Wound assessment techniques

Initial Assessment - First Glance

• Anatomy & Age: Location (e.g., distal limb, pressure area) and duration (acute vs. chronic).
• Bleeding & Borders: Active hemorrhage? Well-defined or irregular edges?
• Color & Circulation: Assess wound bed (red, yellow, black) and periwound tissue perfusion.
• Dimensions: Measure Length x Width x Depth in cm.
• Exudate & Edema: Note fluid type (serous, purulent) and amount; check for surrounding swelling.

⭐ A wound failing to heal by 3 months is typically classified as chronic. This timeframe is critical for escalating care and investigating underlying etiologies like ischemia or infection.

Wound Bed - Reading the Tissues

• Assess tissue types (Viability):

  • Granulation: Beefy red, bumpy, moist. Indicates healthy healing.
  • Epithelial: Pink/translucent, new skin growing from edges.
  • Slough: Yellow, tan, or white. Stringy or fibrinous. Non-viable tissue requiring removal.
  • Eschar: Black or brown, dry, leathery, necrotic tissue. Non-viable.

• Identify Tissue Percentage: Estimate the percentage of each tissue type in the wound bed (e.g., 70% granulation, 30% slough).

• Exudate Assessment: Note color, consistency, and amount.

  • Serous (clear), Sanguineous (bloody), Serosanguineous (pinkish), Purulent (pus).

⭐ In a non-infected, stable heel ulcer with dry eschar and poor arterial flow, do not debride. The eschar acts as a physiologic cover.

Infection & Edges - Spotting Trouble

• Clinical Signs of Infection:

  • 📌 IFEE: Induration, Fever, Erythema, Edema.
  • Also: ↑ pain, purulent or malodorous discharge, localized warmth.
  • Systemic signs: Leukocytosis, fever > 38.5°C.
  • Quantitative swab culture: > 10^5 CFU/g of tissue is diagnostic.

• Wound Edge Assessment:

  • Healthy: Pink, attached, migrating across the wound base (epithelializing).
  • Unhealthy:
    • Macerated: White, boggy from excess moisture.
    • Epibole: Rolled, thickened edges that have stopped migrating.
    • Fibrotic/Calloused: Hard, raised, non-progressive.
    • Undermining/Tunneling: Indicates deeper tissue damage.

⭐ Acute wound infections (<30 days) are most commonly caused by S. aureus. Chronic or delayed infections suggest biofilm or atypical organisms.

High‑Yield Points - ⚡ Biggest Takeaways

• The gold standard for wound culture is a tissue biopsy, not a surface swab, to distinguish infection from colonization.
• Assess lower extremity ulcers with an Ankle-Brachial Index (ABI); an ABI < 0.9 is highly suggestive of peripheral artery disease (PAD).
• A positive probe-to-bone test is highly specific for osteomyelitis in diabetic foot ulcers.
• Wood's lamp examination helps identify certain pathogens, like Pseudomonas (green fluorescence).
• Healthy wounds show red granulation tissue; yellow slough and black eschar require debridement.