WOUND ASSESSMENT: Instructions for Use
Fill out the attached rating sheet to assess a wound after reading the definitions and methods of assessment described below. Evaluate once a week and whenever a change occurs in the wound. Rate according to each item by picking the response that best describes the wound and entering that number in the column for the appropriate date.
1. Size: Use ruler to measure the longest and widest aspect of the wound surface in centimeters; always measure length from head to toe.
2. Depth: Measure in centimeters (cm)
3. Edges: Use this guide:
Indistinct, diffuse = unable to clearly distinguish wound outline.
Attached = even or flush with wound base, no sides or walls present; flat.
Not attached = sides or walls are present; floor or base of wound is deeper than edge.
Rolled under, thickened = soft to firm and flexible to touch
Hyperkeratosis = callous-like tissue formation around wound and at edges
Fibrotic, scarred = hard, rigid to touch
4. Undermining: Assess by inserting a cotton-tipped applicator under the wound edge; advance it as far as it will go without using undue force; raise the tip of the applicator so it may be seen or felt on the surface of the skin; mark the surface with a pen; measure the distance from the mark on the skin to the edge of the wound. Continue process around the wound.
5. Necrotic Tissue Type and Amount: Pick the type of necrotic tissue that is predominant in the wound according to color, consistency adherence, and amount using this guide:
may appear prior to wound opening; skin surface is white or gray.
Non-adherent yellow slough = thin, mucinous substance; scattered throughout wound bed; easily seperated from wound tissue.
Loosely adherent yellow slough = thick, stringy clumps of debris; attached to wound tissue.
Adherent, soft black eschar = soggy tissue; strongly attached to tissue in center or base of wound.
Firmly adherent, hard black = firm, crusty tissue; strongly attached to wound base and edges (like a hard scab).
Indicate % of wound involved next to number in item column for the appropriate date.
6. Exudate Type and Amount: Some dressings interact with wound drainage to produce a gel or trap liquid. Before assesing exudate type, gently cleanse wound with normal saline or water. Pick the exudate type that is predominant in the wound according to color and consistency, using this guide:
thin, bright red
Serosanguineous = thin, watery, pale red to pink
Serous = thin, water, clear*
Purulent = thin or thick, opaque tan to yellow*
Foul purulent = thick, opaque yellow to green with offensive odor*
Use this guide and indicate none, scant, small, moderate or large for amount next to number in column under appropriate date.
None = wound tissues dry
Scant = wound tissues moist; no measurable exudate
Small = wound tissues wet; moisture evenly distributed in wound; drainage involved < 25% of dressing
Moderate = wound tissues saturated; drainage may or may not be evenly distributed in wound; drainage involved > 25% to < 75% of dressing
Large = wound tissues bathed in fluid; drainage freely expressed; may or may not be evenly distributed in wound; drainage involves > 75% of dressing
7. Skin Color Surrounding Wound: Assess tissues within 4 cm of wound edge. Dark-skinned persons show the colors "bright red" and "dark red" as a deepening of normal ethnic skin color or a purple hue. As healing occurs in dark-skinned persons, the new skin is pink and may never darken. *Redness can be a sign of infection.
8. Peripheral Tissue Edema: Assess tissues within a 4 cm of wound edge. Non-pitting edema appears as skin that is shiny and taut. Identify pitting edema by firmly pressing a finger down into the tissues and waiting for 5 seconds; on release of pressure, tissues fail to resume previous position and an indentation appears. Crepitus is accumulation of air or gas in tissues. *Edema can be a sign of infection.
9. Induration: Assess tissues within 4 cm of wound edge. Induration is abnormal firmness of tissues with margins. Assess by gently pinching the tissues. Induration results in an inability to pinch the tissues. *Induration can be a sign of infection.
10. Granulation Tissue: Granulation tissue is the growth of small blood vessels and connective tissue to fill in full-thickness wounds. Tissue is healthy when bright, beefy red, shiny, and granular with a velvety appearance. Poor vascular supply appears as pale pink or blanched to dull, dusky red color.
11. Infection: A wound or tissue infection is present when the signs and symptoms are present. Pus is always an indication of infection. In the absence of pus or purulent drainage four of the following signs and symptoms must be present: heat, fever of 101F, swelling or induration, tenderness/pain, serous drainage, or redness of skin. To indicate infection the appropriate asterisked areas on the form must also be marked.
12. Discomfort: Assess severity of pain on a scale of 0 to 5 with 0 being no pain and 5 being the most discomfort or pain. Also, assess when the patient has pain and place the appropriate number and letter in the column under the appropriate date.
13. Wound Status: Check previous assessment and indicate whether there is improvement, no change or whether the wound is deteriorating. Treatment should be attempted for at least two weeks before changing therapy.
14. Stage: Pressure ulcers only will be staged.
Stage I: Nonblanchable erythema of intact skin, the heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration or hardness may also be indicators.
Stage II: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
Stage III: Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers.
15. Dressing order, order changes, extra changes. The DRESSING ORDER should include everything regarding the treatment of the wound, such as cleansing solution; brand of dressing; whether duoderm has a border or not; wheter it is a rope or guaze; size of dressing; frequency of dressing changes; if packing is required and with what; if it is wet to dry. the dressing order is to written in the box on the first page. DRESSING ORDER CHANGES also, go on the first page and should include all the same information as for a dressing order. EXTRA CHANGES other than the routine dressing changes should be noted on the blank lines on second page. These notes should include the date and reason for the change.
* Indicates infection
ACWCP - 1998