Wound Assessment

Sometimes the most minor wounds can develop into a life- or limb-threatening problem, and sometimes the most horrendous wounds heal well to everyone’s amazement. This article is the first in a series for Wound Management & Prevention addressing the basics of wound care, although some may disagree on individual points. The focus will be on the reasons why clinicians do what they do and the goals of wound care treatment. In this way, it is hoped that treatment guidelines will make more sense and can be more easily modified according to the needs of a particular patient.

WOUND ASSESSMENT

A wound assessment is often done without actually thinking about the reasons for doing it; that is, clinicians and nurses are often not considering the point of the information they are gathering. The following section includes the questions that need to be answered during wound assessment and the rationales behind them. This information should be entered in a wound assessment document. A sample of such a document appears here. 

Type. What type of wound is it? Because different wound types require different treatments and approaches, answering this question is paramount. Types of wounds include venous ulcer, arterial ulcer, diabetic ulcer (Figure 1), traumatic injury, pressure injury (Figure 2), surgical wound (Figure 3), malignant wound, skin condition breakdown, chemical burn, thermal burn, electrical burn, and undetermined.

Apparent size. What are the measurements in terms of length, breadth, and depth? This is important because if done every few days, these measurements tell a health care provider whether the wound is improving, worsening, or staying the same. If the wound is improving, then the provider can continue with whatever he or she is doing because it is obviously working. If the wound is staying the same or worsening, then the provider needs to try to determine why the wound is not improving and alter the treatment plan accordingly. The reason is often that there is an infection present and/or continued trauma to the wound area. Serial photographs, including a visible measuring scale, patient identification, and a date, are useful.

Location. What is the anatomic location of the wound? This often answers question regarding type. Venous ulcers usually occur on the calves and are accompanied by venous stasis. Diabetic ulcers usually are on the feet, often the toes or the side of the foot. Pressure injuries/ulcers occur over bony prominences and sometimes are related to medical devices (eg, oxygen tubing or Foley catheters). Malignant wounds usually malodorous and look necrotic (necrotic tissue is dead tissue, and malignancies look like a disorganized mass). If there is even a question of malignancy, the wound needs to be biopsied as soon as possible.

Infection. Is the wound infected? This is an important question and a major reason for wound assessment. There are multiple signs of infection including increased pain, swelling, redness and tenderness in and around the wound, failure to heal as expected, increased drainage, bad smell, bleeding, and presence of pus or slough. Eschar is usually black or dark brown, frequently has a large bacterial load underneath, and needs to be removed by debridement.

Real size. Is the wound bigger than it appears on the surface? The presence of tunneling or undermining at the edges of the wound indicates a need for debridement and packing the wound.

Acute or chronic. Is the wound chronic? Chronic means more than 30 days old. Generally, it is much easier to cure a superficial acute wound than a chronic wound with stalled healing.

Tissue type. What type of tissue is visible in the wound? New epithelial tissue, which is new skin but looks thinner than regular skin, is a sign of a healing wound. Granulation tissue, which is red with a rough surface, is also a sign of healing. Slough is a mixture of dead bacteria, dead white cells, and cellular debris. It is frequently a sign of infection and should be removed by debridement. Necrotic tissue is dead tissue and usually is brown or black; it frequently is malodorous. It also should be removed by debridement.

If the health care provider knows the purposes of the wound assessment, treatment can be tailored to the patient, with a better chance of a higher cure rate than can be achieved by a “one size fits all” approach.

RECOMMENDED READING

European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. EPUAP/NPIAP/PPPIA; 2019.

Baranoski S, Ayello EA. Wound Care Essentials: Practice Principles. 5th ed. Wolters Kluwer; 2020.

Dr. Davey is a mostly retired wound physician with more than 24 years of practice treating many different types of wounds at the HCA Edward White Hospital Wound and Hyperbaric Medicine Center, St. Petersburg, FL. He can be contacted at drchrisdavey@outlook.com and welcomes all feedback. The opinions and statements made here are not necessarily those of Wound Management & Prevention or HMP Global. This article was not subject to the Wound Management & Prevention peer-review process.