Heart Failure Guideline August 2021 Update

Refer to these definitions and descriptors as you complete the Essential Assessment Questions

1. Types of wounds:
• Venous ulcer ?, Arterial ulcer ?, Pressure ulcer ?, Diabetic/neuropathic ulcer ?, Burn/blister wound ?
2. Anatomical location
3. Wound dimensions:
• Length x width x depth in centimeters
  (Head to toe = Length, Side to side = width, Straight down = depth)

View Diagram


• Undermining & tunneling

View Diagram


4. Extent of tissue loss:
• Non-pressure ulcers: full or partial loss
• Pressure ulcers: staging
5. Tissue present: type and percentage of each present
• Granulating (red granular base)

• Clean, non-granulating

• Hypertrophic Granulation (overgrowth of granulation tissue, sits above skin level)

• Slough

• Eschar

• Epithelial (pink epithelium)

6. Exudate: type and amount present
• Serous, Sanguineous, Serosanguineous, Tan, Yellow, Brown, Green, Clear (thick or thin), Purulent
7. Oder after cleaning with NS/wound cleanser/water
8. Wound edges:
• Open vs. Closed/Rolled

• Distinct vs. indistinct
9. Periwound skin:
• Macerated (white or grey “water-logged” skin)

• Intact
• Erythema
• Candida
• Epidermal stripping