05.02 Wound Care – Assessment

Overview

1. Purpose
   1. Assessing wound characteristics is the only way to know if healing is occurring

Nursing Points

General

1. Supplies
   1. Clean gloves
   2. Measuring tape
   3. Cotton-tipped applicators x 2-3

Assessment

1. Wound bed color
   1. Black – represents full-thickness tissue death
   2. Yellow – represents death of muscle tissue and subcutaneous fat
      1. May be slough
   3. Red  – a red wound bed typically means good vasculature and the wound is healing
      1. Exception – 1st degree burns
   4. Green – gangrenous / infected
2. Wound edges
   1. Approximated – wound edges touching
      1. May be approximated with staples, suture, or glue
   2. Unapproximated – wound edges aren’t touching
   3. Rolled – the epidermis has rolled under towards the wound bed
3. Wound bed characteristics
   1. Eschar – black or yellow – may be tough or leathery – reflects necrosis or dead tissue
   2. Granulation  – pink or red and bumpy – means tissue is growing
   3. Moist/dry – depends on drainage, moist is best in open wounds as long as no infection is present.
   4. Tunnelling – there are holes in the wound bed that extend deeper than the main wound
   5. Undermining – the wound bed extends beyond/underneath the wound edges (it is wider than the opening suggests)
4. Wound drainage
   1. Serous – clear yellow
   2. Serosanguineous – yellow/pink-ish
   3. Sanguineous – bloody
   4. Purulent – white/yellow pus

Nursing Concepts

1. Steps and Nursing Considerations
   1. Review wound care orders
   2. Explain procedure to patient
   3. Perform hand hygiene
   4. Don clean gloves
   5. Raise bed to comfortable working height.
   6. Remove existing dressing and discard in appropriate waste container
   7. Inspect wound:
      1. Wound bed color
      2. Wound edges
      3. Wound bed characteristics
      4. Wound drainage
   8. Measure wound:
      1. Using tape measurer – measure the following:
         1. Length – patient’s head to toe
         2. Width – patient’s side to side
      2. Using a sterile cotton-tipped applicator, determine the depth at the deepest portion
         1. Mark with your finger, then measure with tape
      3. Using a new sterile cotton-tipped applicator for each location – measure depth of any tunnelling or undermining
   9. Discard used supplies
   10. Remove gloves, perform hand hygiene
   11. At this point, you can move on to wound care if applicable – see Wound Care – Dressing Change lesson
   12. Document your findings.

Patient Education

1. Let the patient know whether their wound seems like it’s healing – compare to previous assessment