Guide — Wound Care
Wound Assessment Basics
Accurate, systematic wound assessment is the foundation of effective wound management. A complete assessment documents current wound status, identifies complications early, guides treatment selection, and measures healing progress over time.
10 min read · Wound Care
Educational use only. Wound assessment findings should be documented in the patient's medical record and communicated to the wound care team and provider. Follow facility-specific wound assessment policies and consult wound care specialists for complex wounds. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Assessment Frequency
Wound assessment frequency depends on wound type, acuity, and facility policy. Minimum standards include:
| Setting | Frequency |
|---|---|
| Acute care (hospital) | At each dressing change, minimum every 24–48 hours; skin assessment every shift |
| Long-term care | Weekly and with each dressing change; skin assessment on admission and weekly |
| Home health | Each visit; at minimum weekly |
| Outpatient wound clinic | Each visit — typically weekly or biweekly |
Reassess sooner if there are signs of wound deterioration, infection, or any change in the patient's condition.
Location
Document location using anatomic terminology. Be specific — general terms such as “back” are insufficient. Include laterality (right/left) and anatomic landmark.
For wounds related to medical devices: document the specific device causing the injury (e.g., “nasogastric tube — right naris”).
Size Measurements
Length × Width × Depth (cm)
- Length: longest dimension head-to-toe axis
- Width: widest dimension side-to-side
- Depth: deepest point from wound surface to wound base; use a wound probe or cotton-tipped applicator
- Use a disposable measuring guide or sterile ruler; document in centimeters
- Consistent orientation (clock-face method) ensures reproducibility across assessors
Undermining and Tunneling
- Undermining: tissue destruction extending under wound margins; probe and document using clock-face positions (e.g., undermining 1 cm at 3 o'clock)
- Tunneling (sinus tract): narrow channel of tissue destruction extending from wound base; probe, measure depth, and document direction
- Both indicate wound extension beyond visible surface — important for staging and treatment planning
Wound Bed Tissue Types
| Tissue Type | Appearance | Clinical Significance |
|---|---|---|
| Granulation | Beefy red or pink, moist, granular (cobblestone) texture | Healthy — indicates proliferative healing phase; protect this tissue |
| Epithelial | Pink or pearlescent tissue at wound margins or wound surface | Very healthy — re-epithelialization occurring; avoid disturbing |
| Slough | Yellow, white, or tan; stringy or moist; loosely adherent | Nonviable tissue — requires debridement; delays healing |
| Eschar | Black, brown, or tan; leathery, dry, hard; firmly adherent | Nonviable tissue — usually requires debridement (exception: dry, stable heel eschar) |
| Necrotic (wet) | Gray, green, or black soft tissue; may be malodorous | Nonviable — indicates wound deterioration or infection; requires debridement |
| Bone/Tendon/Muscle | White/yellow (tendon), red (muscle), tan/gray (bone) | Visible in Stage 4 pressure injuries or deep wounds — consult wound care specialist |
Document the percentage of each tissue type visible in the wound bed (e.g., “70% granulation, 30% slough”).
Drainage (Exudate) Evaluation
Evaluate and document drainage type, amount, color, and consistency at every wound assessment. Drainage characteristics provide critical information about wound status and healing trajectory.
| Amount | Description |
|---|---|
| None | Wound bed is dry; no visible moisture |
| Scant | Minimal amount; only traces on dressing |
| Small / Minimal | Covers less than 25% of wound dressing |
| Moderate | Covers 25–75% of wound dressing surface |
| Large / Copious | Covers more than 75% of dressing; may saturate through to outer layer |
Document drainage type alongside amount: e.g., “moderate serosanguineous drainage.” See the Wound Drainage Types reference for full type descriptions and clinical significance.
Wound Edges
| Edge Description | Clinical Meaning |
|---|---|
| Attached and flat | Normal healing — edges approximating the wound base |
| Unattached / rolled under (epibole) | Abnormal — edges have rolled inward, preventing epithelialization; requires debridement to flatten |
| Thickened / fibrotic | Chronic wound changes — edges may require debridement to stimulate healing |
| Irregular / undermined | Tissue destruction extends under edges; document extent with clock-face positions |
| Well-defined / punched out | Characteristic of arterial ulcers — sharp, regular borders on an ischemic wound base |
| Diffuse / poorly defined | Characteristic of venous ulcers or moisture-associated skin damage |
Periwound Skin Assessment
Assess the skin surrounding the wound — changes here often precede wound expansion or signal complications.
Intact
Normal periwound skin
Erythema
Redness — may indicate infection or pressure
Induration
Firm, hardened — inflammation or developing infection
Maceration
Waterlogged, white/pale, soft skin from excessive moisture
Excoriation
Superficial skin loss from irritant contact (moisture, tape)
Ecchymosis
Bruising — may indicate trauma, deep tissue injury
Edema
Swelling — may indicate venous insufficiency or infection
Scaling / Callus
Hyperkeratosis — common in diabetic and venous wounds
Document erythema size: for dark-skinned patients, assess for warmth, induration, or color changes (purple/blue) rather than relying solely on redness — erythema may not be visible.
Odor and Pain Assessment
Odor
Assess odor after removing the old dressing but before cleaning — some drainage odor is normal. Document as: none, faint, moderate, or strong.
- Foul/malodorous odor suggests infection or necrotic tissue
- Some dressing materials (hydrocolloid) normally produce mild odor when removed
- Pseudomonas infection produces characteristic sweet/fruity odor with green/blue-green exudate
Pain
Wound pain provides important diagnostic information. Assess using a validated scale (0–10 NRS) at rest and with dressing changes.
- Increased pain at a previously stable wound may indicate infection
- Arterial ulcers: severe pain, especially at rest or with elevation
- Venous ulcers: aching, heaviness, improved with elevation
- Neuropathic ulcers (diabetic foot): often minimal pain despite wound severity
Signs of Wound Infection
Report to Provider if Present
- Increased warmth, erythema, edema, or induration of surrounding skin
- Purulent drainage — cloudy, yellow, green, or brown; thick consistency
- Foul or malodorous exudate (especially if previously absent)
- Sudden increase in wound pain or tenderness
- Wound enlargement or failure to progress despite appropriate treatment
- Systemic signs: fever, elevated WBC, elevated CRP/ESR
- Cellulitis extending >2 cm from wound margin
Documentation Standards
Use a structured format to ensure completeness and allow comparison across time and assessors. Most facilities use an electronic wound assessment template. Key elements:
- Location: anatomic description with laterality
- Wound type/etiology: pressure injury (stage), surgical wound, venous ulcer, arterial ulcer, diabetic foot ulcer, traumatic wound
- Size: length × width × depth (cm); undermining and tunneling if present
- Wound bed: tissue types and estimated percentage of each
- Drainage: type, amount, color, consistency
- Wound edges: attached/unattached, rolled, thickened, regular/irregular
- Periwound skin: intact, erythema, maceration, induration, edema
- Odor: absent/faint/moderate/strong
- Pain: 0–10 score at rest and with dressing change
- Dressing applied: type, size, change interval
- Photographer: wound photography per facility policy
- Plan: interventions, referrals, provider notification if indicated
The Pressure Ulcer Scale for Healing (PUSH Tool) is a validated instrument for tracking healing progress in pressure injuries over time — uses wound size, exudate amount, and tissue type as parameters.
NCLEX Pearls
- ✦Granulation tissue = good. Red, beefy, moist, granular tissue indicates healing. Eschar and slough = bad (nonviable — delay healing).
- ✦Measure wound with clock-face system: 12 o'clock = toward patient's head; 6 o'clock = toward feet.
- ✦Heel eschar in stable, dry form (non-fluctuant, non-infected, with intact skin) is left intact — removing it opens underlying tissue to infection.
- ✦Rolled/inward wound edges (epibole) prevent epithelialization — require debridement to stimulate healing.
- ✦Wound infection signs: new purulence, increased pain, erythema, odor, fever, or wound enlargement.
- ✦Dark-skinned patients: assess for warmth and induration rather than relying on visible erythema to detect Stage 1 pressure injuries.
- ✦Tunneling and undermining must be probed, measured, and documented — they indicate wound extension not visible from the surface.
Related Resources
Standards & sources
Fact-checked Jun 21, 2026This page is written to align with NPUAP / EPUAP / PPPIA (pressure injury staging) · Wound, Ostomy and Continence Nurses Society (WOCN). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →