Wound Assessment - clinical indications
You need to assess the following aspects of
wounds:
- cause of the wound
- size
- position
- exudate
- odour
- tissue type
- pain
Click on the up/down arrows below to view details of the clinical indication.
Cause 
- How did the wound occur?
- Was it preventable and has the causative factor been removed? For example, a pressure ulcer, scald from a kettle.
- Can the risk of further damage be reduced?
Size
- Evidence of wound size must be documented as per provider guidelines. This is required as a legal record
- How you will measure the wound accurately?
- Tracking healing process – improving?
- Is the wound superficial, partial or full thickness?
- Would a photograph aid re-assessment later? Consent must be obtained.
Position
- Site of wound needs to be accurately documented - where is it located, is it on the right or left side?
- If the type and site of wound is unusual further investigation may be needed - consider the possibility of malignancy or abuse.
- Need to consider how any dressing applied will stay in situ, will it be comfortable for the client?
- Is there a risk of contamination from faeces/urine, will this affect dressing choice?
Exudate
- Colour - does it indicate a chronic or infected wound?
- Consistency? Thin, thick pus like?
- Amount. Record how much of the dressing has absorbed exudate - too dry or too wet will
impact on healing.
- Has it
breached the dressing or has it soiled clothing, distressing the client and
increasing the risk of infection for the client and close contacts?
Odour
- Sign of infection? Warmth, heat, swelling, redness, etc.
- Some wounds have an odour that clients find very distressing and this needs to be
considered when choosing dressings.
- Remember some wounds may have slight odour has they have been enclosed for some time and this alone may not indicate infection.
Tissue Type
- What colour is the wound?
- What sort of tissue is present, is it all the same?
- What does the wound margin look like? Is it healthy, well defined or is it
macerated, reddened, or inflamed indicating possible infection?
- What does the surrounding skin look like? Any indication of infection, maceration, erythema or ischaemia?
Pain
- Is the wound uncomfortable?
- When is it uncomfortable?
- What do you observe? Does the person appear in pain? What are their signs and symptoms?
- Record a pain score using the local care provider tool.
- Aim to alleviate discomfort, remember pain causes vasoconstriction because adrenaline
is secreted and this impacts on healing. There is a potential impact on the
person in psychological and socioeconomic terms if pain prevents normal
activities.
Licensed under the Creative Commons Attribution Non-commercial 3.0 License
All content is © 2011 School of Nursing, Midiwifery and Physiotherapy, University of Nottingham, with the exception of the wound photographs which are copyright of Advancis Medical.