Wound Care Assessment & Documentation for Nurses

Wound Classification

By Cause

• Surgical: Clean, created intentionally
• Traumatic: Lacerations, abrasions, punctures
• Pressure injuries: From sustained pressure on skin
• Vascular: Arterial or venous insufficiency
• Diabetic: Neuropathic ulcers

By Depth

• Superficial: Epidermis only
• Partial-thickness: Epidermis and part of dermis
• Full-thickness: Through dermis into subcutaneous tissue

Pressure Injury Staging (NPUAP)

Stage 1

Intact skin with non-blanchable erythema. Skin may feel warmer or cooler than surrounding tissue.

Stage 2

Partial-thickness skin loss involving epidermis and/or dermis. Presents as a shallow open ulcer or blister.

Stage 3

Full-thickness skin loss. Subcutaneous fat may be visible. Bone, tendon, and muscle are NOT exposed.

Stage 4

Full-thickness tissue loss with exposed bone, tendon, or muscle. May include tunneling or undermining.

Unstageable

Obscured by slough or eschar; cannot determine true depth.

Deep Tissue Injury (DTI)

Intact or non-intact skin with localized area of persistent deep red, maroon, or purple discoloration.

Braden Scale for Pressure Injury Risk

Assesses six subscales (score 6-23):

1. Sensory Perception (1-4)
2. Moisture (1-4)
3. Activity (1-4)
4. Mobility (1-4)
5. Nutrition (1-4)
6. Friction/Shear (1-3)

• Score ≤18: At risk
• Score ≤15: Moderate risk
• Score ≤12: High risk
• Score ≤9: Very high risk

Wound Assessment Documentation

Document using the following framework:

• Location: Anatomical site
• Size: Length × Width × Depth (in cm, measured at greatest point)
• Wound bed: % granulation (red), slough (yellow), eschar (black), epithelialization (pink)
• Exudate: Amount (scant, small, moderate, large), type (serous, sanguineous, serosanguineous, purulent)
• Wound edges: Attached, rolled, undermining, tunneling
• Periwound skin: Intact, macerated, erythematous, indurated
• Pain: At rest and with dressing changes
• Odor: Present or absent

Wound Healing Phases

1. Hemostasis: Blood clotting (minutes)
2. Inflammatory: Redness, warmth, swelling (1-4 days)
3. Proliferative: Granulation tissue formation (4-21 days)
4. Remodeling/Maturation: Scar strengthening (21 days - 2 years)

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