Wound Assessment

Wound Assessment

■ Appearance: Color (pink, healing; yellow, infection; black, necrosis), sloughing, eschar, longitudinal streaking, etc. ■ Size: Measure length, width, and depth in cm. ■ Incisions: Approximated edges, dehiscence, or evisceration. ■ Undermining: Use a sterile, cotton-tipped applicator to probe gently underneath the edges until resistance is met. With a felt-tipped pen, mark where the applicator can be felt under the skin. ■ Induration: Abnormal firmness of tissues with margins. Assess by gently pinching tissue distal to wound edge; if indurated you will be unable to pinch fold of skin. ■ Tissue edema: Note if edema is pitting or nonpitting. Note: If wound is crepitant, notify physician immediately. ■ Granulation: Bright red, shiny, and granular. Indicates that the wound is healing. Note: poorly vascularized tissue appears pale pink, dull, or dusky red. ■ Drainage:Type, (sanguineous, serosanguineous, purulent) amount, color, and consistency. ■ Odor: Foul odor indicates infection. ■ Staging: See Staging Pressure Ulcers, below.