Promoting Healthy Skin - 7. Wound Care

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7B: Assessment

Once you can identify different types of wounds, understand the wound healing process and be aware of the factors that impact wound healing, you are ready to learn about how to assess a wound. Key elements of a wound assessment may include the following:

Assessment	Explanation
The client’s health history	This includes a history of the present wound or symptoms. You might like to ask: How and when did the wound start? How long have you had it for and what does the current treatment involve? (i.e. who is treating the wound, with what treatment and how often). Is there any past history of wounds? Do you have any pain and how would you describe the pain? When is the pain the worst and what relieves the pain? It is also important to ask about general medical conditions the person may have such as their smoking history, mobility, medication and nutritional status.
Wound cause	It is important to determine the cause of the wound (e.g. due to an accident or surgery), the type of wound (e.g. skin tear, venous leg ulcer or pressure injury) and the classification of wound (e.g. the category of skin tear or the stage of pressure injury).
Wound size	The size of a wound should be assessed when it first occurs. You should assess chronic wounds at least monthly or whenever there is any significant change in wound progress. You can measure the size of a wound by tracing the wound margins and wound depth. Doing so allows you to be able to track progress over time. IMAGE - M7 13 Wound tracing IMAGE - M7 14 Measuring wound depth
Wound edge	The wound edge or border can give important clues as to the type of wound that you are treating. These are some common examples: Venous leg ulcers are characterised by a sloping wound edge IMAGE - M7 15 Venous leg ulcer Arterial leg ulcers have a punched out wound edge IMAGE - M7 16 Arterial leg ulcer Undermining is a typical feature of a pressure ulcer IMAGE - M7 17 Pressure injury Diabetic foot ulcers have a calloused wound edge IMAGE - M7 18 Diabetic foot ulcer Skin cancers have a raised wound edge IMAGE - M7 19 Skin cancer
Wound location	The location of the wound can aid diagnosis. For example: Diabetic foot ulcers occur on the sole of the foot and toes Venous ulcers occur on the lower third of the leg below the knee Arterial leg ulcers occur on the top of the foot, toes or ankle bones Pressure injuries occur over bony prominences such as the sacrum, hips or heels Skin cancers tend to occur in sun exposed areas.
Colour of the wound bed (i.e. clinical appearance)	The colour of the tissue in the wound gives an indication as to the health of the wound and this guides treatment options. For example, healthy granulation tissue is beefy red in colour and is an indicator of healing. However, unhealthy granulation tissue appears darker in colour and bleeds easily indicating that an infection may be present. There are five main colours that you can use to describe the predominant type of tissue in the wound bed: Black necrotic tissue IMAGE - M7 20 Black necrotic wound Yellow sloughy tissue IMAGE - M7 21 Yellow sloughy wound Red granulating tissue IMAGE - M7 22 Red granulating wound Pink epithelialising tissue IMAGE - M7 23 Pink epithelialising wound Green infected tissue IMAGE - M7 24 Green infected wound Some wounds may have a component of each colour present (e.g. yellow sloughy and red granulating), but when doing a wound assessment, it is the predominant tissue colour present that you need to be concerned with.
Wound leakage (i.e. exudate)	The type, amount, colour, consistency and odour of wound leakage or exudate should be noted. Types of exudate include: Serous: clear straw-coloured fluid Haemoserous: slight blood-stained serous fluid Sanguineous: frank or heavily blood-stained Purulent: containing pus The amount is described as light, moderate or heavy. The colour relates to the type of exudate but may also indicate the type of bacteria present in a wound. For example, the bacteria Pseudomonas Aeruginosa has a blue-green colour. IMAGE - M7 25 Green infected wound Consistency refers to the thickness or composition of exudate. For example, fistulae may produce a thick fluid. An odour indicates the presence of a wound infection or contamination by body fluids.
Surrounding skin	The condition of the surrounding skin is important to assess because this can assist you when selecting an appropriate wound dressing. For example, if the skin around the wound is white and boggy (maceration), this indicates that the wound is producing moderate to large amounts of leakage (exudate) and you need to select an absorbent dressing. IMAGE - M7 26 Maceration
Wound infection	If a client has a wound infection present, the wound may show the following signs and symptoms: Heat in the skin around the wound or extending more than 2cm beyond the wound margins Redness (erythema) around the wound or extending more than 2cm beyond the wound margins Swelling (oedema) around the wound or extending more than 2cm beyond the wound margins Pain that has changed in intensity Delayed healing Wound tissue that bleeds easily on contact An offensive odour Abnormal granulation tissue IMAGE - M7 27 Wound infection
Pain	Pain is a characteristic of all wounds and it is important to determine its cause. Pain is often related to dressing removal, the result of an underlying condition such as infection or poor blood supply. The nature and type of pain should be identified and treated appropriately. Pain measurement tools such as visual scales, numerical scales or verbal rating scales can help with this process.

VIDEO - M7 V01 Principles of wound assessment (View video transcript)

Now that you have considered how to recognise factors that can impact on the wound healing process and principles of wound assessment, you are ready to learn about how to manage a wound.