How to Assess a Wound
Wounds are assessed at regular intervals to ensure the wound heals correctly and to rule out infection. Wound assessment techniques depend on the location, size and depth of the wound as well as if the wound edges are closed like a sutured incision or open like a pressure ulcer. Wound assessments can occur in a health care institution or at home by a patient or caregiver. Knowing the elements of a wound assessment is important to track healing and the effectiveness of the current treatment.
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Instructions
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1
Wash hands with soap and water, then dry well.
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Measure the length, width and depth of the wound and note the location of the wound site. Compare the measurements against previous measurements.
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Measure and note the location of any tunneling or undermining. Tunneling occurs when the wound branches off deep into healthy tissue and undermining occurs when the wound extends under the intact wound edge.
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Assess any drainage for color and amount. Drainage can range from clear, pink, bloody, yellow, green, white or thick. The amount of drainage can range from none to a large amount.
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Assess the wound for signs and symptoms of infection such as warmth, swelling, poor healing, foul odor, presence of any abnormally colored drainage and increased redness or pain.
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Examine the wound edges and the surrounding skin. Note if the edges are open or closed, if the edges have a distinct outline or if there is evidence of tissue damage beyond the wound border.
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Assess the wound bed for the presence of granulation tissue which is healing tissue that appears pink to red.
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Measure the amount and location of slough (dead tissue) or eschar (dry scab). Slough will look like yellow or white tissue. Eschar is dark, tough tissue.
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Remove and dispose of gloves. Wash hands with soap and water.
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Tips & Warnings
Record all measurements in centimeters.
The location of tunneling and undermining is recorded using the clock face location. An example of using this method is measuring tunneling at "3 o'clock."
Make sure the wound is measured the same way each time. Some people prefer to measure the widest length and the widest width while others prefer to measure the length from head to toe and the width from side to side.
If there are multiple wounds, change your gloves before assessing each wound to avoid cross-contamination.
