Wound Assessment &
Documentation
Anita Hedzik
CDN Ward 5B/C
Princess Margaret Hospital
Wound Assessment
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Holistic Approach
General assessment
Determine Type of Wound
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Acute
• Traumatic
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Abrasions,
lacerations
Burns
• Surgical
• Infective
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Chronic
•
•
•
•
•
Vascular
Neoplastic
Metabolic
Neuropathic
Pressure Ulcers
Acute Traumatic Wound
Chronic Wound
Determine Mode of Healing
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Primary intention
Delayed primary intention
Secondary intention
Graft
Flap
Determine Mode of Healing
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Primary Intention
(Closure)
Determine Mode of Healing

Delayed primary
intention
Secondary Intention
Grafting
Determine Tissue Loss
Superficial
 Partial
 Deep Partial
 Full Thickness
OR
 Stages I - IV
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Superficial
Partial Thickness
Deep Partial Thickness
Full Thickness
Clinical Appearance
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Necrotic
Sloughy
Granulating
Epithelialising
Infected
Wound Location
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Wounds in areas of increased
mobility & friction may be slow to
heal
Healing promoted in areas with good
vascularisation
Areas at risk of pressure & shearing
forces will have delayed healing
Wound Dimensions
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Allows assessment & evaluation of
healing rate and wound management
strategies
Two dimensional: width & length
(ruler)
Three dimensional: measure depth
or tracking (use sterile tipped probe)
Wound measurement tool
Serial Clinical photography
Wound Exudate

Type
• serous, haemoserous, serosanguinous,
purulent

Amount
• major losses can affect fluid & electrolytes,
peri-wound maceration
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Colour
• May indicate bacterial load (Pseudamonas)
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Consistency
Odour
Surrounding Skin
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Inspect & palpate
Observe for signs of cellulitis,
oedema, dermatitis, eczema, allergic
reactions, maceration, foreign bodies
Palpate for warmth, capillary refill,
oedema
Is there evidence of wound healing?
Pain

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Determine cause of pain
Is pain local or systemic?
Is pain related to wound care
practices?
Manage pain appropriately
Wound Infection
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Wounds are classified as: clean,
clean contaminated, contaminated,
infected
Microbiological assessment
Assess on an individual basis
Ask the patient/parent/staff about
symptoms
Consider the patient’s general health
in your assessment
Wound Infection
Psychological Implications
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Self esteem & body image
Alteration in body functions
Socialization
Impact on family
Implement Management Plan
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What is wound care goal?
What is most important for the
patient?
Select appropriate dressing/
treatments
Ensure all treatments/dressings are
documented accurately
Evaluate regularly
Documentation - Accountability
Client
Self
ACCOUNTABILITY
Community
Institution
Professional
Documentation

Consistent

Clear
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Concise
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Legible

Accurate
Assessment
Wound description

Format:
• Standardised document or chart
• Narrative (Descriptive)
Wound Assessment Tool
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Trial Wound assessment tool
currently being developed at PMH
Narrative (Descriptive)
Documentation
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Wound centrally
sloughy with necrotic
eschar at medial
corner, proximal third
pale with epithelial
buds and distal third
granulating OR
20% necrotic, 40%
slough, 20%
granulating & 20%
epithelialising
Documentation in notes
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Wound 70% pink
and granulating,
30% pale slough.
OR
Wound pale on left
arm and left lateral
side of chest, pink
and granulating at
distal left trunk
and over right side
of chest