Overview
This lecture covers key elements for wound assessment, including how to document wound characteristics, recognize types of wounds and tissue, and identify abnormal findings.
Six Key Components of Wound Assessment
- Assess and document the wound’s location with specific anatomical detail.
- Identify the type of wound (incision, laceration, abrasion, puncture, pressure wound, contusion, hematoma).
- Evaluate the wound tissue type (granulation, slough, eschar).
- Measure wound size: width, length, and depth using sterile tools.
- Assess exudate (drainage) for amount, color, consistency, and odor.
- Examine the peri-wound (skin around the wound) for changes or damage.
Types of Wounds
- Incision: Clean, straight edges from surgery.
- Laceration: Tearing of the skin from trauma.
- Abrasion: Superficial scrape (e.g., from falling).
- Puncture: Deep, narrow wound (e.g., knife injury).
- Pressure wound: Results from prolonged pressure, often in immobile patients.
- Contusion: Intact skin with underlying bruising.
- Hematoma: Collection of blood under the skin due to trauma.
Types of Wound Tissue
- Granulation tissue: Red, moist tissue indicating healing.
- Slough: Yellow, dead tissue needing removal.
- Eschar: Black, dead tissue inside the wound (not a scab).
Wound Measurement
- Use length, width, and depth to track healing or worsening.
- Cotton tip applicators and measuring tapes must be sterile.
Exudate (Wound Drainage) Assessment
- Amount: ranges from none, scant, moderate, large, to copious.
- Color: serous (clear/yellow), sanguineous (bloody), serosanguineous (pinkish), purulent (yellow/green/brown, may indicate infection).
- Consistency: thin, thick, or tenacious (sticky).
- Odor: a foul smell can indicate infection.
Peri-Wound Assessment
- Check surrounding skin for redness, warmth, swelling, or breakdown.
- Protect peri-wound skin to maintain overall integrity.
Abnormal Findings to Report
- Increased pain, swelling, or stiffness.
- Purulent (pus-like) or foul-smelling drainage.
- Excess redness, patient fever, failure to heal, gaping wound, or red streaks from the wound.
Key Terms & Definitions
- Peri-wound — skin surrounding the wound.
- Exudate — fluid produced by a healing wound.
- Granulation tissue — healthy new tissue, red and moist.
- Slough — yellow, dead tissue indicating delayed healing.
- Eschar — black, dead tissue inside the wound.
- Copious — unusually large amount of wound drainage.
- Purulent — pus-containing, potentially infected exudate.
Action Items / Next Steps
- Practice documenting wounds using specific anatomical terms.
- Learn to distinguish types of wounds and tissue.
- Observe wound exudate and peri-wound changes in clinical settings.