Wound & Skin Care
Wound assessment: A step-by-step process
BY MARY R. BRENNAN, MBA, RN, CWON
A
CCURATE 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.
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.
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 comor-
bidities such as diabetes and
peripheral arterial disease, prior
treatments, and nutritional status.
Perform medication reconciliation,
including over-the-counter medica-
tions, and herbal and dietary
supplements. Understanding and
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evaluating the patient’s health
history helps determine the path to
appropriate preventive interven-
tions or a treatment plan. For
example, explore how well patients
with diabetes are managing their
disease to help identify patients
who need further diabetes educa-
tion. 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.
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 docu-
mented 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).
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,
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however, intact skin separating Step 4: Tissue type wound infection, the earlier an
the wounds may break down. If How does the wound look? Is viable intervention plan is implemented,
that happens, consider the wound red tissue or perhaps black eschar the better the outcome.
to be one wound and measure it or tan/yellow slough visible?
as such. Clearly document this Quantifying a percentage of the Step 6: Drainage
change in the wound’s charac- tissue type is usually at best an Assess the amount of drainage, if
teristics and the reason for the estimate, but it allows the next present, and its characteristics. How
decrease in the number of wounds observer of the wound to assess often does the drainage saturate
documented. whether the wound is healing. Is the dressing? How saturated is
Measurement is crucial in the granulation tissue red and the dressing and what color is the
assessing a wound. If the wound is viable or pale pink? If viable tissue drainage? Is the drainage serous,
healing, the wound depth will is paling in color, there may either serosanguinous, sanguineous, or
decrease first. The length and width reduced healing, poor tissue purulent? Identifying the amount
may then decrease. Remeasure the oxygenation, or ongoing pressure. affects the choice of wound dress-
wound whenever a debridement is The wound may also be transition- ing: A minimally exuding wound
done.6,7 A wound that increases in ing back to an inflammatory state.2 may need hydration to maintain a
length, width, or depth would be a moist environment while a heavily
concern if this change was not Step 5: Odor exuding wound needs an absorp-
related to the debridement. If an odor is present, does it tive dressing such as a foam,
The presence of undermining and diminish after cleansing the hydrofibers, or a super absorber.
sinus tracts is important to document wound? If so, the odor may be a As a wound heals, the drainage
as accurately as possible. Usage of a result of wound exudate or dress- should decrease accordingly. If a
clock face may be employed to ing byproducts. If the odor remains wound that had been stable and
identify where the undermining or or if the nurse notes any unusual moist begins to exude more drainage,
tunneling is located within the drainage characteristics, this the wound may be receding back to
wound and how extensive the tract may indicate a bioburden, which an inflammatory state. In this case,
and/or the undermined area may be. should be reported to the health- the patient and wound should be
(See How to measure undermining and care provider. In patients with a closely monitored.
tunneling.) compromised immune system or a
Step 7: Periwound skin
The quality of this tissue may affect
How to measure undermining and tunneling the wear time of a dressing, so it is
Undermining occurs when the edges of important to assess this area. Do
the wound pull away from the base of you see any areas of erythema? Is
the wound. To measure undermining, this area blanchable or nonblanch-
moisten a sterile cotton tip applicator able? Nonblanchable erythema may
with sterile 0.9% sodium chloride and indicate that the wound will deterio-
gently insert it into areas of dead rate further. Assess for any tissue loss,
space. Mark the applicator at the point maceration, or fungal lesions (satellite
where it extends from the wound at lesions). This information will help
the wound edge or margin. Measure
inf`orm planning a treatment plan.
the distance in centimeters and document using the clock method (anatomi-
For example, if periwound tissue is
cally, the head is located at the 12 o’clock position).
Tunneling is a narrow course or pathway that can extend in any direc-
macerated, the objective may be to
tion from the wound and results in dead space with a potential for consider a stronger absorbent and a
abscess formation. Measure tunneling by moistening a sterile cotton tip topical protection to protect the tissue.
applicator with sterile 0.9% sodium chloride and gently inserting it into After obtaining the patient’s health
areas of dead space. Measure the distance in centimeters and document history and completing the wound
the location. assessment, the plan of care should
Source: Baranoski S, Ayello EA. Wound Care Essentials: Practice Principles. 4th ed. Philadelphia, PA: result from your findings, as the
Wolters Kluwer Health; 2016.
following example illustrates.

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 Wound & Skin Care
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 dai-
ly 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
64 l Nursing2019 l Volume 49, Number 8
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
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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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.
DOI-10.1097/01.NURSE.0000559936.42877.4a
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