Other Descriptors

Wound Assessment Other Descriptors

Good wound management and appropriate dressing selection relies on the comprehensive assessment of all characteristics of the wound and surrounding skin.

Also see Red Flag: Wound Infection

Peri-wound condition

• Healthy and intact
• Fragile/ skin tearing
• Bruised
• Dry/ cracking/ desiccated
• Dermatitis
  
• Macerated or soggy
  
• Erythema/ inflammation/ cellulitis
  
• Oedematous/ swelling
  
• Excoriated
  
• Induration
  
• Fibrotic / scarred
  
• Hyperkeratotic
  
• Callus

Exudate

• Exudate amount: Nil / Low; Small / Moderate; High; Large / Copious
• Exudate type: Serous / clear (amber coloured); Haemoserous (pink), Purulent (thick, opaque, creamy)

Wound Edges

• Epithelialisation (i.e. clearly defined attached edges)
• Indistinct / Diffuse, Macerated (i.e. moist, wet, soggy)
• Rolled edge
  
• Raised edge
• Tracking, tunnelling or sinus tract
  
• Undermined unattached edges
  
  Courtesy of National Library of Medicine

Odour

• Strong
• Foul
• Pungent
• Faecal
• Musty
• Sweet

Wound Bed

• Granulation (i.e. dark pink / red, clean)
  
• Epithelialisation (i.e. pink, clean)
  
• Slough (i.e. white, yellow, stringy tissue)
  
• Necrotic / Eschar (i.e. black)
  
• Hyper - granulation (i.e. dark pink, red, bumpy)
  

Temperature of surrounding skin

• Normal
• Warm
• Hot
• Cool

Pain

• Location
• Intensity (Pain score /10)