Wound assessment

Use this procedure to assess wounds for specialist advice and/or to help decide which dressings are best

• Consider health, cultural and environmental factors that could impact on wound healing
• Expert advice is always helpful, essential if wound is chronic. Most major hospitals have a dedicated wounds nurse
• Contact by email, MMS (mobile phone), webcam, telehealth etc 
• Check what information your specialist service needs so images and information are appropriate

Always ask permission before photographing and sending images or arranging a webcam link up, preferably with written consent

Check — person

• Things that can affect healing
• Medical — diabetes, heart disease, kidney disease, transplant, cancer, rheumatoid arthritis, anaemia, bowel disease, vascular disease, autoimmune disease, TB
• Lifestyle factors — smoking, alcohol, illicit drug use, diet, lack of exercise, hygiene
• Nutritional status — BMI, waist measurement, recent history of weight gain or loss, hair and skin changes
• Age 
• Previous wounds and outcomes
• Allergies, sensitivities
• Medicines — over the counter, traditional/bush, prescribed. In particular immunosuppressants, NSAIDs, cytotoxics, steroids, antibiotics
• Results — MC&S, biopsy, x-ray, doppler
• Psychosocial
• Anxiety, depression, other mental health problems — may impact on ability to manage wound. Consider cognitive assessment
• Impact of wound on lifestyle, ability to participate in treatment program
• Consider
• Pain assessment — acute and chronic
• Assessment of mobility, falls, skin integrity
• Vascular assessment
• Sensory assessment

Check — wound

Record all findings, wound measurements and tracings in person's file

• Type — trauma, surgical, burn, pressure, infected, chronic
• Cause of original wound
• How long have they had it — acute wound becomes chronic if it fails to respond to treatment within 4 weeks
• Location
• Size — length, width, depth, circumference
• To measure depth of cavity or sinus — use cotton tip applicator or sterile non-metal wound probe
• To record wound area — cover with cling wrap or sterile plastic, trace with waterproof marker, redraw onto grid

Use colours to help you identify the different conditions in a wound

• Pink = epithelialisation tissue (new skin growing over the wound)
• Red = granulation tissue( healthy tissue in the wound) 
• Green = may indicate infection, wound may have been colonised by bacteria
• Yellow = sloughy tissue (dead tissue that may be wet or dry)
• Black = necrotic (dead tissue that is drying out, and is brown, leathery or hard) 

You may also see

• Overgranulation or hypergranulation — red tissue that is higher than skin level
• Exposed tendon or bone

Use TIME to help you assess wound and consider dressings

T issue
I nflammation/ Infection
M oisture
E dge of wound

Look at wound bed (uppermost visible layer of wound) for

Tissue — is it viable (good) or non-viable (bad)

• If sloughy or necrotic (bad tissue) — remove by dressing choice (eg hydrogel) or debridement
• Gangrene of toes (dry black areas, pulseless) —medical consult
• If tissue healthy — continue using same dressing

Inflammation/Infection

• Look for signs of infection — swollen, hot, red, tender, increase in exudate (ooze), green areas, darker skin may have darker colour around edge of wound
• If infection present 
• Wash with antiseptic
• Clean with saline
• Take swab send for MC&S and commence antibiotics
• Use antimicrobial dressings 
• If no infection — use normal dressings to help with healing

Moisture — is wound too wet or too dry

• If too wet — use dressing that will soak up moisture (eg seaweed, alginate)
• If too dry — use dressing that adds moisture (rehydrates) (eg gel)
• If moisture balanced — keep using same dressing
• Do not rehydrate gangrene — specialist consult

Edge of wound

• Are edges of wound healing (coming together)
• If no — consider why. Consider general health, diet, dressings
• If yes — keep using same dressing
• If edges further apart after 2–4 weeks. The wound is chronic — medical consult

Take digital photograph of wound

• Ask person for consent as per local policy
• If possible, photograph wound before removing dressing — allows specialist to assess exudate (ooze) and type of dressing
• Irrigate (clean) wound with normal saline
• Put ruler or tape (or mark 1cm on piece of paper) next to wound
• Use disposable ruler/tape to avoid cross contamination
• Make sure wound is well lit but don’t use flash. This can cause reflection
• If background included in picture — use neutral pale colour without any lines or other objects
• If able to print photograph — write date, name, DOB, HRN (Health Record Number), type and current problem with the wound and history (eg diabetes, cardiac, foot pulse, leg swelling) on hard copy and keep in file notes

Send images, patient information, your assessment to specialist for advice