AR K ANSA S INN OVAT IV E PER F O R M AN C E PR O GR A M (AIPP) Skin Management

TOOLKIT

F314
Federal Regulations of Pressure Sores
12 Components of Wound Assessment
and Documentation
1. Identify location of wound
n Specify the wound location by identifying where the ulcer occurs on the individual’s body.
• Sometimes individuals have more than one ulcer, or develop additional ulcers over time.
• The wound assessment should always reflect the accurate location of the wound.

2. Determine etiology of wound

n The etiology or cause of the wound must be correctly identified.
n There are different types of ulcers, including:
• Pressure Ulcers
• Diabetic Ulcers
• Venous Ulcers
• Arterial Ulcers
• Mixed Ulcers
*One should review medical conditions, wound characteristics, typical presentation, and diagnostic tests if necessary,
when determining the type of wound.

3. Determine wound classification and/or stage

n Wounds should be evaluated for certain characteristics including the extent of tissue damage.
Stages of superficial, partial-thickness, and full-thickness wounds include the following:
• Stage I: Superficial; involving only the epidermis.
• Stage II: Partial-thickness; affects the epidermis, and may extend into the dermis, but not through it.
• Stage III: Full-thickness; extends through the dermis and in to tissues below; adipose tissue.
• Stage IV: Full-thickness; may be exposing muscle or bone
n Suspected deep tissue injury: Identified as a localized area of discoloration sometimes purple or maroon,
intact skin or blood filled blister.
Unstageable: Full-thickness tissue loss. Wound bed is not visible due to slough and/or eschar.

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4. Measure size of wound (length, width, and depth)

n For consistency, one method for measuring should be adopted by your facility.
• Record measurements in centimeters in documentation.

5. Measure amount of wound tunneling and undermining

n Tunneling and / or undermining may or may not be present in the wound. It should always be
accurately assessed.
• It needs to be measured in centimeters.
• Document the extent and / or location by envisioning the face of a clock over the wound.
The individual’s head should be referenced as the 12 o’clock position and their feet as the 6 o’clock position.

6. Assess the wound bed

n Document the type of tissue and structures observed in the wound bed.
• The wound bed may need to be cleaned so you can visualize it.
• There are different tissue types that may present in the wound beds.
• It is always important to note anatomical structures (bones, tendons, etc.), as well as, foreign objects.

7. Assess wound exudate

n Document both the type of exudate and amount of exudate observed.
• Type of exudate may be described as:
1. Serous
2. Serosanguineous
3. Sanguineous
4. Purulent
• Amount of exudate may be described as:
1. Minimal
2. Light
3. Moderate
4. Heavy

8. Assess surrounding skin

n Surrounding skin assessments assist in determining damage or unhealthy areas around the wound’s perimeter.

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TOOLKIT

9. Assess wound edges

n Wound edges or margins must be assessed and documented.
n Be on the lookout for unhealthy edges or margins that may present as:
• Rolled
• Tunneled
• With Undermining
• Fibrotic
• Unattached

10. Assess for signs and symptoms of wound infections

n There may be clinical signs or symptoms indicating the presence of an infection.
• Examples may include:
1. Increasing ulcer pain; warmth; foul odor; purulent exudate; delayed healing; etc.
n The only definitive way to determine an infection is by obtaining a wound culture.

11. Assess individual’s pain

n Assessing one for pain is a critical and imperative piece of the overall wound assessment.
n Be sensitive to events that may elicit pain, such as dressing changes, etc.
n Use a pain scale that is appropriate for the individual.
• Be consistent with the scale used.

12. Document findings

n All 12 components of assessment must be included in weekly documentation.
• This may be in the form of a narrative nurse’s note or a wound assessment form.
Always follow your facility’s protocol!

THIS MATERIAL WAS PREPARED BY THE ARKANSAS FOUNDATION FOR MEDICAL CARE INC. (AFMC) UNDER CONTRACT WITH THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES.
THE CONTENTS PRESENTED DO NOT NECESSARILY REFLECT ARKANSAS DHS POLICY. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT.

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