Learning Objectives
By the end of this section, you will be able to:
- Describe the clinical guidelines used for wound assessment
- Recognize the different tools available for wound assessment
- Identify important aspects of nursing documentation of the wound assessment
Clinical Guidelines for Wound Assessment
Wound treatment varies widely depending on the type, location, age, and appearance of the wound, as well as the characteristics of the patient, type of wound care specialist, and setting of the patient care. Thus, prior to planning for treatment of any wound, initial, thorough wound assessment must take place. The nurse must also consider that wound treatment is also affected by the needs and abilities of the patient as well as family support for ongoing wound care. Consider the wound pictures in Figure 8.7. Each image shows a different type of wound and each type requires different treatment and management strategies on the part of healthcare providers. However, before treatment can begin, assessment must occur.
Type of Wound
Determining how the wound was created helps to determine the type of wound (Nagle et al., 2023). In some cases, the type may be very clear. For example, in Figure 8.7, image (d) is clearly a traumatic wound of some type. The patient can easily state to providers how it occurred (a table saw) and providers know how to manage it appropriately. However, other wounds may be more difficult to manage. Images (a) and (c) both show wounds that require additional investigation before the type can actually be assessed. Image (a) shows an ulcer of some type and image (c) shows a skin infection, but without additional assessment, the exact type of ulcer or infection remains unknown.
Wound Location
Wound locations dramatically impact the strategies providers can use in wound treatment (Nagle et al., 2023). Wounds on skin surfaces that are difficult to keep clean and/or dry, such as skin folds, the perineal area, hands, feet, and/or face, will be managed differently than those that are easier to keep clean and dry, such as the abdomen or arm. Other location concerns include the amount of weight-bearing performed at or near the wound’s location. Wound healing requires oxygenation of the surrounding tissue, and areas that bear consistent weight, such as bony prominences such as the coccyx, may heal more slowly or require alternative strategies. Other locations, such as being near major arteries or vessels, may impact the types of interventions that can be utilized (Nagle et al., 2023).
Visual inspection should include inspecting the wound and surrounding area. Note any visible landmarks or anatomical structures that can help accurately describe the wound location. Use adequate lighting to enhance visibility. Identify nearby anatomical landmarks to describe the wound’s location accurately. These landmarks may include bones, joints, muscles, and other structures. For example, a wound could be described as “located on the anterior aspect of the lower leg, approximately 2 in (5 cm) above the medial malleolus.” Use of a clock face or grid system is also recommended. If applicable, use a clock face analogy or a grid system to precisely pinpoint the wound location. For instance, you might describe a wound as “located at the two-o’clock position on the dorsal aspect of the right foot” or “in the upper left quadrant of the abdomen.”
Wound Characteristics
There are a variety of wound characteristics that also impact diagnosis and treatment interventions (Table 8.4). Each of these must be assessed and documented as part of the initial treatment process.
| Characteristic | Examples | Importance |
|---|---|---|
| Appearance | Color, depth, surrounding skin, shape, presence of foreign bodies, and exposed muscle or bone |
|
| Measurement | Circumference, depth, length, and width |
|
| Edges | Smooth, jagged, rounded edges, presence of undermining (erosion beneath skin surface beyond visible edges) or tunneling (erosion in channels beneath intact skin surrounding a wound) should be noted. Approximated (clean edges, that close easily) versus not approximated (jagged edges) should be documented. |
|
| Exudate (liquid that secretes from the wound) | Purulent (pus, tan to yellow), foul purulent (purulent with foul odor), serous (thin, watery, clear), serosanguineous (mix of serous fluid and blood), sanguineous (bloody) |
|
Skin Tone
Skin tone is another critical piece of wound assessment. Identifying a baseline skin tone enables changes to be identified quickly. Also, different skin tones reflect wounds and injuries in different ways. Consider erythema, a change in skin color due to a change in blood flow. Traditionally, erythema has been described by “redness.” However, erythema generally only appears red for individuals with pale skin tones (Dhoonmoon et al., 2023). For patients with darker skin tones, erythema may also be pink or purple, or simply a darkening of the surrounding skin. Thus, particularly for patients with darker skin tones, textural or temperature-based skin changes may be more important than appearance (Dhoonmoon et al., 2023).
Wound Assessment Tools
Wounds may include intentional wounds such as surgical sites that are prone to infection and complicated wounds such as pressure injuries, traumatic injuries, and various types of venous ulcers. There is a variety of wound assessment tools used to confirm the risk of developing wounds or to monitor healing. Different strategies can be employed depending on the risks various patients experience. For wounds that are more difficult to heal, providers must have reliable assessment methods to ensure appropriate and accurate communication among team members and allow for accurate assessment of changes between visits (Bates-Jensen et al., 2019).
Braden Scale
The Braden Scale is the most used pressure injury risk assessment tool in the United States and is used across many healthcare settings, including critical and acute care, long-term care, rehabilitation, and even by home-based nursing (Kennerly et al., 2022). It evaluates the relative risk of a patient developing skin breakdown and pressure injuries. The scores can be used to tailor pressure injury prevention interventions to patients at risk of injuries (Kennerly et al., 2022).
The Braden Scale uses six subscales: mobility, activity, sensory perception, nutrition, friction/shear, moisture (Kennerly et al., 2022). Each of these six factors is scored on a scale from 1 to 4, depending on the factor. After each item is decided, the ratings are added together for a possible score between 6 and 23. The lower the score, the greater the risk for development of a pressure injury. All patients scoring 18 and below should be reassessed regularly, on a schedule dictated by facility and healthcare setting. Patients scoring above 18 should be reassessed when they experience condition-related changes.
Link to Learning
The Braden Scale is a very helpful tool to establish the relative risk of a patient experiencing issues with skin breakdown.
The Braden Scale is a tool used by nurses to identify a patient’s risk of developing pressure injuries and is typically completed on admission to a hospital or other healthcare facility (Table 8.5). This evidence-based assessment tool rates the patient on a scale of 1 (completely limited) to 4 (no impairment) in the following categories: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The ranges for the scores are mild risk (15–18), moderate risk (13–14), high risk (10–12), and severe risk (9 or less).
| Category | 1 (most severe) | 2 | 3 | 4 |
|---|---|---|---|---|
| Sensory perception | Completely limited, unresponsive | Very limited, only responds to painful stimuli | Responds to verbal commands but limited communication | No impairment, responds and communicates |
| Moisture | Constant moisture | Frequent moisture/linen changes | Occasional moisture/extra linen change | Usually dry/routine linen change |
| Activity | Bedbound | Chairbound, limited walking | Short-distance walking | Frequent walking |
| Mobility | Immobile | Very limited | Slight limitations | No limitations |
| Nutrition | Very poor | Likely inadequate | Adequate | Excellent |
| Friction, shear | Constant friction, requires assistance | Movement with minimal assistance | Independent movement | N/a |
Simplified Surgical Site Event Risk Assessment (SSERA) Model
Despite the use of best practices in surgeries, there remains a risk for surgical site infections (SSIs) for everyone undergoing major surgery. In the United States alone, there is are estimated 200,000 SSIs annually, with a cost of up to $10 billion a year (SSERA Group, 2023). The simplified Surgical Site Event Risk Assessment (SSERA) model uses six risk factors to individually evaluate a patient’s risk for an SSI and each risk factor is assigned a color (green, orange, or red) based on the relative risk for an SSI.
Link to Learning
You can view the Surgical Site Event Risk Assessment (SSERA) model in Figure 1 of this publication. The SEERA model helps surgeons determine an individual patient’s risk for surgical site infection, based on six risk factors.
A patient’s risk for SSI is evaluated based on the data in the table. If a patient is positive for any red box or three orange boxes, they are considered a high risk for SSI. Any two orange boxes make them an elevated risk for SSI (SSERA Group, 2023). Once a patient’s risk for SSI is known, additional protections can be used (where possible) to monitor for and prevent SSIs.
Wagner Ulcer Classification System
In patients with diabetes, foot infections are common, due to peripheral neuropathy (loss of feeling in the extremities that keeps patients from recognizing they have a wound) and may result in amputations (Bhowmik, 2023). Long-term glucose changes related to diabetes affects circulation and blood vessels, increasing the healing time for wounds and the risk of infection and gangrene (Shah et al., 2022). The Wagner Ulcer Classification System is one of many types of assessment tools used for patients with diabetic foot ulcers.
The Wagner system is used to determine the severity of a diabetic ulcer by looking at depth, amount of tissue necrosis (tissue death), and presence of osteomyelitis (bone infection) (Bhowmik, 2023). It classifies diabetic foot ulcers into grades between 0 and 5 (Table 8.6) (Song et al., 2022; Shah et al., 2022).
| Wagner Grade | Description |
|---|---|
| 0 | Intact skin that may have bunions, claw toes, or Charcot breakdown. There may also be hyperkeratotic lesions near bony deformities, indicating the foot is at risk of breakdown. |
| 1 | Superficial ulcer with no penetration to deep layers. The base of the ulcer may be necrotic or granulating (tissue regrowth). |
| 2 | Deeper lesion extending to bone, ligament, tendon, or deep fascia. There is no abscess or osteomyelitis at this stage. |
| 3 | Deep abscess, osteomyelitis, or infection of tendon. This stage often requires imaging, probing to the bone, and/or bone biopsy to assess the extent. |
| 4 | Some portion of the forefoot or toes is gangrenous. Gangrene may be classified as wet or dry. |
| 5 | Severe gangrene with no potential for healing, necessitating the amputation of all of the gangrenous area. |
Link to Learning
Sometimes the best way to understand wound classifications is to see examples. You can see images of the Wagner staging and learn more about the Wagner classification system in this helpful reference guide. Please be prepared; some of the images are very graphic.
Bates-Jensen Wound Assessment Tool (BWAT)
The Bates-Jensen Wound Assessment Tool (BWAT) is used to evaluate wound status and healing; it measures thirteen wound characteristics. The BWAT was initially developed to be used with pressure injuries; however, it has been widely used with a variety of wounds including post-surgical, infected, and various ulcerative wounds (Bates-Jensen et al., 2019). The BWAT (Table 8.7) is a good assessment tool because it can be used by individuals with limited wound care experience; however, it is slightly less accurate when used on patients with darker skin tones.
| Item | Assessment |
|---|---|
| Size | Use a ruler to measure length and width and then multiply to get the area. |
| Depth | Choose the appropriate depth ranging from intact, nonblanchable skin to underlying structural damage, such as damage to tendons and bone. |
| Edges | Describe edges from indistinct, attached but flat and flush with wound base, not attached (base of wound is deeper than the edge), thickened or rolled under, callous-like, or fibrotic (hard, and rigid to the touch). |
| Undermining | Assess by using a cotton applicator under the wound edge and advance as far as possible without adding pressure. Measure the distance between the edge and end of cotton applicator. Continue around the wound to look for undermining at all points. |
| Necrotic tissue | Choose the predominant type of necrotic tissue according to color, consistency, and attachment to wound: white/grey nonviable tissue, yellow slough that does not adhere to the wound but lifts out easily, yellow slough that is loosely attached to wound, boggy black eschar attached to wound bed, or firm crusty hard/black eschar tissue attached to base and edges. |
| Necrotic tissue amount | Use a transparent measuring guide to determine the percentage of necrotic involvement. |
| Exudate type | Cleanse wound with normal saline or water before assessing due to the way some dressings work. Choose the most predominant from bloody, serosanguineous, serous, purulent, and foul purulent (thick yellow to green with odor). |
| Exudate amount | Determine the amount of exudate based on wound bed and used patient’s dressing; range from none to large (> 75 percent of dressing saturated or wound bathed in fluids). |
| Skin color of surrounding wound | Assess tissues within 1.6 in (4 cm) of edges. People with darker skin will show deepening of normal skin color or purple. When healing, their new skin may be pink and may not darken. |
| Peripheral tissue edema | Assess tissue within 1.6 in (4 cm) of wound edges. Observe for skin that is puffy, shiny, and tight. Press fingertip into intact tissue for five seconds and observe for indentation. Measure how far edema expands from wound edge. |
| Peripheral issue induration | Assess tissue within 1.6 in (4 cm) of wound edges. Observe for areas of abnormal firmness with clear boundaries (such as bumps under the skin). Measure size and distance from wound edge. |
| Granulation tissue | Early tissue regrowth: Health granulation is bright, beefy red, and shiny. Poor circulation appears pale pink or blanched to a dull color. |
| Epithelialization | Skin regrowth: Young skin is usually pink or red; may be in base of wound or only growing in from the edges. Measure percentage with a transparent measurement tape. |
Patient Conversations
Using the BWAT
Scenario: In this clinical narrative, a wound care nurse answers a patient’s questions about using the BWAT.
Nurse: Hi, Mr. Johnson. How are you feeling today?
Patient: Oh, not too bad, I guess.
Nurse: Can I take a look at your wound?
Patient: Well, you can, but I don’t know why you’d want to! Gives me the heebie-jeebies.
Nurse: I can understand if you’re feeling a little squeamish, but it’s important that we keep an eye on it and make sure it’s healing. Let me go ahead and put on my gloves, and we’ll see how it’s doing, okay?
Patient: Sure.
[After putting on sterile gloves, the nurse starts to gently uncover the patient’s wound.]
Nurse: Okay, let’s have a look.
Patient: What are you looking for, anyway? [chuckles] Bugs?
Nurse: Not exactly! When I check your wound, I’m looking for signs that it’s not healing well or is infected. So, I want to see if your skin is red and swollen, if there’s any pus or blood coming out.
Patient: It isn’t bleeding anymore, but sometimes the bandage feels a little damp.
Nurse: That’s good to know! Paying attention to how your wound looks and feels is very helpful for me. It can be normal for there to be some fluid coming out of the wound as it heals, but we still want to see how much there is and what it looks like. Even what it smells like!
Patient: I think that’s a little too much for me! I’ll let you do a sniff test.
Nurse: Fortunately, I think your wound is in pretty good shape. See how the edges are starting to come together? That’s a sign that your skin is doing its job to heal and close up the wound. I don’t see any signs of an infection, which is great. How’s your pain?
Patient: Not as bad as it was, but it still twinges sometimes.
Nurse: That can be a normal part of the healing process—but tell me if it starts to hurt more or you think the discomfort is getting worse.
Patient: Okay.
Nurse: Before we get a new dressing on there, do you mind if I snap a picture?
Patient: Ha! For your personal collection?
Nurse: No, photos are kept in your file for medical purposes only. Remember last time I took a photo for your record? I’ll compare the one I take today to that one to get a better idea of how your healing is progressing. I can’t remember every detail of all the wounds I treat, so having pictures is very helpful.
Scenario follow-up: In this example, the nurse has efficiently performed a wound check on a patient while also answering his questions about the importance of tracking progress.
Nursing Documentation of Wound Assessment
When documenting wound assessments, nurses must be careful to document accurately and without assumption. Incorrect documentation may negatively impact patients as clinicians reviewing the documents will be unable to accurately evaluate the severity of the wound and information about the healing process. Documentation is also important for regulatory agencies such as departments of health, third-party payers such as private insurance and the Centers for Medicare & Medicaid Services, accreditation bodies such as the Joint Commission and the Long-Term Care Institute, and even for potential legal proceedings (WoundSource, 2022). Ensure the following information is included in wound documentation (Song et al., 2022; WoundSource, 2022):
- type of wound or cause, such as pressure injury, surgical site, traumatic wound
- any related healthcare conditions such as diabetes, neuropathy, or gangrene
- location information including anatomical body part and information, such as right/left, front/back, top/bottom, midway between
- wound size: length, width, depth in centimeters
- wound thickness: amount of skin breakdown, fat exposure, and bone and/or muscle involvement
- any indication of infection, such as fever, increased drainage, odor, heat, swelling, or pain
- patient variables including refusal to participate in care or adhere to treatment plans
- photographic evidence of the wound (both for legal reasons and to monitor wound-healing progress
Correct Terminology
When documenting a wound, always use the correct terminology and location information (Table 8.8).
| Description Type | Terms |
|---|---|
| Wound bed characteristics | Granulation: healing state in which new tissue begins to form
(credit: “Granulation tissue” by John Campbell/Flickr, Public Domain)
|
| Slough: wet yellow to white tissue in wound bed made of dead cells; may or may not be attached to wound bed
(credit: “Biofilm delays wound healing” by National Library of Medicine, CC BY 4.0)
|
|
| Eschar: dead tissue formed over healthy skin
(credit: modification of “pntd.0005020.g003”, by National Library of Medicine, Public Domain)
|
|
| Epithelialization: growth of epidermis (skin cells) over skin and wound surface; healing to close wound
(credit: modification of “Photo-documentation of wound epithelialization of crusted lesions after removal of the crusts” by National Library of Medicine, CC BY 4.0)
|
|
| Wound edges | Defined versus undefined: how clear are the boundaries of the wound from the surrounding skin? |
| Attached versus unattached: are the edges of the wound attached to the underlying tissue or can a cotton swab or instrument slide between the layers? | |
| Approximated versus not approximated: are wound edges brought together and aligned in a close or near-close manner or are do they remain separated or open? | |
| Epibole | |
| Maceration | |
| Callused or fibrotic edge (toughened skin around wound edges) | |
| Wound margin (edges of wound) | |
| Skin beyond the wound | Color |
| Temperature | |
| Edema (swelling): present or absent | |
| Boggy (spongy) | |
| Induration (thickened or hardened area): provide a location and size
(credit: modification of “Initial clinical appearance of right nipple” by National Library of Medicine, CC BY 4.0)
|
|
| Undermining, tunneling, or sinus tracts (cavity leading from an abscess beneath the wound to the surface) | |
| Exudate type | Serous |
| Sanguineous | |
| Serosanguineous | |
| Purulent | |
| Foul purulent | |
| Exudate amount | Scant: wound tissue moist, no drainage on dressings |
| Minimal: tissue moist, light exudate on dressing | |
| Moderate: tissue wet, up to 75 percent of dressing saturated over twenty-four hours | |
| Large: wound filled with fluid; > 75 percent of dressing saturated |
Link to Learning
Restorix Health and American Medical Technologies published a document to help study and learn appropriate documentation of wounds in patients.
Recommendation for Reevaluation
Most wounds progress normally through the four stages of healing: hemostasis, inflammatory, proliferation, and maturation. They should be reevaluated throughout the healing process to ensure they are healing effectively and appropriately. This process is described further in 8.3 Wound Management. When issues occur at any stage, additional steps may be required to ensure wound healing.