How does the wound look? Is viable red tissue or perhaps black eschar or tan/yellow slough visible? Quantifying a percentage of the tissue type is usually at best an estimate, but it allows the next observer of the wound to assess whether the wound is healing. Is the granulation tissue red and viable or pale pink? If viable tissue is paling in color, there may either reduced healing, poor tissue oxygenation, or ongoing pressure. The wound may also be transitioning back to an inflammatory state.2

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Step 5: Odor

If an odor is present, does it diminish after cleansing the wound? If so, the odor may be a result of wound exudate or dressing byproducts. If the odor remains or if the nurse notes any unusual drainage characteristics, this may indicate a bioburden, which should be reported to the healthcare provider. In patients with a compromised immune system or a wound infection, the earlier an intervention plan is implemented, the better the outcome.

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Step 6: Drainage

Assess the amount of drainage, if present, and its characteristics. How often does the drainage saturate the dressing? How saturated is the dressing and what color is the drainage? Is the drainage serous, serosanguinous, sanguineous, or purulent? Identifying the amount affects the choice of wound dressing: A minimally exuding wound may need hydration to maintain a moist environment while a heavily exuding wound needs an absorptive dressing such as a foam, hydrofibers, or a super absorber.

As a wound heals, the drainage should decrease accordingly. If a wound that had been stable and moist begins to exude more drainage, the wound may be receding back to an inflammatory state. In this case, the patient and wound should be closely monitored.

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Step 7: Periwound skin

The quality of this tissue may affect the wear time of a dressing, so it is important to assess this area. Do you see any areas of erythema? Is this area blanchable or nonblanchable? Nonblanchable erythema may indicate that the wound will deteriorate further. Assess for any tissue loss, maceration, or fungal lesions (satellite lesions). This information will help inf`orm planning a treatment plan. For example, if periwound tissue is macerated, the objective may be to consider a stronger absorbent and a topical protection to protect the tissue.

After obtaining the patient's health history and completing the wound assessment, the plan of care should result from your findings, as the following example illustrates.

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Case study

KB, 68, has a history of multiple sclerosis (MS). She developed a right trochanteric Stage 4 pressure injury during a prior admission. She has been receiving wound care at home from a home care nurse who comes every other day and packs the wound with a hydrogel dressing. The wound has been healing slowly. The patient performs scheduled urinary catheterizations and adheres to a daily bowel program. Her dietary intake has been fair to good at home.

This morning, the home care nurse noted an increase in serous wound drainage. No odor was identified. Medications include ocrelizumab infusions (a CD20-directed cytolytic antibody to treat her relapsing MS) and a baclofen pump to treat severe MS-related spasticity. She requires assistance getting out of bed and into her wheelchair and is adamant about trying to stay as mobile as possible. Preserving as much independence as possible is very important to her.

The wound measurement is 5.2 cm long, 4.4 cm wide, and 1.0 cm deep with 2 cm undermining at 12 o'clock to 3 o'clock. The wound edges are macerated. The wound has no odor and a moderate amount of serous drainage. There is 100% viable tissue in the wound base, and there is periwound skin with superficial tissue loss.

Goals of care will include maintaining a moist wound healing environment, redistributing pressure, ensuring adequate nutrition, and monitoring for any signs or symptoms of infection. Treatment choices may include:

  • Cleansing with normal saline and patting dry. Use a skin protective prep pad on periwound skin to protect skin from exposure to excessive moisture and from any trauma with adhesive removal.
  • Negative pressure wound therapy (NPWT) or a hydrofiber or a calcium alginate dressing to absorb the drainage. A nonadherent dressing should be placed over the bone before the NPWT dressing. The undermining should be gently packed with foam if using NPWT or with the absorbent dressings.
  • Pressure redistribution surfaces for the bed and for the chair/wheelchair.
  • Nutritional consult to assess current nutritional state.
  • Wound assessments weekly or with any change in the wound.
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How to measure undermining and tunneling

Figure

Figure

Undermining occurs when the edges of the wound pull away from the base of the wound. To measure undermining, moisten a sterile cotton tip applicator with sterile 0.9% sodium chloride and gently insert it into areas of dead space. Mark the applicator at the point where it extends from the wound at the wound edge or margin. Measure the distance in centimeters and document using the clock method (anatomically, the head is located at the 12 o'clock position).

Tunneling is a narrow course or pathway that can extend in any direction from the wound and results in dead space with a potential for abscess formation. Measure tunneling by moistening a sterile cotton tip applicator with sterile 0.9% sodium chloride and gently inserting it into areas of dead space. Measure the distance in centimeters and document the location.

Source: Baranoski S, Ayello EA. Wound Care Essentials: Practice Principles. 4th ed. Philadelphia, PA: Wolters Kluwer Health; 2016.

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REFERENCES

1. Greatrex-White S, Moxey H. Wound assessment tools and nurses' needs: an evaluation study. Int Wound J. 2015;12(3):293–301.
2. Keast DH, Bowering CK, Evans AW, Mackean GL, Burrows C, D'Souza L. MEASURE: a proposed assessment framework for developing best practice recommendations for wound assessment. Wound Repair Regen. 2004;12(3 suppl):S1–S17.
3. Berke CT. Visual guide for accurately designating the anatomic location of buttocks lesions. J Wound Ostomy Continence Nurs. 2016;43(2):148–149.
4. Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel pressure injury staging system: revised pressure injury staging system. J Wound Ostomy Continence Nurs. 2016;43(6):585–597.
6. Shah A, Wollak C, Shah JB. Wound measurement techniques: comparing the use of ruler method, 2D imaging and 3D scanner. J Am Coll Clin Wound Spec. 2015;5(3):52–57.
7. Flanagan M. Improving accuracy of wound measurement in clinical practice. Ostomy Wound Manage. 2003;49(10):28–40.
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