wound assessment

Clinical manifestations

• location
• wound size & shape, length, width, depth
  • pressure ulcer staging (see pressure ulcer assessment)
  • grading of diabetic foot ulcer
• wound bed
  • color
  • presence of slough, necrotic tissue, granulation tissue, epithelial tissue
  • underminining or tunneling
• exudate: purulent vs non purulent, serous, serosanginous
• edges: distinct, diffuse, rolled under
• periwound skin & soft tissue: erythema, edema, induration, temperature
• presence of pain at rest & with wound care procedures
• signs of wound infection
  • necrotic tissue
  • foul odor
  • purulent exudate
  • erythema at wound edges
  • pain
  • edema
  • friable granulation tissue
  • non healing or enlarging wound
  • heat

Laboratory

• see wound culture

More general terms

• clinical procedure

More specific terms

• pressure ulcer assessment