General Wound Assessment

Fundamental Review 8-1
General Wound Assessment
Wounds are assessed for appearance, size, drainage, pain, presence of sutures, drains, and tubes, and evidence of complications. Refer to Chapter 3 for additional information related to assessment of the skin and integumentary system. Performing General Wound Assessment Note the location of the wound. Location is described in relation to the nearest anatomic landmark, such as bony prominences (Taylor et al., 2023). Assess the wound's appearance by inspecting and palpating. Look for the approximation of the edges of a healing surgical wound and the color of the wound and surrounding area. The edges should be clean and well approximated. Edges may be reddened and slightly swollen for about a week, then closer to normal in appearance. Skin around the wound may be bruised initially. Observe for signs of infection: redness, erythema, warmth, pain, edema/swelling, presence of purulent drainage (WOCN, 2016). Observe for these additional signs of infection in chronic wounds, as the classic symptoms of infection may be diminished or altered: serous drainage with concurrent inflammation, delayed healing, discolored and/or friable granulation tissue, pocketing at the base of the wound, foul odor, wound breakdown (WOCN, 2016). Note the presence of any sutures, drains, and tubes. These areas are assessed in the same manner as the incision. Make sure they are intact and functioning. Assess the amount, color, odor, and consistency of any wound drainage. Assess the patient's pain, using an objective scale. Incisional pain is usually most severe for the first 2 to 3 days, after which it progressively diminishes. Increased or constant pain, especially an acute change in pain, requires further assessment. It can be a sign of delayed healing, infection, or other complication. Assess the patient's general condition for signs and symptoms of infection and hemorrhage. Consider use of photography to document the appearance of the wound, based on access and facility policy (Baranoski & Ayello, 2020). Consider use of a tool to monitor and document patient symptoms and wound healing, such as the Pressure Ulcer Scale for Healing (PUSH), the Bates-Jensen Wound Assessment Tool (BWAT), and the Toronto Symptom Assessment System for Wounds (TSAS-W) (Baranoski & Ayello, 2016; Harris et al., 2010; Maida et al., 2009; McNichol et al., 2022).

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Fundamental Review 8-1